HomeMy WebLinkAboutMortgage_Memmer (5)"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun ip Year
__ , FOR DEDUCTION FROM ASSESSED VALUATION
� State Fwm 03709 (R71 / 6-09)
�' Preuti0e4 by DepartrneM of Loml GovemmerLL Fuance
� Fi
INSTRUCTIONS:
To 6e filed in person a by mail wifh the CounryA�ditor or Counry RecoNer o/ the county where fhe pmperty is located. F� �� ��
Filirg Dates: 1) Real Property: Must file dunrg the year /or which the deduction is sought �� ��p�
2) Mo6ile / Manufactuled Homes not assessed as Real P�opeAy: Must fi/e dunng the twelve (72) months
6efore March 37 of each year the deduction is snught ❑ �+� e�
GI SO
See reverse side tor adtliGOnal inshuctions arM qualifications.
App&anl ror buyer-see onre ide)
Ta ' Dis ' K r I legal d R numbu Page umDer
- / - - 03-���. SS-Da // o
�ahc poperty as d Mwtgage / Contrarl ude6tedr�s unpaid a W Mwtgage I Contrad iMehtetlnnss unGaid as d Is Me sPP�� tlu sde
IMad� 1, ammt Mard� 7. wrtmt Y� aate orappGption Q%%.rYv-. legal «equireEle vmren
.�7 /1 U a s ) n Yes n No
If ro, what fs his / her eraf2
narne m
Name of nnrtgagee ar mntraU seller
P�CenY in Vuestion: MmiaUyAs.cSUA
�I ProPe�Y ❑ M^ual�Y Attessed
Moble Home (IC 61.
Add(ess ot rtnr[gageP or mntrad se�er (num6ei ehd stree; tdy. Stae. aM ZIPCOde)
Name of assi�ee vWMf awner or MWer of morigage
cdy, slete. aM ZIP cotle)
.�—.. --"" vunty.� I VJhal Tadtg Disltict? I� rt�¢CU� 6een requested at O�nY
❑ Ye5 ❑
Drawer NO..�. p..� � . ':••
Card NO. ...o�.� �O. a.......
zo— � z° � z° � 2°—
Date (npnth. tlaY. Yea�
I/ We certify under Ne penaly oi perjury Nat the above and (oregang infortnalion is We antl cwre<Y arW Mat Me applinnt is a resident of IMiara aM
owner / contraU buyer of the aforementioned D�rtY rn date applicalion is filed.
�naoue (owner5lu0 neme)%l _ Date (�m7h. daY lBa�
reef, dtl:
ny a�h �ewced rower oranorrier «M �c G7.1-1z-o-7
pCSd� (nurt102fd�ItlSbBBt,flfy,Std(B.eMLIYCOC¢) .
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