HomeMy WebLinkAboutMortgage_Hackworth"'n STATEMENT OF MORTGAGE OR CONTRACfi1N[�EB�ED6IES Coun�
__, FOR DEDUCTION FROM ASSESSED VALUATION
�• StateFwm43709IR11/6-09) FEB 2 � 2012
�,�,� l PretmbeC by Departmen� of Local Govemmenl Frence
�c.�.m�
STRUCT70NS:
6e filed in person w by mail wi[h the CountyAUditor or Counry Recorder o�the Counry where t E � rty is located.
Fdin9 Dates: 7) Real Property: Must file durirg fhe yrear (or which Ne dedutBO� r��c�7�UNT Y AU DITp�
2) Mobde / Manulactured Homes rat assessed as Real Property Must fife dunng fhe tweNe (72) months
6efore March 37 0/ each year the deduclion is sayht.
See /everse side tor additional inshuctions and qualifications.
Apq6pnt (owrrer orcontBrt buyer- see re�trictbru m�revgrse siYe)
Asesxd va4ie d real Pmpe+�Y as W
Mart3i 1. nrrent ym
1! M. W�1916 �1115 /�1Cf CYdC� 5�13f8 Of 1f1�2lCSl�
airrent year
If runie m rewtd is OiRerent Ihan Nat ot applitant. "uWirate CelmK
mortgagee or
File Mark
Form t�ed wiN:
Counry Auditor
Counry Recorder
1 az W Monga9e I ContraG iMebteMess unpaid as d Is Me eOW�t �he sde
date of appGration kgal or edultade avneR
❑ Yes ❑ No
If owneE +niN someorre Mrer �han spouse. iMicate with whnn
s of nnrtgagce or mntraa se0er (nwMer and slree4 cdy. s�. end IIPmde)
ol ass'ryiee or other owner w halder W mortg
Dra�ver \O.. t�.Q.%�......
s ot assgnce (number antl stme4 �y. sfate. �
Dces aPplinnl aM+� pmperty in any oNer
counry in Indiaru?
❑ Yes
IDeduction approveA m the amount oE
20 20
Card NO. ....�J,J,C,d.........
20 20 20
Co�mry
Is the property in Ques6on: MnuaOy AsSesseO
��T1eal ProPertY ❑ ArmuallyAssessed
�Yv Moble Fim�e !IC 6
Has Na deEUCtion been reQursted m G�oM'+lY
tor w�rent yeaR ❑
❑ Yes
20 I 20
I/ We certify under ihe penalry o( perjury Nat the above arW foregoing information is true and cortecl ard that Me applipnt is a resident of IMiara aM
owner / mntrad buyer o( tl�e aforemerrtioned property on date appfica0on is filed.
i u r: nm oav�) n , / ./l oa�e pm�m, ear. rge�
oty, slatgy antl
aower wnumrey
PdCress of auMar¢ed person (number ard sLeel. ary. sfafe, and ZlPmtle)
Date (monfh. daY. l'aa�