HomeMy WebLinkAboutMortgage_Brakmeier^�n STATEMENT OF MORTGAGE OR CONTRACT INDEB� Township Year
. FOR DEDUCTION FROM ASSESSED VALUATION �
� State Fortn 43709 (R71 / 6-09)
�' � � Presaibetl by Departmenl of local Govemmenl F�ance
•" JUL 11 2012 File Mark
WSTRUCTIONS: F� fl� �:
To be filed in person or 6y maii wifh the CountyAUditor or Counry Recorder of the counry whele�ihe'P � ocated.
Fifirg Dates: 1J Real Pmperty: Must file dunng fhe year for which the deduction is soughL � Counly Auditor
2) Mo6de / ManulaUured Homes rwt assessed as Real Propery Must file dunng the tweNe ths
before Maich 31 o(each yearthe deduction is sought. G�BSON COUNTY ❑ �unty Recorder
au�iroR
See revarse side /or adtlitional instnictions arrd qualifirations.
nppG�am(oxnarwcry�qaubuyer-see�restri�tixuarie�saside)� •
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_J.._7__ .�m.�Q6 oG� �d l
Mort9a9e / Contraa 4We6tedn¢ss unPaid as of MortB:
Mard� 1, curtent year date o
�a� is his / Mr e�ct share of intrlest?
on reoortl is dMe�t Man ihat W aPP�t
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Mdress of mMga9ee «contracl seuer �numoer ena sn
p�yma o( yssigne¢ ar other owner w twldu of morigage
� ��.
AdER55 of asSignGe (numb¢r eM streef, cdy. state, antl ZIP COtle)
Does appli�nt ovm property in any oUer If yes, what muny.+
munry in IMana? n Yes ❑ No
20 _ � 20 - I 20 I 20
mmearie
W1�3t Tadrg
AUDROR �
Record numbnl Page numbu
ao a 3
vY' tlebteAness unpaid as of Is ihe appfxant the mle
� legal w eQUitaWe ame(.�
❑ Yes ❑ No
m Cian sparse. c�d¢ate r'vh vA�vn
� \W � W��'\�
ao��._....
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v� ���'°`
3a11 ......
Ca� � \�. .....
20 _
Has Nis dedutlirn Eeen requested on property
tor wrtent yeaR � Ye5 ❑ 'i
20_ � Z�_
Sigfuwre W Ca�mb Auditw I Caunry I Date (mw+M. daY. Y��
I/ We certify under lhe pena�ry of perryry Ihat ihe above and faregoing irrtortnaGOn is We and mrtect arM that the applirant is a resident of I�iana arW
owner / contrac[ buyer of the aforementioned property on date appiicalion is filed.
$igraWre (o�meYS fiAl+�eme) e.. Date (monih, OaY. Yma�
�C -, /' --� /=( _ /Z,
fesiEem a0tlress of appircant (ni
/397 � 7'a
:an aWmtretl tr/ OWy esearcetl
�; �ra.
Address of aNhor¢ed person (number aM streel, crty, sta(e,
142-0J
Dare (mmN. tlaY. Y��