HomeMy WebLinkAboutMortgage_Smith (13)a"' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coum
FOR DEDUCTION FROM ASSESSED VALUATION
• Sfa[a Fwm 43709 (R11 / 6-09)
� � PresaibeG M OepanmeM of Lad Govemmerrt Po�ance
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INSTRUCTIONS:
b 6e fiied 'm person w by mail wiN the CountyAUditor or Counry Recorder of the counry where the pioperty is located.
F7ing Dates: 1) Real Pmperty Must file dunm� fhe yrear /or which the tleduction is mught.
2J Mobile /Manufactured Homes nof essesced as Real Property: Must fiie dunng the IweNe (72) months
6efore March 31 o7each yearthe deduclion is s�ught.
See reverse side for addifional instrucGons and qualifications.
ro, what is his / ner exaa snare o� intelesfr
name m remrC's Offaent Nan Nat of aPP�t uWinte bebw.
ryam¢ p( nqrtgagee or mnuad seller
AGdr� of nwrtga9ce w rantract sM
��
name m atsignea w wwl owner or m�oej w��vu
Add2ss of assignae (n�mber antl svec4 �y, s7ate,
Ooes ePd�nt wm pfoperty in any ot�er
counryinlMana? ❑ Y25 ❑ No
ction aaaroved m u�e amoun� of:
p_ 1 N
' V�'VD�.((/�7�
aa irde6tetlness unpaid as of Mortgege I
year �aU o( app
�
Year
� ����o���.
County Recorder
OIBSON COUNTY F
Remrd num � � Pa9e
�Q
Yes LI No
�is/tpe popertyinQuestm:Mnua%ASSessed
�yRea� Rnperty ❑ a�nnua�ywssessed
� � bbble Harie (IC 61.
riry. sfete, aM LP m�+��. _--- __' .
If yes, �Mat muny
. �I.I.....
Drawer NO:... �
/%a� ....
C'did � O• •• ••: ••� Eeen reGUested m p�operty
❑ Yes ❑
zo � zo _ � zo _ � zo _ � 20 _
Sigria4ve d Camb Aueitor I Caunry - I Date (rmW, daY, Y�A
1/ We certfy undu the penalty of perjury that the above and foregoing infortnalion is W e and cortecl aM that the applinnt �s a resident of IrMiana afM
owner I contract buyer oT the afaemeMioned pmperty on date ap�"mation is filed. �
Sigr9Lire (owneh rmme) - Date (manfh. deY. Y��)
r'<�/� =
�revCent a0dress of appGmnt (num6erantl sbeet �+N, state, ard LP oode)
��6 S o7 � GJ U l�E.vs v i//K �ti , �/�6Ea�
Petson aWqReE Gy dWy ezecuted Power o(A1tGmeY a bY IC 67.7-12�.) Da1e (/nantA. dsY Y��
lddress of aWhometl persa+ (number arnd sbee( cily. state, an0 LP cotlo) .
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