HomeMy WebLinkAboutMortgage_Ivy^'� STATEMENT OF MORTGAGE OR��CbN�CTjINDEBfiEDNESS Coun Township vear
__._ • FOR DEDUCTION FROM ASSESSED'VALUATION
' Siate Fortn 43709 (R77 16-09) AP R 9 2012
� � Prestribed by DePartn�erit of Loral Gwemment Fwnce
�� ��� File Mark
JSTRUCT10N5 G����
To 6e filed in person or by mail with the CounryAUditor or Counry Recorder of the coun(y-vthere the pmperty is located. F� �� ��
Fif'mg Dates: 1) Real Pmperty Must fi!e during the year for which Ne deducfim��sOtiqfi!)TOR Counry Auditor
2J Mo6ile / ManuFactured Homes irot assessed a�'Resl�Pmp�i�'y� �fust fi/e dunng the tweNe (72) monfhs
betore March 310/ each year the deduciion is sought ❑ Counry Recorder
See reverse side for addilional instructions arM qualiflcations.
Key nuP es / legal desaiplion
`@-�a-i�-
a d Mwt9eae / �aG'vWel
Mamh 1, aamY }mr
1! ro, what a his / her e� share of intrmt?
If fame an rem�d is dAtefmt Nan that o/ appl
Name of mortqagee or mntracl seoer
Address W rtartga9ee w contrad uAer (num
uMicate Eebw
Name of assynee w oiher owrrer w twlder o( mortgage
AGdress of as9gnee (number aM spee4
ooes aacem�c � wna�r
munry in IrW"ena? r
�
appovca m tra amoum or.
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�- cho3.o��-
unpaid as of Mongage / ConV:
ctiy. sbte, arrd LP code)
Stefi, antl [If' cotl�
��,�.w
I No
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sorneane
�sp�aid
sPouse.
Yes LI No
Is tice V�VenY in 7uestion: MnuaOyASSessed
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1/ We certify undel the penalry of perjury that ihe above and foregdng informalion is We and cortect arW Nat Me applicant is a resident of IMiana and
rnmer I contract buyer of the afwemenuoned property on date application is fiied.
�rewre (mmer5 fiArertre) Date (monfi, daY. lea�
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Pddress of auNoraed persm (numberald sbce; rit}; state. an0 LP mde)
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