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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS T s'p Year
FOR DEDUCTION FROM ASSESSED VALUATION
� � Sfata fortn 93709 (R17 / frW) ✓
1 y�. Presaibetl q' OeParlmeM o1 Local GovemmeM Fi�ance �
F� ��q11U
INSTRUCTIONS: S F�p��:
To be filed in person a by mad with fhe CountyAudhor or Counry Recader o/ the county where the propeM is located.
Frlhg Dafes: 7 J Real Property: Must fife rluring fhe yaar for which fhe deduclion is wughL .— �/,Cp(�niv quditor
2) Mobde / Manufactuied Hanes not assessed as Real Property Must Ae during the lweNe (72) rtanMs 6 �""'
6efore March 37 of each year the deducfion is sought �Id�
ql�q0 NTY
See reverse side 7or additional instnictlons and qualfications.
MP��� (owrrer m mrnrdct Auyer- sse msbicto� m re.erse sde) c--
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rtpage / ContraR IMehteEness uMaid as d Mortgage / Contraa
ud� 7, artm[ year date of appOCation
5 tus I her r>aG share W intrlr_st?
tl name m rcmd'n QAfemnt than Mat of appkant, 6Mi� bebw:
Nartre af
�a
or oNer owner or halder of marcga9e
AAGress of asagnea (number and stree4 �: sfefe, antl
Dpey a�pfi�nt wm poperry in any oNc
munry m InCiara? � ..
at:
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cdy. smfe. arW LP cod[
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CO
I/ We certify urWu the penalry of perjury that Ne above and foregoii
owner I contract buyer of the a(oremerrtioned property on date appli
dp; s1are, ar�d
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Person authoraed Cy Ouly ezecuted Pawer
P4tlms of aWiomed pr�sm (number arN svee4 �: ��. � LP mde)
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Rxad numbg I Pa9e rvm�ba
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Yes ❑ NO
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steO m P�PP+�Y
Yes ❑ No
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