Mortgage_Owens (4)"'n STATEMENT OF MORTGAGE OR CO SS Coun Township vear
_ FOR DEDUCTION FROM ASSESSED L�
� s�e wm a3�oe (aii � sos�
S � Presm'bed M OeP�nt af LorW Govemment F�
N��'] Z��2 FileMark
lNSTRUCPONS:
To 6e filed in person or by maB with the CowityA Wifor or Counry RecordeEb(�h0'o31Zi7�'OU^y$ the pioperty is bcated. Fam t�ed
Filiig Dates: 7) Real Pmperty: Must fife dufig the year for which the deduction is sol� L CouMy Auditw
2J Mo68e / Manufaclured Homes rrot assessed as Real Pmperty Must S� the hveAre (tz) months � counry Recorder
befora March 31 of each year the deduction is so6�48SON C 0 U NTY AU D ITO R
See reverse side (a addiL'nnal insWcGons end qualfications. �
MPWan� (owlce i(aC A."Ye(��-i°p�s�b°ns�n ...
T fiG Keyiumiberllegaldnsaiption
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asussm��tre�w�m�� �;�i�,�
Me�d� 7. tlxm1R yPat �
�i M. W�13I �S �YS � ilEf EYdf15�12IE Oi N}CfE51�
tt rwne m reaetl Lv 6Rerrsl Uw� ihat ot app&ani, uiCUate Gelow.
Nart�e W mortEa9� v contrarl seCer
Addres of mortgagce a contrad se0er (mm6er aM sbee4 rY�•tate. and.
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I I We certify under ihe pena
owner I contraa buyer of the a
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a�l� 0 0 12 511
4dehtetlness unpaid as of Mortgage / Cantrxi udebtedness unPaitl as of La Ne aDP�ont the sde
tlate of aPPGption legal a eWitable ameft
S O� ❑ Yes ❑ No
If awned vnY� someofre Wher than SPO�. Ndicate wiN wMm
IS tM P�GQrtY Yl VIICSCOIL M(LL12LY A5241.V
❑ Real RoPertY ❑ Armualy ASSessed . . .
zo
What Ta�d�g 0¢trin?
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Nis tledudion Eeen
�rten� rean.
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� G�P�Y
❑ No
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of perjury ih t e above and foregoing infortnation is true and cortect and that Ne applirant is a resident � 1� and
o2mention pmperty on date application is filed.
Date (month, daY. Ye�
��
iber and sLee4 �l: state, aM ZIP cotle7
Date (monlh. daY.
auCioraed prlsnn (number arM saee4 �'iry, state, erM LP code)