HomeMy WebLinkAboutMortgage_Cooper (5)"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun shi ar
__ ; FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R11 / 6-09)
S�u. PrewibeE Gy DeP��N of Laml Gorernment Fi�w¢c
�STRUCTIONS: ��
io be filed in FO11 ��"
person w by mail with the CountyAUditor or County Recoide� oI the counry where the property is located. C �
F�7irg Dates: 1� Real Pmperty: Must file during the year for which the deduction is soughL Qm"C��}�Udi�
2) Mobde / Manufactured Homes rrot assessed as Real Pmperty Must file dunng the tweNe (12) months \\ �\ .
6efae MarcA 31 0l each year the dedurlion is woght G IB ON �UNTY Y����r ef
See reverse side lor addi�ional ins�ructions alM quali�catbns.
Ap rwcanhac�uyer-yy�erestr�nsmreverseside)
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asessed vawe ar real popgty as a nbrcgage � cono-sa indnb
Ma�di 7. amnl year Mar� t. wrtent year
If ro. wha� a his ! her erad share of interest?
If name m remN is Gifrerent Nan Nat af appGpn2, mCirate bebw
Name of mort�agee or mntrarl seller ��%� �
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Pddress of frortgagee or oontrad seJler (nvmber and 5Lee4 . slate, and i
Name o( assi�ee or otlrer owner w halder o( mwtgage
ACdresso(aaignee(numberaMStree4�Y.slate,endZ/Pmde�--� /�.,/
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Does appli2nt oxn ynperty in any ofher If yes, what munt/+
munry in IMana?
❑ Yes ❑ No
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U U�• / �' Q� �P Recad G�� P�e n� /
aid as of Mortgage / ContraiY " ebteAness unpai0 as W Is Me aPplipnt the sde
date of aPP���+ kgal or ewirade oxnM
Q �, � ❑ Yes ❑ No
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W�a1 Taring Distric[?
)UNTYAUDROR
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�vhwn
ie property in Questim: MnuaOy AssesuW
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Dra���er NO..Q.�.��. I..........
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I I We cert'rfy under Ue penalry of perjury Ittat Ne above and foregoing in(ortnation is true and CorreCt arW Nat Me appliqnt is a resident of IrWiana and
amer I contract buyer of ihe aforementloned property on date application is filed.
� tu (o�me/s fiN nam� n � Dale (rm�rh. daY. Yaa�)
sfate,
Person auRnr�E Gy tlWy exewtetl Power af Alfomey rn by IC 61.1-f2-0.7
P4tlr�s of autharsed persori (number aId suee4 dly. sbfe. arM LP m0e)
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