HomeMy WebLinkAboutMortgage_Clevenger^�� STATEMENT OF MORTGAGE OR
_ � FOR DEDUCTION FROM ASSES:
• Slate Fwm 0.i709IR11 / 6-09)
•�' i p��be0 by DeG�er�t of Locai Govemment Firam
DEC_0 8 201Z
INSTRUCTIONS: �r�[�
To be filed in person w by mai7 with the CowtyAudito� o� Counry Recorder of the wwHp rty is bcated.
Fdtig Dates: 7) Real Properfy. Must fJe dunrg the year for which the deducrttiyon is soughL Q /��7
zJ6eforeMarch3lofeachyearthedeductionismugM�eGl SONCOUnNTtYAU I pRm°nths
See 2verse side for addifional instrucGons and qualifiptlons.
(owre�w mntrart - seeN on reverse side)
T
T' istriG Key rvm6er / Mgal drsaiCtim
_a0 / ooG o
Assessed raM1re d��perry es o( Mortga�e / Contrac[ indebtedness unpaid as of MMgage / Contract 4�dehtedness
Mard� 1. arrem 1� Martl� —vrent Y� date of app�catian
tt no, what !s his! trer esaU share
Ii narne m moNd is dtlferPflt Nan
Name of mortgagee a contraU seAer
�
AddRSS of monga9ee w mntract seller (numbrl e�
Name ol assignee w other awner or hdder of moru
AEtlrnss of assi9�e (number ar�d speet tlry, sfate,
ooes applimnt own praperty in any oNer
counbmindana? ❑ XgS ❑ No
ciry, sfate. aM ZIP code)
rt yes. wna[ muntyt
File Mark
Farm Ari wiN:
�CounryAuditor
Counry Recorder
unpaid as d
sPouse. IMltate wlCi wM
Is ihe properry in quesiio
�eei PfoPenY ❑
Page number
iita6le amell
Yes ❑ No
C.�PVe�c � m�Q �Jov ���,P�
-r �1,� 1�� 1— � r� ❑ Ne
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I ,;t � l��l� �3
20 _ 20 _ 20 _ 20 _ _ _ 20 _
SlgnaWra N Coimb Auditw Caunq' Dete (+rnnth. daY YEa�
I I We certify uMer the penalty of perjury Nat the above arM foregoing infortnaGon is W e end corteG arM Mat Ne applipnt is a resident of Ifxliana and
owner I wntract buyer of the aforementirned properry on date appfication is filed. -
S�tl1re (owne/s fi� qan� Date (monN. daY. Yaa�
iuthp'sec by dWy exE
of aWaraed person
�na stree4 �1; s+ate. s+rtl LP m
of evw W IC G1.142-07
cry, stale,
Date (monfh. tlaY.
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