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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun sh
__ POR DEDUCTION FROM ASSESSED VALUATION
� � Stdte Fortn 03709 (R17/6-W)
�' ,,,, Prewibea q DeparVnartl oi Lom Grnemmem Fuw�ce
iNSrnucnoNS: OFL�T `k5 2010
Fortn Ned whh:
To be filed in person a by mati witlr the County Audhor ol Counry Recortier o/ fhe counry where the poperry is bcated.
Filing Dates: 1) Real Property: Must file durirg the year fol which Ne deduction is soughG �C�ud'rtor
2) Mob�e / ManWactured Homes not assessed as Real Propeny Must fife dunng fhe hvehre (12) months �� �d�
belore March 37 0/ each year fhe dedu�ion is sought.
GIB
See 2verse side for addrfionel insLUCtions and qualfiptbns.
M ( rormntrau�Wef',389F�"�O^P9"reve;seside) n
AsesscH vWUe d real {ivdcrcy as d
Msmh 1. amm yPar V
If rw. whai Is h'a / Aer uxc share of intrlest?
If narne m 2wn1's 6rterast Man Nat
Name N rtnrtgagea o�
of assignee w other wmtt or Imlder of mM9a9e
(numhererd sLee4 �Y. �e�
Does appimnt oM+� wopeml � eny
munp' m I!M-ena? r-� ..
desmption
— S— 0�— c
ae / Coniraa intlebtedness
� ffi�.
iF yes, what munt�?
�
WtatTadM D'stric
other U�an
Inumbrl Pagerw
6 G �
Is Me app0ont Ma sde
legal a eQUireHa ownel+
I ❑ Yes ❑ No
h tl�e pmpatY in 0�+�: M�aa9Y Assessed
❑ Real P�opMY ❑ ArmuallY Assessed
Moble Flane OC 6
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