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CERTIFICATE OF MORTGAGE OR CONTRAC INDEBTEDIUESS �-
TO/ BE FILED IN PERSON OR $Y MAIL IN DUPLICATE EACH YEAR BY THE OWNER WITH THE COU ITOR
! I �(IN WHICH THE PROPERTY IS LOCATED) BETWEEh MARCH 1 AND MAY 10, [NCLU
\ / (61.1-12-1 THROUGH 6-1.1-12-8) -D O y�
� 'OQUALIFICATIONS ON BACK"• ��
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STATE OF INDIANA � COUNTY, ss: .
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certify that I, (We) was/were legal resident(s) of the State of [ndiana and owner(s) of real property on March 1, 19
statement is made for the purpose oC obtaining a deduction from that real property located in Taxing DistriM,fCi
Legal Description/or Key Number Y �� L� 9 J / U—
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� Name on property tar records if different from abave.
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z Are you the sole legal or equitable owner of the real estate? Yes � No V
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If no, what is your exact share ot interest in it? _ �� •�"' ����0 11 `
� Assessed value of real estate as of March 1; current year �
� Amount of Mortgage or ContraM Indebtedness unpaid as of March 1, current year $ ��
/� , Dlongage or Contract recorded /=1-[�y7�- County Recorder's Office, Record h �
/ �" � ' ^Name and e �of ort tract seller ��/Ld-t � �.!/uGa�L CJL ��
� Do you kn� �r��i�r bona fide owner or holder of the mortgage or contract? Yes —
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Qwhat is the namA� �e%�7 5
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Does the ow�If�T,E a . 29cribed real pmperty own real property in any ather County m
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� Yes � No If yes, what County and Taxing District?
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Q Has this deduction been requested on that property for the current year? Yes No
i/i Amount Allowed ��_�/�
F G�/�l�i �b - a i- a�. �'s-
z COUNTY BOARD OF REVIEW /�n y� •See False Statement Penalry Below
�.., ACTION �'�
(.Wy APPROVED IN AMOUNT �OF $
� IOW.' R'S Nil �A.�
3 REMARKS _
_� V � �PERSON AUTHO�IZED BS DULY E%ECUTE
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Desakebed to wit:
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No If yes,
the State of Indiana? ,I
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��� n (FULL RFSIOENCE AIJDRFSS OF OW\ER — MUST BE GIV6Y1 �
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� SECREfARY OF BOARD �� 1 DR OF AVfHOAIZED PE Y)
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