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"'3 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
• FOR DEDUCTION FROM ASSESSED VALUATION
• S1ate Fwm 4i709IR71 / 6-09)
,�' � p�¢so�be0 by Department of Lnd GovemmeM Friance
INSTRUCT70NS:
To be filed in person w by mail with the CowtyAuditor or County Recorder o/ the county where Me property is bcafed.
FiTrg Dates: i) Real Property: Must h7e during the year for which the deduction is sought.
2) Mobile / Manufactured Homes not assessed az Real P�operty: Must file dunng the hveNe (72J months
before March 31 of each year fhe deduction is sought.
See reverse side for additional inshuctbns and qualifiptions.
AppGCarn (oy�erw cwivart buyer y�ee rgstnrlinru o'reverx side)
As¢ssea vdue m mal yoperry as N �R9a9e / Gont
M3td� 1. ne�etrt yeer March i. cvrtent
If tw, what Is his / her enact share of interesi?
tt name on remtl b dMerent Uan Nat of appGCan, Ndipte below.
Nameotmort9ageew ntractsHler
Addres of mwtgag w mntract seAer (num
Name af assignee w othu owner or hdder of
munry
-O -ODO. $O y - ol�'
4debtedness unpaid as of Marigage I Can7atl udehtedness
v tlate of appfmatnn
4US'�oo1
IF awned vriN mmeone dMr tlian spo�se, M1
ena 5uee4 �}: state, ena ur co0e) �
7 /-!o /p0 AL
i any oNer If yes, whet county7 What Tarilg D"sbid?
! Yes ❑ No
CouCnty,A(�u'd,itor�
� �J�1ty�w�eoraer
RecotO number Pape numher
0o d- �( (03
unpaid as af Is ihe aPPli�ant Ux 5oL
v� u r+o
questlm: Mnu.
b � Nviva
PAob�e
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