HomeMy WebLinkAboutMortgage_Chamberlain (5)"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS n� ship Year �
_ + FOR DEDUCTION FROM ASSESSED VALUATION �?
Sbta Fwm 43709IR71 / 6O9) r
� t PreSaibed Oy DePa�eM of Local Govemmerd FtranCe
Fle Mark
wsrnucno,vs: JAN 1 2 2
To be fiied in person w by mail with the CounlyAUdifo� or Counry Recorder of the counry wheie the property is located. ��� ��
Fitirg Dates: 7) Real Property Must file dunrn� the year for which the deducfion is sought. C,�, County Auditor
2J Mobi(e /Manufaduied Homes iwt assessed as Real PropeRy: Must file during the fweNe (72) months
6efae March 31 o/each year the deduction is soughG County Recorder
Seereversesideforadditionalinstnlctbnsandqualifications. GIBSON COUNTY
Aoofrant {owneror mn72C buver- see re.mirAOns oweverse sidvfl I ..
AssrsscE vah�e d ma17MeRY � M Mw[ga
ro
� 1. anPlli yYdf Mattl�
tt nq what k his / her erm7 share ol intnmst?
tl name on �emrd "s dffemst Uan [hat of aPp�aN, cqka
Name of mortBa9ee ar c trx� seper '
OA/h7/l/YI �iU1//Ji
Pddrea d mM�a9� ar mntrad seYer (n and shE
Name c1 assignee m other awner ar holder of mortgage
ACa�ess of assgnee (number eM streeL mY. stafe. aM:
dawiptirn
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Contrarl indeCteEness unpaid as W Moriga9e I Contract rtWe6tedness unpaid as d Is the appOtant tlie sde
i^?"� year /���-, Cata or evP�� legal or eW itade owneR
/ (p, � (/�,/ ) ❑ Yes ❑ No
ciry, sb�, ard LP mde)
If owneO vriN someone oNer Nan spouse. u�dkate u�tli nhom
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C µRm a� �,a�,�.�%� y
m_j f} �j wNrvnuoROa
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20_ /1�_.flh_J:4� /7�R��C2C',i3*�
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20 _ � 20 _
Counry
Is ihe propeny in question: Anm�aRy Assessed
�Real ProPenY ❑ %'m��N�
e�,wie 4u...e nr a
Has Na deduction Ecen reQUested on pmperty
r� o,�� y�n
❑ ves ❑ No
20_ 20_
��,,�,�.�Y��
I/ We cert'rfy under Ne penalty of pe�ury that the above and foregoing infortnalion is We and cortect and tliat the applicant is a resident of I�iana aM
ovmer / contrad buyer o e me�rooned property on date appliration is filed.
ya/nue(qyx��s futl Date (rm�tli, daY. Y�e�
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by dWy ezewtetl Pwml af Atmrtiey w 6y IC G7.1-12-0.7
AEOreR of aWrot'vetl permn (numDer aM Sbee; dry. state.