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""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
FOR DEDUCTION FROM ASSESSED VALUATION �
$I�e Fam 43709 (R70 H7-08) Q
\ % �/
P(asaibed 7y DepaM�ent NLor� GwernmeN Fi�nw \
i
INSTRUC770NS: � FI8 Mark
To be filed in permn a by mad witl� the Cou�yAuditol d ifie county wheie the poper(y is bcated.
Flirg Dates: iJ Real PropeAy: Must ke dun�g the yee� (or which fhe deduction is so�ght.
2) Mobde / MarnAectured Homes not assessed es Real PropeRy: Must file tlunng tlre tweNe (12J mmUu be7ae Malch 3101 eadi year
the dedirt:tion is saighL
See reveise sitle !or/e�al instrudions and 4ualifice6ons ^` ' �/�
Appfiram (axna oontrac! -�ee msb�ians m�ovet4P � e) . . i.
atl vaiue W ieal properly as
1. artreN yBa
ro, wtut is hn I her exad shara d i�rasfl '
rama m recnd is d�era�ri lhan that of aOVGrain, iMimEe Celwr.
Pddrass d rtnrtgapee a
Name d auf8nea or oMer wrt�er a MEm d motiBaGe
nddrass ot assipnee (�wm6c
w
�a����
camymim�m�
OeOucfian appm+ed in �he a
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Sipnature d Courrty Auditw
��� aa0-eol• /$�-do26
tl udeblednass urrytitl es d Mortpaga / Confad indeMadnes
parl � � dale of appf�tion
J
I( ameE with someorre dher Ihan spouse,
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N_ � 20_
rn
un4eiE as d� Is �he a70�� Na sde
legal ar equGa�le ameR
❑ Yes ❑ No
Is tha WnGeM in aue5im: MnuaN'AUessed
❑ Real Pmperty Q Mnualy AssesseC
Mahik Hane QC 6
r�s m�s aad�a� �, �a�e�a o� m�ro
ror artrerrt r�n r-� .. r-�
N1 _ � 20 � 20
I! We certify under ihe penalty ot perjury that fhe above and (oregairg 'v�fortnation is true antl correG and �hat the applicant is a iesident af Indare and
owner 1 mntrad buyer of the aforementia�ed property on date apptiration is filed.
ss d appGtant (nuMara�d sboet, rify, �fi. aM
�t.�(� Qj^. �/� 1
oy euy ema,�ea ro«er d ummar or ey ic s-�.i�
:ed persan (nunbrl arW street, dty, sbfe, and Lf
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oa�a (�,�,rn, aar. r�A