HomeMy WebLinkAboutMortgage_Brines (2)"n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
_. FOR DEDUCTION FROM ASSESSED VALUATION
sa�e F«m as�os tR„ i s as�
�' �.�. Resa;cea Cr cev��� ar Lda c�ovemmem Fumnca
INSTRUC770NS:
b be ned in person a by mad with the CountyAuditor w Counry Recorder o! the county where the property is lo�� I
Frf'mg Dates: 7) Real Property: Must fi1e durng fhe year for which the deduclion is sought.
2J Mobr7e /Manufactu2d Homes rwt assessed as Real Property Must file durirg the RveHe (12J months
before March 31 of each year the Ceductiwi is sought. �7-y�
p'/aW.
See revers�side for �ddrtional insVUCtbns a� qualificafions. �� �� a
Ap or . bl+yxr - see r�'qr6'dp revgrsg /� ♦ � �""""" YY�
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1, cnesrt year
ro. what Is his / her exaa shafe ot interest?
riame m remE
„��v,la-ae- /o�
�� a� ������
of rtpRgaqee u contrad se�er (nuMer erd sLeet ub.
Name ot "cy. ee w aNr1 owner or halder of rtortgage
Address at assignee (numbereM sneeL my. s+ete,
any
DeEuction app�oved in ihe amount oF.
so— � s°—
trMebtee�xss imvaie as d
tlata
Counry Audimr
Counry Recorder
���
La Ne eppOrant tlre sde
kgal a eqWtade ovmM
❑ Yes ❑ No
If wmeC wiM someo�x other Ihan spousa. Indiate Wth Mlun
-_.
No - ��� ....
j�l':l\\`Cl' \� ...............
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� , � � �� �I 20 —
Counry
19 CIC 7�7�Y IIl Gt16U0f1: M11118�' ASSCSSCd
❑ Reai Pmperry ❑ Armuany Assessed
Nas U�is tledudion Caen m9u�ted m ptopnity
far arrent Y��' ❑ Ves
❑ No
F.��
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Fi�]
I I We certfy under the penalty ot perjury Nat the above and foregoing infwmation is We end cortect and that Ne applicant is a resident of Irxliana and
owner I contrad buyer of the aforementioned properry on date applicatlon is fileC.
�nawre (awnafs hN name). n �� . . Date (month, daY. YgeA
Person auttpRed Cy dWy exewted Power M Attaney
person (numGer aM sbeeL ml: sbte, and Z!P code)
Date (monfh. daY. Y��