HomeMy WebLinkAboutMortgage_Kelsey "-":11;.,:?::, STATEMENT OF MORTGAGE OR CONTRAL N@E T '!1- illi County Township Year
FOR DEDUCTION FROM ASSESSED VALUUU/�AATTTIdddkkk
r,,,,�-'- State Farm 43709(R11/6-09) •_•
j s Presmbed by Department of Local Government Finance
FEB 5 2013
ill File Mark
INSTRUCTIONS: • •,
^11!%r. Form filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the co I , r• 111.1171t rty is o ated.
Filing Dates: 1) Real Property Must file during the year for which the deduction iss$•LG a gboTY AUDIT OK unty Auditor
2)Mobile/Manufactured Homes not assessed as Real Propeltaw�! •LfVfg the twelve(12)months
ry Recorder
before March 31 of each year the deduction is sought County
See reverse side for additional instructions and qualifications,rse Ap- coritract b see n�e�I(. YO& c �2� /) _
T ' us ct Key /leg deswiptbn �`�',`('�"p°n,/r//J-r•-,7_ Record number Page nrgib ow _,l/a -you-co/• �i/o /3
Assessed valued real property es of Mortgage/Con tedness unpaid as of Mortgage/Contract Indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,arrtrnl date of application legal or equitable Amer?
J 150� ❑ Yes ❑ No
If no.what Is his I her exact share of interest? / If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant Indicate below. Is the property hu question:Annually Assessed
❑Real Property ❑Annually Assessed
Name of mortgagee or contras seller ,1i
Mobile Home QC 6-1.1-7)•
�.-�, a � `Yl
Address of mortgagee or centred sager(number and sheet city,seta,and ZIP code)
aSili
keLsey int Pal
I3- %. county? What Taring District? Has this deduction been requested on property
for anent year? ❑ Yes
❑ No
COUNTY AUDITOR
Dalucbon approved in the amount of:
20 20 20 7r 20 20 20 20
Signature of N/ d•r County Date(month,day,year)
•I f ce • under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
Amer I contract buyer of the aforementioned property on date application is filed.
Signature(owner's NY name) 1 Date(month,day.year)
.u1, �1 gd�,l
F�dlresident address of appacan, nu card aTy.state,end ZIP rode)
resident
y33 S . ��rfn frl1ny+Cl-nl0 IA) U1 (P70
Person authorized by duly exec• Power y or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
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