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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship Year
__ : FOR DEDUCTION FROM ASSESSED VALUATION �
n$�ale Fam 93709IR71 / fr09) � g
�,w, ? Presaited by DePart�nt of Lacal Govemment France p
JL.� File Mark
INSTRUCTIONS:
To be filed in person or by mail wifh the CounryAUditor or Counry Recorder of the county wher� �S�Jp P�3y �a ted. F� �� ��
Filirg Dates: 1� Real PropeRy: Must file during the year /or which the deduction is wught. �: L� I L � County Auditor
2) Mobile /Manufactured Homes not assessed as Real Pruperty: Must file dunrtq fhe fweNe (12) monfhs
before March 31 of each year the deducfion is sought `� �� � County Recorder
See reverse side �itional ins(nrcJions ar�qualifications. �
qpp6cam(owner j.yryer-�e _ ; s reve r��E81d �Rr AUDITOR
— Key numCer/laqyl d �escn�tion ,�_ � O� �O`. J�_ O�. / Re�y u/�, Pa9e� [T�
�XVT J�� 1 �� OC J
2al qopeM1y a d MortgaBe / Contraa indebtednPSS unpaid as of Mongage / ContrarY indebtedness unpaid as d Is Ne eppG�ant the sole
� �,,. ��aa i �-� �� of��, � o ,�e o
Yes No
W�Id� �5 �IR / i12f 0%dC� 5�13R O( VIiCR5l7
If name on �emrE is diMerent Nan ihat
Name of nnrtgagee a contra�a
(numhgandsveeL �}: s+ate,
other owner or hdder of mortgage
Ad�ress oi assignee (nurtNer aM sVeet �y. s/ate, aM ZIP oo0e)
If owned wrth mmaorre dher ihan spouse, 6Micate wtth whom
Dces aP�nt w.n pmperry in any oNer I If yes. whal county? I NTat Taring D'aGid7
munryinlndaw? n., n.�
Is the ProPeNY in QuesGOn: MnueOY AssesSetl
❑ Reai a'operty ❑ amuany Assessed
Mod7e Hm�e QC 61.
Has N"s dedudion Eeen 29uested m pmperty
for tu�rent yea(? 1"I .._ _ I-1 .�