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Presaib d by the Surc Bm�d a[ Tex Comm"vaionm r�l� � O O 1 n�. O O
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CERTIFICATE OF MORTGAGE OR CONTRACT INDEBTEDNE55
� TO BE FILED IN PERSON OR 8Y MAIL IN DUPLICATE EACH YEAR BY THE OWNER WITH THE COUN'I'Y AUDITOR
�(IN WHICH THE PROPERTY IS LOCATED) BETR'EEN MARCH 1 AND MAY 1Q INCLUSNE
(6-11-12-1 THROUGH 6-I.1-12•8)
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� 1 •••QUALIFICATIONS ON BACK'•• �'7-3
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STATE OF INDIANA ��2QG� COUNTY, ss:
�I. (We) � L.iAJ�Y� `� (`),C1 1`M Ly � � b (Q - �l S I o
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certify that I, (We) was/were legal resident(s) of the State of Indiana and owner(s) of real property on March 1, 19 � and that this
statement is made for the purpose of obtaining a deduction from that real property located in Taxing District (City, Town, Township)
Legal Description/or Key Number
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Described to wih
� A'ame on property tarz recozds if different from above?
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,Z Are you the sole legal or equitable owner o[ the real estate? Yes � No 1
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� If no, what is your exact share of interest in it?
�� Assessed value of real estate as of March 1, curzent year � �
� Amount of Mortgage or Contract Indebtedness unpaid as.of March 1, current year S ��vv
, �, �7ortgage or Contrect recorded County Recorder's Office, Record No. � Page �..��
�ame and address of mongagee or contract seller ��\ N �
�- Do you know if there is any assignee or bona fide owner or holder ot the mortgage or contract? Yes
� what is the name and residence?
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No If yes,
z Does the owner of the above. described real property own real property in any other Caunty � in -the State of indiana?
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(� Yes Na If es, what County and Taxin District.
Q Has [his deduction been requested on that property for the current year? Yes No l((� .�O ���
CJ1 Amount Allowed � � O_ �" �
E �00 �e �6 �1' � . b �
z COUNTY BOARD OF REVIEW I_��1 =See False Statement Penalty Belo.�
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(� �PR�V�N�O[ T F $ 6 �
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MAR 2 3 1Q8^ / �PERSO� ORIZE� B' DULS E%ECVI'ED PoWER OF ATTOR6EY)
��±'a � �a�5 �NLL ftFSiOE�CE DRES� OF OWtiEft — MUST BE GIVE.��
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o r;�����ro , /•(��ao8-
� SECRETARI' OF BOTRD /� Q�n • P IADORESi OF ALTHORV.ED PERSOY) O b�� (O
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DATE � �P'o�.�a— �d �.C-(��. '