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CERTIFICATE OF MORTGAGE OR CONTRdCY IMDEBTEDMESS
TO BE FILED IN PERSON OR BY MAIL IN DUPLICATE EACH YEAR BY THE OWNER WITH THE WUNTY AUDITOR
"(IN WHICH THE PROPEBTY IS LOCATED) BETR'EEN MARCH 1 AND MAY 1Q INCLUSIVE
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� •'•QUALIFICATIONS ON BACK^• �
r STATE OF INDIANA ����� COUNTY, ss: %�
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certify that I, (�Ve) was/were legal resident(s) of the State of Indiana and owner(s) of real property on March 1, 19 �nd that this
statement is made for the purpose of obtaining a deduction from that real property located in Taxing District (City, Towq Township)
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L.egal Descrip6on/ar Key Number
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Name on property tax records if different fmm above?
Are you the sole legal or equitable owner of the real estate? Yes No
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Described to wit:
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If no, what is your exact share of interest in it?
Assessed value of real estate as of March 1, cune t,
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Amount o[ Mortgage or Contract Indebtedness unpaid as of March l, current year $�,�� 1 ln
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or Contract
and address of mortgagee or contract seller
County Recordei s Otfice, Record No. Page 6
'� Do you know if there is any assignee or bona fide owner or holder of the mortga�e or contract? Yes ' N/ If yes,
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d�what is the name and residence?
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� z Does the owner of the above. described real property own real property in any other County in the State of Indiana?
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(,�j Yes �, No IC yes, what County and Taxing District?
I e. Has this deduction been requested on that property tor the cunent year? Yes No `� "/ �
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(/� Amount Ailowed
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i z COUNTY BOARD OF RE IEW
",y ACTION
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SECREI'ARY OF BOARD
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'See False Statement Penalty Below
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�( (AOURFSS OF AVI'HORIZED PER50�)
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