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^� STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
_ ; FOR DEDUCTION FROM ASSESSED VALUATION
Smte Fwm 43709 (R71 / 609)
�' f Presaibed by �ePartmenl M Local Gwemmenl Firance
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i�si'.�`i� � s ��,
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INSTRUCTIONS:
To be (led in person w 6y mail with fhe CountyAUditw or Counry Recorder o( the county where the property is located. C�7
F7irg Dates: 7J Real Property: Must file during the year (or which the deduction is sought q� i��
2) Mo6�7e / Manufactured Hanes not assessed as Real Property Must file dunrrg the hvelve (t 2) months p�T( pl OK
6e/ora March 37 oleacA year the deduction is sougAt. G�gSON D�L'J �nty Remrder �/
See reverse side lo� adtlitional ipst���s and puali�cafions.
PW�`/
If rm. what is h's / her exafY
Keyrwmber/legal tpn
'� / 9-�9 - a�
Mortgage / Contraa' ebtedness unpai0 az ot MMgage I ContraU indebte0ness unpaiE as of Is ihe eppbranl Ne sde
Mamh 1, artent �/� DO ^ aate of aDP�� kgal O ede owne(.�
U ❑ NO
If name m recdd "s dAfuent than that o( aDP�ant, u�Gicate Eebw.
Name of rtprtgagee ar mnux{ s¢qer
ana�
�
w contrad seAer (num6er and sneeG ray. 5afe, aM LP code)
C L � ��06t, SNet.Ill- �2
D�- 8 v��
wiM wmeone other than spouse, iMimte wBh whom
wna� r�rg oao-kcz
Is me OrovertY in auestion: MnuaM Assessed
❑ Real RoPeKY ❑'M��a�YA�e�
Fias t�s tleauclwn Deen reqursteU m propsty
for cvnent yea(.+
❑ Yes ❑ No