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w <br />�rvl o -xerox i e IeCOPier '/021 ;IU— 7-91 <br />Form � 1y al <br />/� rs P820 aler! ificate �r <br />8 : 4 3 <br />COUNTY ADMIN. -• <br />612 464 4568;$t 3 <br />Number <br />L {{li <br />t - ❑ <br />to t <br />10 if a mortgage or contract for deed is not a variable market rate but the te: ms of payment are scheduied tochangeon a fixed date. fill in its fine number from above, the <br />month and year of thechange, and what it will change to (or attach 3 copies of payment schedule): -k, <br />Fill out schedule 6 on the back of this sheet to determine the amountof your deed tax <br />r F <br />I declare that the information filled in on this form is true, correct and compiete to the best of my knoWedge and belief. _ <br />Print or type name of person signing this form -;. _ r . Signature _t . _ �., .,�.. Listed Pbpne Number _ S Date <br />21�i <br />Yr/� / . ,L.jJ 61C� TOh /j,.� Ptat—PatCefr;yst Yr 6 d Yr +-` L'C3 1 :aog !T _ %� —t - J/ _ p d CS f <br />s Q� % <br />iJ¢��- epartment of Revenue Use Only <br />k H(; GT F.d15 �— I v---dp F41 <br />1 vu v/ <br />C:c -� CT T -� date --T--'�� <br />