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I, __________________________________________________ WISH TO CLAIM SURPLUS ON THE
FOLLOWING PROPERTY:
ADDRESS:
___________________________________________________________
___________________________________________________________
DATE SOLD:
_______________________________
SIGNED:
____________________________________________________________
DATE:
_______________________________
STATE OF INDIANA
COUNTY OF VANDERBURGH
)
) SS
)
Before me, a Notary Public, in and for the State of Indiana, personally appeared
_______________________________________, who acknowledged the execution of the foregoing
claim, and who having been duly sworn, states that any representations therein contained are true.
Witness my hand and Notarial Seal this _________ day of ________________, _________.
Date
Month
Year
My Commission Expires: _______________________.
_______________________________________
NOTARY PUBLIC
Printed Name: ___________________________
County of Residence: _____________________