Mortgage_Turpin (7)"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship Year
_ ; FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Fortn 43709 (R77 / 6-09) � � � �j"1
�' ,�r 1 Presaibe0 �y Depariment of Laal Govemment Fnance HJ
Y.% File Mark
wsrRUCnoNS:
To 6e filed in person w by ma�l with fhe CounryAUditor or Counry Remrder o/ the countyy�p2{he pl�� is located. F� m� �:
F7ing Dates: i) Real Pmperty: Must file durirg the year for which the tleduction is mujw!"�« i � Counry Auditor
2) Mo6ile / Manulectwed Homes irot assessed as Real Property: Must file dunng the tweNe (12J monfhs
6e7ole March 31 a! each year the deducfion is sought. ❑ Counry Recorder
See reverse side lof additional insWCtions arM qualifications. `�1QAIL�I '
AppGpnt(owrrerarwntraGy uyer-seeresflicbons reverse '
`�hnn/D��o �lf' i�f�,_ c iin�.,,� 1
Ta�drg Oisfiq
Aae55ed vaqx oF real popsty as d
Mamh 1, Nmn[ yeer
If no, whxt is his / her euC share of intelrsi?
on
r�a�,�e a
7
ihan Nat ol appG[an4 mAicate Eelaw
_F�CS
sbte,
o( assynee w other owner w hdder of mortgage
tlry, vate, and ZIP cotle)
> �a d �c5 `9 � I �� � � I P�e'�m / 1L
unpaid as of MM�age / ConVacY'uMeCtedness unpaid as of Is Ne aDP�� �e sde
date of application leual or eaueaNe �R
No
c°?� I �-�i7°`�
� �LA V ��
Does appfimnt o+m yoperry in any other I If yes. what munty.� I What Taz �,tt A� �
munryinlMana? �}�{ / I � ��
❑ Yes ❑ No y.l ��/�5w
`T�
COUNTVAUDROF
Deductlan approved'c� Ihe amount aE
20 _ 20 _ 20 20 (x�ae�� "`" ' ' w ' �•
Sigfawre W CoimryAUGitw �+^N � V �V I'� �`J �
I I We certify under Ne penalry of perjury thai the above and toregoing infwmalion is tn C� \, I�..
owner I contrad buyer of the aforemerrooned property on date appliratlon is filed. J
Mnanirolnwnn/efifinmm�l _
ot aPG�^j(rwm6erAntl sLee4 tily
PP1son autnor�0 6y7uy ezecute0 Poxer of/WOmey or by IC
Pdtlress o( auNOraetl person (number aM sbee; tlry, state, a
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