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'°� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ FOR DEDUCTION FROM ASSESSED VALUATION
State Farm 43709 (R71 / 6-09)
, � PresaibeE M�PartmeM of Lxal Govemment Finance
"° a
wsrRUCnoNS: ma1w�
b 6e filed in person or by mail with fhe CountyAutliror or Counry Recorder of the counry where Ihe property is located. � V J� Z � � �
FiNrg Dates: 7J Real Proparty: Must fde dunrrg Ne year lor whirh the deduction is soughG � Counry Auditur
2) Mo6ile / Manu/actured Homes not assessed as Real Property Must file dunrg the tweHe (12) monfhs
6efore Malch 37 0! each year the dedudion is soughG ��� �P� Remrder
See reversa side Ior additional instructions aM quelificat6on5.
MP�P� (dM�� or oontract buyar- see ievlicbons o{ryyerse side) •
Key nmba / legel desa
�/n'1�1_
eE rdWe d rcal pnpe�ty aa of
1, anent yPar
tl no. what Ls his / trer erarl
h�Cirate beb�r.
- 3 0 0-000. aoo - 0 7-
aa indrbtedness unpaid as d Mortgage / Con�ac['uMe
yeer „ tlateo(appfi�alion
mr�ga3ee «mnract seuer
oi rtphgagce or mntraU se�� (nunbe� and sbee[ �Y. smte.
Name of assignee v oNU ownar or halder o/ mortgage
AGCmss of astignee (number antl sfine; rity, state, anc
�d m���,��
k{/al a W�tade owne//
❑ Yes ❑ No
with wtwm
Dra�ver \TO.....�.�. �:.....
Cai•d \`O. ....:��.J........
� I_35; �oD
muMy inB�IM�a� � n Y �❑ No I Ir �, what munryt I what Ta�dn9 �isviu7 � for wnerv yea(' � O � ❑ No I