HomeMy WebLinkAboutMortgage_Coffman"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS o hi Year
__ FOR DEDUCTION FROM ASSESSED VALUATION �
Sfate Fwm 43709 (R71 / 649)
�' ,•„ � PrescnheE Dy Department of Lnral Govemrtrent Frarxe h n � �8 ��
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�NSrRUCnoNS:
Farm 0ed with:
To be filed in person w by mad with the CounryAuditw or Counry RecoNer o/ the oounry whe2 the property is locat ,
Fifing Dates: 7J Real PropeRy Must fJe during fhe year for which the deduction is soughL County Auditnr
2) Mo6ile /Manufactured Homes irot assessed as Real Property: Must file dunng the hreNe �f�� sCOU T U emder
6efore March 31 ot each year the deduction is sought. �%�
See reverse side for additional instnatbns and qualifications.
MP��L(��J�ercrno^OactDN'�'seercst�pnsm�f sitle)
Ass� vWue af real 7dpe
Mamh 1. a+m3 yrar
Ii rq, what is his I her e�ar�
nartie on
Name of mwtgagee a conuaU seAer
4�P�
-a � -i� -ctx, ,
�e / Contraa inCebted�ress unpaid a N
Addrea of mortgagee w wntracl seAer (nuMer aM sveeL �y. s+ate. aM ZIP aode)
slate,
ooes evW�m ox�, v�a�'i �o anr ane. I u yes..N,at w�my?
munryinlMiaru? ❑ Y�
❑ No
DeducGOn approveC in Ure amoun
20 _ 20
sigr�awre d co�ma ab�wr
+z���z��
H
�9a9e / Con�
date of appfication
someone oNer Can spouse,
Page
as o( Is Ne epp�ant the sole
Iegal w ewitade avneR
❑ Yes ❑ No
�vNi villom
is iM P�PertY in 9uestian: MnuaDy Assessetl
�al RoPeNY Q ?,!°walh' Asse��
d
Dra�ver 11'0...����
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Card i1'O. .... -/O� � ❑
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— 2�— � �— �I —
I I We certify unEer Ne penalry of perjury that the above aM frnegoing infortnalion is W e and mrrect and ihat the applipnt is a resident of Indiana aiW
owner f mntract buyer of ihe aforeme�rtioned property on date applicabon is filed.
y�awre (owne/s�il rame) Date (monm, daY. Yva�
fesiEent
state,
ezeCUteO Power W Attpney or by
S
Pddress ot autlroraed person (number arM sbeeL �; s+at& antl LP code)
DaIH (rtronfh. daY yea�