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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Court
__ ; FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Fortn 43709 (R11 / 6-09)
� y,� � PmsaiGed �y DepartmeM of Lxal Govemmanl Firiance '
INSTRUCTIONS:
7o be filed in person or by mail with the CounryAUditor or Counry Recortier o/ the county whe�e the property is located.
Fring Dates: 1) Real Property: Must file during Ne year for which the detluclion is sought.
2) Mo6i7e / Manulactured Homes not assessed as Real Property: Must h7e d�nng the Iwehre (12) months
before March 37 0/ eacA year Ne deduction is sought.
See reverse side for additional insVUCtbns erM qualiflcafions.
ApqrcantS orq� b r-sqe mny� siee) GIE
lil°�`i�ila_ � f �/��efr�C�. n„ rQn
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MMh 1, amnt year
rc m. wna� � ns i t� �a � or mferesca
tl name m rerntl o d0:erent Nan Nat W appl
mor10agee or mntraa se9er �
of mxtgagce or mntrad seDer (numbar
Y [� lc�c�,a�m�
❑ Counry Recorder
,,�-��3�.3 -aao. 3! ��a� � j l�
ge/ Contraa Irdebtedness unpaid as N Mortgage I Contracl iMe6teEness unpaW a of la
1,airtentyrar dateotap�tion k
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tt awnad wkh someane oUier than sW�+se. Nd'�Se wfih whar
name m asvgnee or omer ovmer or'mwer m morcgage
�a� o� �� i��� e� �t
Daes applimnt wm property in any oNe�
No
Oetluctlon approved'v� tlre amount ot
rify, stete. aM LP cada)���`'�—
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D1':1�\'CC 1�0........
Card NO. ...c�..�J,!i„��.........
AUDITOR
Pmenumbv
\'�7��iC]
poperty in Questiav MnueDy PSSe55e0
al Proaerfi ❑ Mnually As�ed
Modle Fiane fIC 6
Mas Ih's dMUGim Eeen reGU�tetl m 7ropenY
K �l.11 ^ ^ . /cT Por artent YeaR ❑ Yes ❑
lN� v v
_ _..�. � r AUOROR
20 _ 20 _ 20 _ 20 _ 20 20 _ 20 _
�faaMe o( Camb AuOitor Camry Date (month. daY. Y��
I/ We certify under the penatty of perjury that the above and toregoing in(ortnatlon is We and cortect aM thal the applirant is a resident of IrWiaria and
owner I mntrad buyer ot Ne aForementioned property on date aPpfxation is f0ed.
ntaene (oxnafs !� namel .. . Date (rtmtl1. daY. Y�/)
iCent aOCress d appfimnt (numbe� stree4 �: sbta. and ZIP oode)
o s s. w;<�, .� s� Fb.,-�.,�� � �
autfpml.M by duly ezew:etl Power o( Atlbney w Oy IC E1.7-12-0.7
s of auUqrtred person (number arM s�eet �: sfeta. eM ZIP coEe)
Date (monW. tlay Y�A