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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS C Year
; FOR DEDUCTION FROM ASSESSED VALUATION
� S�[eFOrmd3709(R71/6-09) QUG Q ZQQ9
S f Presmbed by Department ol Loral Govemment Flnance
File Mark
wsrrtucnoNS: �7( �
Fortn etiwith:
To be filed in person or by mail with !he CountyAuditor or Counry Recorder o7 fhe County whe2 Ihe poperty is bcated. V
Filirg Dates: 1) Real Properry: Must file durirnJ the year (or which the deduction is sought. G IBSON CO Tl'�6jL},FbQ�, q�d�
2) Ab6de / Manufactured Homes rwt assessed es Real Property.� Must file dudng the fweNe (72) months F�-�
6e/we March 31 ot each year Ne deduction is sougAt. ❑ Counry Remrder
See reverse side 7or additional insLucfions and qualificatrons.
Key iwm0er I legal dPSaipfion
a�-��-ay-aaa-
Av�ssed vdue d real prapaty az d I MoRg
MarU 7, artent year Marq
E
�i f10. W�12� 6 i16 ��Iff fYdQ 5�1319 Oi N!ERSi�
If name on remrtl is Cirterent Nan ihat ot appMan; Indit
Name o1 rtnrn,7agee n ❑ seDer
T��l�
Address ot rtartgagee ar mntra seJler (number end s0
Name ot assignea w oNer ownet or hdder af morigage
MC�s of assignee (numbar end sfreet �Y• stete. ena
Dces epqkant own praperty in any oNer
ooumY m trwana?
❑ Yes ❑ No
Dr�umon approved in Ihe amount oE
CantracTinCebteEness
���.
yes. what munt�/1
20 � 20 _ � 20
AuEibr
20
WIa1TauM
tgage I Con� mdebtedness unpaitl as of Is Ihe apd�t Me sole
: of appfrcation le9al w epuitaNe awnefi
❑ Yes ❑ No
mmeorre aher than spaise. Udimie wM whom
Is ihe pmperty in Question: MnuaM Atsessed
j��tea�Froperty ❑MnuaOyA�ssed
AbWle Hort�e QC 61.7-�
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D�-�„���-.o. a.�.�.........
3 �� I
CardNO . .....................
20 � 20
Date (month. daY• Y��
20
��o
I I We cerOfy under Ne penalry of perjury that [he above arW foregoing in(ortnaUon is true and cortect arid that the applirant is a resident of IrWiana arW
owner / mntraa buyer of Ne aforeme�rtioned property on date apP��hon is filed.
vawre fowneh 7v0 namel _ n Da� (^�°^�. �Y. Yme�
M1(num6er antl stree4 �4: �re. antl
<',PST .�7�4�P.5�✓L
auNOr�d Ey dWy exewtetl Power
person (num6u arW soae; ciry, state. anE ZIP code)
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