HomeMy WebLinkAboutMortgage_Brink (3)^�n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship vear
. FOR DEDUCTION FROM ASSESSED VALUATION
'� .--.. ' State Fwm 93709 (R11 / 6-09) d�
�` ,�r � Presuibed by Departrtrent of Loral Govemmenl F�ance
� File Mark
INSTRUCTIONS: �
Fortn I�ed with:
To be filed in person w by mail with Ihe CountyAuditor or Counry Recorder o( fhe couniy where the pioperty is located.
Fil"mg Dates: 7) Real Property: Must file dunrg the year for which the deduclion is sought � County Auditor
2) Mobi7e / Manufactured Homes rwt assessed as Real Property: Must file dunng the fweNe (72) monfhs ❑
6efore March 31 of each year the deduclion is saght. County Recorder
See 2verse side 7or addrtronal instrt�ctions and qualifications.
AppGpnt(ownerormntrs�uye�-see�oArerersesd � n . �
Assessed ra4e d real P�P�Y az ot
'�a(U i ame�v year
tt no. what is his / her esaa share o
If name m remN's ddtuent than tl
� 1 1 � 1 \ 1 �
as U Mortgage / Contrart uiEeb[etlness unpaid az d is Me applifanl Ne sole
date af appGrabon legal w eWitable ox+reR
❑ Yes ❑ No
y� I H awneE wiN someo� dher ihan spouse. iMirate wiN Mwm
avP��t h�0ipte belov` h Ihe DroPertY in Question: MnuaM Assesse0
❑ Real Property ❑ nrmua�y Assessea
Name af mort9a9ee or mnaarl seDer
Mtlress of mwtga9ee w contrsd se�er (i
Name of assignee or aher owner or hdd
ACtlress ot assignee (number arnl stroe4
Does appli�ant own praperty in any aher
munry in InC'ana? ❑ Y�
appa,ea m u,e ama,m
��.
er oi rtnrtgage
ciry, sfate. aM Z/P cotleJ
���.�
❑ No
Ocb;'.V.� . . . . . ..
— pt �\\'Cl' 1�...... .
3\`�5.........
C�1-� tp• .......
�o�N �35,q�o.�
o�
❑ No
20 _ 20 _ 2Q _ 20 20 _ 20 20 _
�ture d CountY Auditor Caunry Date (rtanN. daY Yea�
I/ We certify urdu ihe penalry of perjury Nat ihe above and foregoing infortnation is W e and cortect arM that the applican[ is a resident of Indiana and
owner I conVact buyer of lhe aforementioned properry on date application is filed.
6ate (rt�N. daY. Y�+)
�fawrejuwnF/`797nartre) � � ♦ -.
Fw�siOem atldress ol appGmnt (num6eiand s7ree4 dry, state, aM 21P ootlej
�l
Perpn auUro�aed Gy duly executed Power of Attomey or by IC G7.7-12-0.7
Address of a�Nwraed perso� (numberaM sveet. dry, sfate, aM Z1P code)
c,�. �r,