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r� STATEMENT OF MORTGAGE OR CONTRqCT IIvD SS
FOR DEDUCTION FROM ASSESSED VALUATIG Townsnip �
x�� ^,'�,� Slate Form 43709 (R71 / 6-09) —
�°� �� Prascrlbetl by Oeparmenc o: Local Govem�r,enl Flnance - _ . �
INSTRUCTIONS: . AI I!? 0��O�O ' File Mark
To be fifedln person orbymalL «���'�
FilingDates: 1)RealPiopeifyMusfbecompletedanddaledlnlhewlenda�yea�fo�w thede udlnlssoaghL, Fortn;Jedwl;h; .
Must 6e filed w(;h fhe CountyAudita�orCountyRecordero; thacounN�� � � Counyquditor �
on o� befoie January 5 0/ Ihe fmmedfztelysucceeding calenda� yeai
2)Mo6ile/ManufacturedNomesnolassessedasP,ealProperty:MustlileGlbSOflC0Uf1(yR@COfd2f � Coun:yRecorder
_ county whera the pmperty ls loca(ed dunng the hvelve (12J months b�
deducfion is sovgh:. - . - ��
See �everse s/de for addlUonallnstrvctions and quali(ca�lons. - �
AppOwnt (awne� w confrecf�rye�- see lastncfians an mw.:e .;d.�
av vaiuea�rea� prop�y as ot
Mzrchl,cu;rentyear �
If no, wha[ Is Ns / her axact share o(
If nama an record Is tliflamnl Ihan lh��
Name ot asslgnee
r � �r�- t�1). L`�
owneror�oltlerofmotlgage
erendsUee„ Uty, s(ala, end
�aes appll�ane ovm pmperty in eny
wuntylnlndlana7 ,—,
cu;rentyear
ZlPcode)
I'yes, what munry7
o;
VJhat7�ing
someone
c�an approved In Ihe amounl oY. ,
zo_ zo_ zo_ zo za
� Slgnamre
I/We
owner
underthe
e�Nvrizetl by tluly ezecutaC
i of auNOrheC person (num
esa unpala as af Is Iha apppmnt Iha aale
�Q ' IaB� o�r eXqula6le owneR
iy Yes ❑ No
e. Indlwte with v+qom
D�Pertylnques;lan:AnnualtyAssassed .
:alYmperty �qru�va(IyASSessed -
Has Nls deductlon baen reqvesled on property.
for cwrent year! � _ �
— _ zo _ zo
Counry - . OaL-{monfh.4ey. yea� .
of perjury that Ihe above and fioragol,�g infomatlon Is uue and correU anC ;hat iha applirzr,t.s a�resideni ci inc!ena anC
o'e entianed proparty on date applicaUOn is f1e0. � _
Uate (manN�,day, year)
:1ty, sta(e, and
ar bylC 6-7.1�
slaf¢, andLf
Da:e (monlh, day, year)