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ry� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ FOR DEDUCTION FROM ASSESSED VALUATION
� State Form 93709 (R71 / 609)
�' �«. � Prgaibetl by DePartmeM of Lxal Govemmeril Finance
I
INS7RUCT10NS: �t� I Fiqtinp
To be filed in person or by mail with the Counry Auditor or Counry Recorder ot the counry where the p�operty is lor,�� 1 Y [ 11 I I���
FiRrg Dales: 1) Real Property: Must file durirg the year (or which the deduction is sought � C�unty Auditor
2) Mo6Ae / Manutedured Homes rat assessed as Real Prtiperty: Must file dunng the M1veNe (72) �wntlJ
before Maich 31 of each year the deduction is sought. County Recordu
See reverse side (or additional instructions end qualilcations.
Aookamlounaiormntrartbuver-seensUi�o2sonrev¢rsesidel � i n • _
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fi,a+mrtl�ar
tt ro. what Is ha I her eraa share OI intnlrst?
If rwre m rem�d a 63eRnt tlran tha[ of appi
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�.a3-oD/. �38-0 �. �`°'�` aa`�'
R'uNebteEness unpaid as af Mortgaqe / Crntra� cdehtednns� �mpaitl a d Is Ne appGmnt Ne sde
P°• Eate of appfication legal or equila6le v.meYt
Q � ❑ Yes ❑ No
rc awne0 wiN sameone othm than spouse. udkate wtth whan
Is peliy in Quesoon: MnueOy Assessed
Real Property Q MnuallyAssessed
Name a mortvasee a mnvaa sN�er �/�
Pddress o( rtiwtga9�s or mnbaG sWU (nunWer aM sheet, ciN• state.
Name o1 assignee or oNer owner ar halder ot morigage
AdCress f asvgnea (number eM stree4 �}: slafe. aM ZIP mCe)
�`� %�—� 3 / /
Dces appfinnt own pnperty in any oNer If yes, wfiat m
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sy�n�
1/We
owne`
Sg�anue
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1 ryT ' Yl�—r]
under the penalry of
act buver of Ne afor
Pefsm aufM�'ve0 by CWj erewied
Address of autliaraed pe�sm (num
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streeG �: sm�e. arM
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�regoing informalion is we and cor
application is filed.
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