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""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
_ , FOR DEDUCTION FROM ASSESSED VALUATION
$fate Fwm C3709 (R71 / 609)
,' Presm'betl Oy Department of l.ocai Govemment Fumnca
wr
wsrRUCnoNS:
To 6e filed in person or by mail with the CountyAUditw or Counry Recorder o/ the county whele the pmperty is located. �
Frtirg Dafes: 1) Real Property Must fiJe dunrg fhe year Ior which the deduclion is sought. � O,,q�d�
2) Mobde / Manufettured Homes irot assessed as Real Prt�peAy: Must h7e d�nng the fweNe (72) months ❑
6etoia March 37 of each year the daduction is swght C un Recorder
See /everse side for additional insfructlrns and quali�cations.
I noe[vnt (owrer ar mwau bwrr-.�e iestrir�or�t m lewrse sifa) n OR
. � �,�c..�2
ia Key nunbel / k9al dewiption
� a� -�a -os- yoo- �o . y �-o
A�sed raqie cf real V WenY a N A1ort�ag e/ Contract intleWedness unPaid az W Mortgage I ConYan
MmUi 1. a�rnnt year A1emh 1. aiJ�v� Cate of eppfxafion
/ �-�O, 00[7
tt ro, what ls tris I Irer eucT sAare O( L
tt name m recwC B 6rteratl V�an Ma�
Name of rnortgagm «mntrari se0er
or tontraa se0u (nunDrJ ard sbaeG �y. atate. ard LP cade)
w athn oxnet or holder d mort9x9e
MarPSS o/ astigrree (numDer eM aLee4 �}: state.
Daev a�nt own O�P�Y in arry aner
counry in In0'mna? ❑ Yes I
Deauction apptoued'e� tlm amowu af:
20 20
Si9'qture d Coimb Auditnr
I I We certify u Ne penalty of p
ownerlcontraG uyer N
(o
�
up ' ent atlGrs o 0 nt ( 6e �
� � �
a by Euh e<ewre0 Powel
.00Eren of authorveA persm (num0e! ark
�:u:s:�::
i o � �-SG f3
� d �s Ihe aVd�t the sde
k9al «equiratle ow�rert
❑ Yes ❑ No
wiCi MTrnn
h the property in pueSDd[ MnuaOy Assessed
�kea�Pmrerry ❑?+muaM�
�,��, OT S 5 E $-�- -1 O � 9 9 /9-
If yes. whal murLL�? What Ta�drg D'striclT Has N's dM+�m Eaen requeste0 a+ Woperty
���� ❑ Yes ❑ No
COUNTYAUDROR
�iC/��'o��, ��sNuA�(''.S
20 20 20 � "��� `J
Caunry
that the above and foregoing infortnadon is true and can
ned property on date applicatlon is filed.
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