HomeMy WebLinkAboutMortgage_Worthington""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship vear
_ : FOR DEDUCTION FROM ASSESSED VALUATION
• State Farm 63709 (R71 / 6-09)
�' �.�. t Pf�aioea M oev�nt of Lttal covemment Fuance /�
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wsrRUCnorvs: i
To 6e (led in person or by mail wiN fhe CountyAuditw or Counry Recnrdei f.the county m pro rty located �
Filing Dates: 1) Real PmpeRy: Must file dunrg fhe year /o� which the deduction is soughL County AudiWr
2) Mo6ife / Manufectumd Homes nof assessed as Rea! Property: Musf file dunng the nvelve (72) months.
before March 31 oJeacA year the deduction is sougAL N� ���b�
See reverse side lof addifional instructions and qvalilrcations. -
Appfrant (owne� oontrdp buyer - see sL'cfibns on re�e e) � �
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nm,w
rc �e
7�G�Y
r eYatl snare ot lntei
tlifterent IAan Nat W
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Mo�(paqe / Contraa "uWe6teEness unpaid a
Mard�i.curtentyear
p p0
ff�
ant 6Wicate Delmr.
Name ot rtartgagee a contraU se4er n� ' �' n/
C� /' / �
Mdress d rtiortgagex ar mntraG se�er �numbel and L�Y sbte. aM
/
Name of assignee w other owner or hdEer W mortgage
didnt own pmperty in any oNer
��ag��
❑ Yes
DeducCOn app�oveE in tla amount oE
No
Ir yes. what muntyl
'!Jf!L•7
I u Y� u No
th someane dher ihan spouse, 4�dicate wBh whom
Is Cre perty in QuesOrn: MnuaOy Aswssed
eat afopertr � A^^�N�
Mobile Hort�e QC G7.7-7
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DI"II\1'CI' �i�...::•••.`.....�.....
vma� r�rg o�� t/ D I
dca 1
Cai'd \O . .....................
�uorroR � o'1����,�
20 _ 20 _ 20 20 20 _ 20 _ 20 _
s'y�awre or coimb a,ditor couruy osre (rmrth, dar r��)
i I We certify under the penalty of perjury that the above and (oregoing informalion is We and mrtect and that ihe appiinnt is a resident of Indiana antl
owner I contrad buyecof �e afaemerttioned proOertY an Qate applicalion is filed.
ident adQe}, ot appGrant numDer aM sfree4 ciry, slate, and ZIP e)
�� I I o� t. ri nc� I1�1 ��l
auu�nrzed ty auy ezecutea aoxer arwu�er or ey �c s1.7-�z-0.7 oate (monm, ear• r��_ �--'- —
s of auUwr'vsN person (number antl sbea; cdy, slafe, aM LP mde) , �� -