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°"� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
_ : FOR DEDUCTION FROM ASSESSED VALUATION
� State Fortn 43709 (R11 / 6W)
,,,,. Prgoibetl by Deparvne�rt of Lotal Govemmenl Fitwice
INSTRUCTIONS:
To be filed in person or by mail wifh Ihe CounryAuditor or Counry Recorder of the county where the piopeRy is located.
Fitirg Dates: i) Real Pmperty: Must file duri�g the year for which the derluction is sough[ D E
2) Mo6ile /ManWaUUmd Homes rat assessed as Real P`operfy Must fi7e dunng fhe M1velve (72) months
be(ore MamJr 31 07 each year the deduclion is sought.
See 2verse siCe for additional inshuclions arM qual�ications.
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aaintlebtetlriess
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It name m recortl n EiRe�ft than (hal of app&ant. 6Mitate Debw:
Name o( rtnrtBa9� a contraa seDu
Address of rtartgagce w oontracl sW
Addmss of assig�e (number eid snee4 dry. s7ele, eM LP cotle)
Dces a�nt own property in any othei If yes, what county?
Cq1IMJYllIld0113� ❑ i�ES
❑ No
F!:I" i^� �:;
W�at Taring D'atriri?
DeEucrion apprweE in ihe amount of.
20 20 _ 20 _ 20 2b
Sig�aWre of Camy AudP,w Counry
I/ We certify under the penalty of perjury that Ne above and toregoing infortnalion is W e and cortect am
r I wntracl huyer of ihe aforemertlioned pmperty o� date applicabon is filed.
(owneh hdl ) .
jent atldfess o1 a�nt (numbera/t8slree4 �`L �fe, erM Z1P mb
o�w y u o s O cv.n� c Ur i I� ��'. . �( 7,(�S�
Address of auttra'¢e� person (numberaM stree; crty, sbte, an0
' _� � _' _ r..�_
Year
C �1 ��}(�jAuditor
Caunty Remrder
/O
�ipde ovmeri
Yes ❑ No
ie G�Pe�' in 7uestion: MnuaM Assessed
Real PtoPenY � �^�Y �
HaSlha deaxtim Dcen re9uesteE m proprlty
for cLrteN Y� r"f .. I"1
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