Mortgage_Fuhs (2)�
�
""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ovmship Year
.�_,. � FOR DEDUCTION FROM ASSESSED VALUATION
Sfate fvm a3705 (R71 / 6W)
•�' ,,,, � Presrnbed M Departmem ot Lnol Govemmerd Firw¢e .
File Ma
INSTRUCT70NS: Q
To be fiied in person or by mad wifh the CountyAuditor or Counry RecoNer oI the county where the pioperry is bcated. ��Z
Fd'ug Dates: i) Real Properly: Must file durirg Ne year for which the deduction is soughG C. Counry Avditw
2) Mo6Be / Manufactured Homes lrot assessed as Real Pioperty: Must fiie during the fwelve (12J montAs
before March 31 of each year the deduction is sanght. nty Recorder
See reverse side /or additional instructions and quzl�cations. GI BS�N C UNT
Aopfr�l{omre�witontraUbwPf-seeresNCf�anreversesifeL ✓ i Tnn
Key / I desaiption
� /�-�/- -Qo�. � 5� _ �a�
papelly as o7 Mortpag� / Contracl in0ehtedness unpaid az ot Mortgage / Contrarl' ehtec
Ma�ch 1, curtent year date of appOt,g�op� � �
n no, wna� 5 rus � rrer e�dct snare ar interesrt I tt ownea wim
It name m remd is dfiermt Nan ihat of appBwnL h�di�ata helow.
Nartre of mortgagee a contraG seller ��� � ^
���
Addres of rtwrt�agee w contracl seller (number eM svea , stete, aM ZIP mde)
Name of assignee or other owner or hdder ot rtqrtgage
Address of assigfree (nurtNer arM svee4 U+y. s+ate, antl LP cade)
Ooes eppli`ant own pmperty in any oUer If yes. what munty7 What 7adrg
munry in IrW'mna?
❑ Yes ❑ No
D�umon approveE Yf ttre amouni of:
DY:115'CI' 1���. �O�`
20— z°— �!1........
s:y�anne a co�n,ry a,dror C:1 t'� 1�TO. 56 O
1/ We certiry uMer the penalry M perjury that the above arn, �..�..�_. ��/$��. C'�3
owner I contract buyer of the afwementioned p`operty on date appliration is filea.
Slgfa¢ue(ownelshmrreme) _ �J -
slate, e�LPOOtle)
autha¢ee M dWY e:ea:etl
prlson (numOerarMSbeeL�}:S+ate.antlLPCOtle)
��
�
Yes LI No
Is the property in quesfion: MnuaDy Pssessed
� Real P(oPenY ❑ %���Y �
Has ihis deduction been requested on P��Y
far artent yeaR ❑ NI
❑ Yes
zo zo _
aate (mmth. dal: YEa�
uM that Ne applirant is a resident of 1�'pna a�
Date (rtmGt, day, yean
1�� l 8 � I?�
Date (rtianlh. daY. Y�tl