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'°3 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship Year
,: • FOR DEDUCTION FROM ASSESSED VALUATION
• State Fwm 43709 (Ri t/ 6�09)
�' -' f p��yty py pepa�nt of Loral Govemment Frunce
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INSTRUCTIONS:
To be filed in person or by mail with the CountyAUdito� or Counry Recorder of the county where fhe pioperty is located. S
Fil'ng Dates: 1J Real Pioperty: Must fi!e dunng the year for which Ihe deducfion is sought.
2) Mo6i/e / Manufactured Homes not assessed as Real Property: Must fiIe dunng the hvehre (72) months C
6efo,e March 31 of each year the deducGon is �M1t.
See reverse side /or additional instructions and qualfiwtions.
APP� (owrrer or mntraG buyer' se4l�trc0°^s � r4rerse side). � �
— v�—�
Abr1page / Conbau 4
Ma� 1. artent yeer
ii M. W�131 �S �IlSI i12f 0%dQ 5�12l8 0� VI(CIPSI�
If narne on �emrd'a 6Re�aft than iha� ot app6cant 6�Oicate Cebw.
Recorder
Remrdnumbu Page umCa
�-GI�JQ.Io�.�_009
etlness unpaid as d Mortgage /(',ontrad irdebtedness unpaitl as d Is Ihe appa'ant the wb
tlate of ap �gal w equitade own�l
� ❑ Yes ❑ No
It av.med vri� someone oticer spouse, iMiraie wiTh wlwm
Is propelty in qurs5on: M�wa�y AssesseE
Real ProPeRY ❑ ��Y �
Modle Fbme OC 61.1-i
Name oi rtnriga�ee m m�tracc seuer �/�
Addres of rtrrcgagee «contraa seAer (n and stree4 �dY. ffite. aM LP code)
Name of assignee w oCwl owner or holtler M rt�wtgage ��
AGCress of assu]�e (numbei aM stree; tlly, state. antl LP cade) /
l
Do¢5 applimnt own property in any other I! yes. whel munt�t
counryinlntliana? n .,__ n .._
I�'^•�f�7.Ti1
20
amountoF.
20
Tadng DisVicl?
COUNTYAUDROR
20_ � 20_
Sigfunne or Counb Auditor I Counry
I/ We certify under Ne penaly o( perjury Nat lhe above and foregoing intortnalion is W e:
owner I contract bu of the atwementioned property on date apD���tion is filed.
Signahire (owne/s ra
Pddress of auth«'seE person
u by IC G7.142-0.7
state. anE LP cade)
Has Ufs AeEU�tion Eeen 2CUesteO m p�opelly
forartemY�n r-� '" r-� ,
20 _ .I .. . 20 —_ I _ 20
_ — -�
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