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"�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun o ship
___ : FOR DEDUCTION FROM ASSESSED VALUATION
• State Fortn d3709 (R11/6-09) '
�' �� PreWib¢tl by DepartmeM otLOCaI Govemmenl Frence
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wsrRUCnoNS:
To be fried in rson a b mail wifh fhe Coun Auditor or Coun Recorder o/ the coun where the F� �
ae r h b N r�aenr ��oca�ed.
Fitirg Dates: 1) Real Property Must file duriig Ne year tor which the deduction is wught. � Cou A r
2) Mobde /Manu(actured Homes rrot assessed as Real Property Must file dunng the hveHe (12) months GI O�OI t�ax��jt
6efore Ma�ch 31 of each year the deduction is sought.
See 2verse side 7or additional instructions arM qualfications.
anr�r�nt faMwi �rmnvactbuwr- see rcsfycfions m 2verse si1911 , li �. — i � /� •
Asesse0 veWe af mal pfape�:Y a d
Mamh 1, ament Year
If no. whal is his / trer e�G share of'v
If name on �em�d s Eifrerent Nan Nat
artre ot rtaRgagee w contract se4er
Addrea of mort9a9ce w contrad se�i
Name ol "gnee w athrl owner ar h
AGtlress of assgnce (number arM atre
Does epplimnt wm paperty in any W
munry in Intlaw? ❑ Ye5
Deauctim appfoved In ihe amaunt ol:
zo
Syrature
—oiv ^w v-.�
o�(qage / Conbaa'uWeOted�s unpaid az ot Mwt9age I
Mard� 1, wrtent yrsr date ot apF
�? H ovrtred wiN mrneo
aPP�^L �dinte Eebw:
Q / �
� �J
nd sLeel, cdy, sta2e. aM LP coda)
^r ot rrortga9e
rdy, stale, aM ZIP mde)
tl ye5. nfia[
No
zo _ � zo
Record numbu Page u
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�s unpaid a of Is Ne app0�ant the sole
legal or eQuttable owne/?
❑ Yes ❑ No
:. Gdicate wiN whom
prop¢rty in Qu¢snpn: Mnually AssesSeA
eal P(operty ❑ AMUally Pssessed . . .
Tad(g D'stricl7 Has Ihe deduction Eeen reque=+^^ �
COUNTYAUDROR
20_
Caunry
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I I We certify under Ne penalry of perjury Nat lhe above and foregoing infortnalion is We and mrtec[ arW that fhe applirant is a resident of t�iana aM
owner I contract buyer of the aforementioned property on date applicalion is filed.
3n��1// imeLG� � Date (rrnnlh. daY. YYa�
autho�¢ed Ey CWy executetl
person
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�er M AttorneY a M IC Gi.t-12�.7
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Date (monN,