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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coum
__,_ � FOR DEDUCTION FROM ASSESSED VALUATION
• 51ate Fam C3709 (R71 / 6-09) �
�' y�a � Presaibed M DePanmeM of Lo�I Govemrtrent France
INSTRUCTIONS:
To be (ded in person or by mail wifh the CounryAuditor or Counry Recorder o/ the county where the pmperty is located.
Fifirg Dafes: i) Real Ploperty Must fde during Ne year for which the deduction is sought.
2) Mo6ile / Manufactu2d Homes rwt assessed as Real Property: Musf file d�nng the tweNe (72J months
6efore Adarcfr 37 of each year tAe deduction is sought.
See mverse side (or addi[ional insLUCf;�s and quali�cations.
Appl'�n� q�(�rnerprconvaU6�yxr-sea m2versesite)
_ �� a S�- /D� -
airtentyear
It name on rt,mtl ia C'itlerent Wn that of app6rant, triGUa[e bebw:
Name of rmrt�agee or contraC seller
nedr¢s ot morigayee «w�traa sea
w
Name of assi�ee w oNer owner or F
�re.
Aearess oi assi9�e (number end stmt a+Y• stata, and LP coee)
DOPS 8�1K2M OWII P�GenY Y12ny OfhP! I( yCS. wh2l IbUf1IJ/T
ca,kY �� �naiana? ❑ No
❑ Yes
Dflduc6on app�w�.M u� Ne amount oE
T �s c,/��IIQ� n„eaor
�(i Recorder
' II -Qa-1 C� �
af Mongage I Confra�Y inEebtedness unpaiE az of Is Ne eppfrcant Ihe sde
Eale of appG�ation legal w equitade wmeY.�
�� �� ❑ Yes ❑ No
N owned vnN someo(re o4w1
AUDITOR
Is Ihe P�VertY in Ouestion: MnuaDy Assessetl
❑ Real Propeity ❑ NmualyAssessed
AloGle Hame fIC 61.
Dra���cr NO.,,��,Q.�9.........
Card NO. .. p�y `5.........
�,�.C'�, �55,cm.�/
20 _ 20 20 _ 20 _ 20 _ 20 _ 20 _
irarirte of Caunb AuCimr Counb Date (monN. daY. Y��
I/ We certify under fhe penalry of perjury that ihe above and foregoing infortnalion is we and mrtect arid Nat the applipnt is a resident of IrWiana and
owner / mntract buyer of the afaemerrtioned property on date applicatlon is filed. �
nunue Iox�rrerY NO oamel Date (monM, daY. yea�
FWI RsiOent a0tlmss o/ appGmnt (numDerand sbeeC dry, sfate. antl Z1P rn
�blu� w tisps Gwe� cv;lle �iV 4�6G�
Pefson auNmaed Gy dWy exew:etl Power dAitomey or by IC G7.1-12-0.7
Pddress of authortreC prlson (number aM sbee; riry, state, and LP mde)
�r. rea�