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"^n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
r_ _, FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R71/6-09) a
�' w� Ptesfiibed Ey Departmertl a( ln�al Govemrtmnt Fuams �
i e Mark
INSTRUCTIONS:
Fi,a'L" eE%ii4S cu i..
To be filed in person w 6y ma0 with the CountyAUdifor or Counry Recader of the counry where the property is located.
Fiing Dates: 7) Real Property: Mus1 file during fhe year for which the deduction is soughG � County Audimr
2J Mo6Re /Manu/actured Homes not essessed as Real Property. Must file dunng fhe nvelve (f 2J months � ,,�/.:
be/ore AAamAi 31 of each year the deduGion is soughG ��.�-�W`����
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See �everse side for add'NOnal insvuctbns end qualilcations. _ _,.,,.,,., rnnNTY hUD�T�p
� 0" ' Key raanher! legal desaiWion Remcd number Page wm
G- P- -�- ao . _ aa� o�o .�o�
ed vahce aF � paperty as of Mortpa ge / Canbaa 4Ne6ted�ss unpaid az of Mongage I ConYact cidebteMess unpaid as d Is Ne appGont the sole
1. a�tl year Mert3i 1. artent Y�� date o( aVP��� // �vv�� lega� or eWilahle avmeYt
� �YD (�.CJ ❑ Yes ❑ No
If M. Wh2l IS h6 / h¢f EXdC Sh3I8 Of VISCf¢SlT
I( name m recortl is Eifle2nt Nan Nat of aPP��L NAicate bebw:
JL:�.!f.:�'''•-,:r
Mdress M mat9a9ce W
Name o( assgnee w oMer awner ar hdder ot mwigage
�N.
ACdress W assignee (number arN s1ree4 ary, s+ete, eM ZIP code)
Dce5 eppl'vant own rynperty in any oMu
munry in IMana? � ..
�— I �— I �—
tt owned wRh someone dher Ihan spotise. ifMim[e with whom
�Isy{{� propertyinQursOOn:MwaMASSessed
j�RealProPenY ❑!!�^�!�Y�
"- 3 -// �
Nas Nis detlu�p
far nufmt Yea(.�
COUNTYAUDROR
requestea m v�ocenY
❑ Yes ❑ No
20
D1'a\\'er NO..... ��.�........
,renae of Camb Autlbnr Coun
�ar NO.....�%4.�.��?....... —
I I We certity urber 1he penalty of perjury fhat the above ard foregoing intortnation LI via aM
owner I mntraU buyer of Ne atwementioned properry on date appiication is filed. �� �� Tb� �_ —�
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�re,
Ey tlWy ezew:etl Power af Attomey rn q
0¢5M (numOeiaM sfree4 �: sfafe.
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