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"' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS cou o ear
__ ,= FOR DEDUCTION FROM ASSESSED VALUATION
� Sfate Fwm 43709 (R71 / 6-09)
�' ,�,� � Presaibed by �eDaRmenl 01 Local Govemment Frmnce
File Ma
INSTRUCTIONS: C
To 6e filed in person w by mail with fhe CountyAUditor or Counry Reoorder o! the county where the prope�ty is located.
Fr7irg Dates: 7) Real PmpeRy: Must (�le dunng the year (or which the deduction is sought. u udimr
2) Mobde /Manulac2red Homes not assessed as Real Prtiperfy: Must fi7e dunng the fwelve (72) mori�.�SO C Y�U I��
before March 37 0/ each year the deduction is sought. n er
See ieverse side for additional instrucUons arM qualificafions.
what a his / her e<aG share ot interest?
If narne on �eowtl a CiRuent Nan ihat ot applicant uMifa[e 6ebw:
Name or rt�jgagee n
/1/1 / /1' Rem� Ober Pape n � � `_
/1
W C/ LJ
unpaid as o( Mor�qaga I Conbaa'ud ess unpaid as d Is Ne appkanf Ne sale
date of appGration legal w epuitade owfreR
❑ Yes ❑ No
If owned with someone other than spouse, indiqte w�h whom
seller (nurtiber and stree( ciry. sfale. aM ZIP crotle)
Na�rie of a"'�nee or aNer owner or halAer of mortgage
AEdress of assignec (number arM 5tree4 �1: slete, antl ZIP cade)
Is tM property in puestion: Mnually AssesuW
�'Rea� afovero ❑ Nmuanyassessed
Drawer \O...o��1\.........
any oMer IfYes. whatcounq/.� Wha l�ii �-� ,ro. .....aa�b ....... n P�
�- ❑ No
Yes ❑ No O.`
�Q '�'`�T,�' \J
`Y. �J ��
cGOn apprrned'u� tlre amounl oF.
20 20
rtu�e W CoiaiH A�Witor
COUNTY AUD.. _..
20 _ 20 20
Counry
20 20
Date (morvh. tlay. Yea�
I/ We certify untler ihe penalry of peryury that Ne above aM foregoing infwmation is We and cortect and Nat Me applipnt is a resident o( IrWiara aM
owner / contrad buyer ot ihe aforemenlioned property on date application is filed.
p���ry � I�/�—
resitlem atltlre� of appfrant (iwmbe� antl sbcet, dry, state, and
_ ��/ZO �. Da� ,Q.a�y�2 �S/
�on aulha¢eC by Culy ezewted Power of y m Cy IC G7.1
person (number aM sheet tdy. Stdle. antl ZIP ootle)
�j
Date (rronCi. daY. Ya�
o�e �rt,aun, dar. r�