HomeMy WebLinkAboutMortgage_Fithian� � Evansv� i 11e �Ci�les p
d � STATEMEI�:T OF iJIORTGAGE OR CONTRqCT fI�DEBTE0NE55 C� To
� '��� FOR �EDUCTIOt�i FROM ASSESSED VALUATION P r
'�' sleta Farm 437a5 (Rit / 5-09)
r � Prasal6ed6y0epar}mento(Lnca�Gvvam�nenlFlnance � �� ' '
� INSTRUCT70N5: . 1 qp�./�p
Tobe(!)edlnpersonorbymail. � uUN L1J �Z���
Flling Dates: if RealPiope�}y; Musf be compleled znd da,edln lhe calenda�yeaffo�which �e deduc(!on')s sough , Form N�dwith; � ,
Musthe6ledwllhtheCountyAudirororGauntyRecortferofthesauntywherefhepropertylslow( J.
onorbeforeJanuary5ofthelmmedle(elysuccee�ingcalendafyear. ��tor �
� � 2) Mobda /Manv(acfv�ed Nomes nof assessedar R,eal Pmpei}y; Must �e wi(h 'he CountyAvdi,o� of GItiSO Ci�� �j����
, . county whem ;he propertyls /oca(eJ dudng the hyelve (f2) monfhs 6efore h.farsh 3iof eech yeartl�e�
� deducUon is sought.
See revelse slde foraddlOonellnsWct/ons and qvafifica[lons. � � �
AppOcant(owqe�wmnlnct vyp�_`eertsNcfivnsonrevers8sidel � �
/\-�. _� �
t tlnp0lstrlct _ Key�umb r/Je alde:
�� �-1�-1�-?
Assessedvalueafrva�p�pe�tyaso� Mortgage!
Marz:� i�airtnn; yeaf Mz� }. q
�( no, what Is his f har exaU sham c( �p�u�7
• If name oi rnwrd Is diRemnf Nan Iha( of app�iwnl, Ir.dlcata b�
� Nameo(r,iortgageeorwntra4se0e� �
, /���• of �qa�ee or wntractse6er (numberand sbaeL c
Na�e o{ eaalpnee or olhe� oH
Addaa v( ansignee (num6er
counly
e�or�oldero/mortpapa '
aCsbee( clty, sla/e, andLPrnde)
enyolher Ilyez,whatcounty7
Yes No
.. umucUon appmved N Iha xmounl of.
20 _ 20
SlgnaNre o(CounlyAUdllo�
I/ We ceN(y under the penaL o; p�
owner! ct erof[ e n
� � Slan �oWnel' , me}
. Fu resldenled a � nl(nvmbe�e
5
Persan authodzed by duly esecufed p�,yar i
.Addressa(eulhorkedperson (numbvand
20_
20
ipal�
owred
��l �
'hafShan ipouse, �ndlrate
20 __
as
a o1v��e•j'j'
❑ No
perty In qVeztlon: MnuellyAssas{ed
P�°Pery �AnnuallyAssecca�i
fcrcv.:entyeaYl
20
s�ea on ploperty,
�
Yes rl n
20
ymanm, aey, Y_�
th [ th bo and tor going mfor�etlon Is trve and cor,PU and Ihzt the appllcan[k a�reslden; o( Indlanz
nad property on da[e appllca�on Is 51ad. � .
sfale,
sta[e,
— � � � � � � U
i
Oate (mvnfh, day, yea�