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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
s FOR DEDUCTION FROM ASSESSED VALUATION
• State Fwm 93709 (R11 / 6-09)
♦ l PresQibed by Departmerd af Loml Govemment Fuance
INSTRUCT10N5:
To 6e filed in M � '1
person w 6y maii wifh tlre CountyAuditor or Counry Recorder o( fhe counry where the property is located.
Fifirg Dates: 1) Real Pmperty: Must file dun�g fhe year for which the deducfion is sought unry Auditnr
2) Mo6ile / Manulectured Homes rwt assessed as Real Properry: Must file dunng the nvelve (12) months
6ePore March 31 0/ each year the deduction is sought. C� � nry Recorder
See reverse sFde (a adtlifional insVUClions and qualificafions.
An t fowrer or cont�U bwe� see restrictio� mhverse sitlal //1 R
'w�g Distri Ke)*wm5er / leryal desaiP� ' / Remrtl numbc Page numbrl
� ala-l`l-/8- 30 _oo�. �oS-o�-6 a-orl Y8
airh 1, anrnt Y� �Y as W 'MORgage��tra� ebtedness unpaid az of Oet�e of aPPlication uWehted�ress un7aid as d I�I a eWitaWe owneR
rd�
�%� D� ❑Yes ❑No
ro. what k h"s / her e�aU share of intrlestt tl avmed wiM somea�re ather ihan spausa� uWwate with whom
(wrie m
6Widte
perty in quesUOn: MnuaDy AssesuE
�� pr�,�iyn�a
Name of rt¢xig2g¢¢ d � tl sel�� '. - - - . . _ _ . " ' ._ - _ _' ' ' ' ___ _ _' _ '
�.% /�
AOdress of rtnrtgagee n contra (nuMer end sbe� 1\� F---V ` V, \`!1 __ �7/ �/
.LJ �v Jl./l/ � I / �N /�� ��
Name W assignee or oNer ow�er rn holder af mortgage
PilE�ess o( assign (numberaM sveet mY. state. and � ��/ /� A/ (/ �
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Dces eppti nt orm property in any oNer
oouiuyinlnaana? ❑ Yes ❑ No
Dr�umon aGW� In tln amount oF:
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I/ We certify undes the
avmer I ntrad buyer �
7faL�rei. rshNname)
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Ihat I
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aa�e ayµ...c.........
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prJmn (number aM sbeet cGy, sfa[e. arq LP mde)
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