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"' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS 7o Year
_, FOR DEDUCTION FROM ASSESSED VALUATION
• StateFwm43709IR11/6-W)
�,�,� j Presvibed by DeP��ttl a( Laal Gavemme�rt Firence -
File Mark
INSTRUCTIONS: � �
To 6e h7ed in person w by mail wiM the CountyAuditor or Counry Recoider of the counry where the property is located. �
Fifiny Dates: i) Real PropeRy: Must file dunrrg Ne yaar /or which the tleducfion is soughL � � ly q�d�
2J Mobde / ManufaGUred Homes iwt assessed as Real Prt�perty: Must fiie dunng the tweHe (12) mon[hs � Ja� �
befora March 31 of each year the deduclion rs sayht. . Recorde�
v
See �everse side (oraddilional insfixtbns and qualfications. GIBSO� �
MO�Siq�erorcantrarl6u/y�-seerewicnonsmreversesid�w.�_.l'M _ I L �l�ii?/k�Q��
��e/�i �7����n.0. �
T���,�,�I a�
Assessed vapie af re� P�oPerty as d
kerch i, a+m�tl year
rc no, wna� Ls ria � nu e�aa stwre or inrerest?
It name m 2md is NRe2nt Nan Ihat U appl
Nartm af rturt9egee «cmtract se9er
Mdrea of rtnrtgegee w mntrad se�er (nun
Does aPplimnt ov.n propeM1y in any oNer
Wuky ui ItqOne?
❑ Yes ❑ No
Detluc9on aOWV+eC in Ure
�
Sg�nae d Ca�mb AuOimr
,7-d�T-'!UU -UU/,
rtgage / Contract'udebledness unpaid as
rt� 7, wrtent ypar
/ 00 (�
If rn
ikate oemw-
shae; city, fe. aM LP oode)
-o o ......._...D r U� w� 9 i�
ge / Con�act'v�tlebtetlness unpaid a d U Ne appBrant Ne sde
' appOmtion legal a epuitade o�meR
❑ Yes ❑ No
spouse, IMkate with whom
Is Ne property in 9ue5tian: MrwaDy AssesuM
❑ Real ProPertY Q Mnua1�Y.Assessed
antl LP mtl�
s a`f-a-9 a.00 �G
If yes. �Met CounlyT VYhat Ted�g Distrirl7 H
�_ i �_ i Zo
_ _—_ _ — _' -
_ _'
�` aoro
n�-a������ �ro ...................
Ca►•d NO. .....��1.�......
� � � �5�y. a�
i I We certify urdu the penalry of perjury that Ne above arW foregoing infwmation is We an
owner /FOnY�ict bWler ot Ne aforementioned property on date appiication is filed.
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person (numDer aM sheet �fi: ��. � LP cade)
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