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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
� FOR DEDUCTION FROM ASSESSED VALUATION �� �
Sta[e Fam 43709 (R71 / 6-09)
,` ,w r Presaibe0 7Y �eD���nt al Lxal Go�emment Frerce
File Mark
INSTRUCTIONS: ^�
F �' �
To be �led in person or by mail wi[h the CounryAUdito� or Counry Recorder of the counry where the pioperty is located.
FiRny Dates: 7) Real Pmperty: Must file durirg Ne year /or which fhe deduc6on is soughL C� m��ty udimr
2) Mo6Ae / Manulactured Homes not assessed as Real Property Must frie dunng Me twelve (12) monNs (C �
betore March 31 of each year Ne deduction is sought. ❑ Counry Rv der
SeereversesideforadditionalinstrucGOnsarMqualficatbns. GIBa v�vurvi � Muv�i�
Aoo&ant(owncrwconfIDCbuver-seereshicb'onsmreversesidel 1 _ n _f�
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I( no. what Ls his / her exaC share ot interest?
II nama on remN is dAferent Nan ihat ol aPpl
e of mo a9ee or contra<Y se0er�
Address ot mortoaoce w contracl seAer (num
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and stree4 �y, sta+e, aM ZIP code)
Nart�e W assignee or Wher owner or holder of mortgage
PAtlress of assgnee (nUmber eM SheeS mY. state, end ZIP Code)
epplifant ovm property in any ot
ry in IMana?
Yes
Koan appmved In Ne amount oF
20 20
If a�med v,iN
.'�bRI�Y�7sR�Z�l7
20 � 20 _
��Y
I/ We certity uMer Ne penalty of perjury that Ihe above and foregoing urfwmatim is W e a
ovmer I wntract buyer of the aforementioned properry on date appliption is filed.
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by didy executetl Paxer
AEEress of authw'vcd perwn (num0er arM sbaet �Y. sbfe.
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