HomeMy WebLinkAboutMortgage_Owens (3)"�� STATEMENT OF MORTGAGE OR CONTRACIFIN�� Coun 7ownship vear
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: FOR DEDUCTION FROM ASSESSED VALUATION
• State Fwm 43709 (R71 / 609) MAY 2 4 2012
S l Presr+ibed by Departmenl of Loml Govemrtrent Fi�nca
�w C � File Mark
�STRUCTIONS:
Fortn Ned wnh:
To be filed in person w by mail with the County Auditor or County Recorder o� the county where the pro is located.
Fil'mg Dates: 7J Real PropeRy: Must file during the year(orwhich the deduc(dL0&QkfhDUNTY A I OR �) �unryAuditor
2) Mobde / Manufactumd Hortres rwt assessed as Real Propefty: Must fiIe dunrg the fweHe (12) months /�
6efore March 37 0/ each year the Aeduclion is saght. ❑ Caunry Recorder
See 2verse side /or addiUOnal instructioru antl qualficat'ans.
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If ro, what fs his I her e�2 sha�a W
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Name of rnoRgagee « mnVacl se0er
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mortgagex a oontrad srder (ntsMrl end streeG �l: state.
�ssignee or otlw rnmer w hdder W mM9a9e
�W�� ���1 p
a-�yao
ctian approveE um Ne amount or.
20 _ 20 _ 20
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I/ We certify undu ihe penalry of perjuryFhat the above and (or ng
owner I contract buyer of the aforementioned property on date aQ lipl
' �awre(o /slutlname)
�s�"��e�,o .L lJl1�n,�.0
revdent addrrss ol ap t numberen0 sbee4 dty, e, eM ZIP �
� 10� . L�-�a.r��,eld�ve. ri
Pasm autho�aed by Ouh/ ezecuted Power of AlbmeY a�' IC 61.1-t2-0.7
PGdress of author'aed person (number aM sfree( cily, sYate, arM Z!P cade)
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Rxn(d��br1 F� / —
�mGaid as o( Is Ne ePW�t Me sde
kgal w epuitaGe own�
❑ Yes ❑ No
H owried wiin someone aher than spouse, IMicate wiih whom
20 _
IS CIC P��CQnY N VUCSOOtI: Mf W2DY ASSCSSCE
❑ Real ProPeRY ❑ ���h' �
MoW7e Home !IC 61.
�ate (monfh, deY,
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informalion is We and mrtect and Nat the apptirant is a resident oi IrWiana aM
ion is fiied.
Date (nrnfi. day, yea�
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