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CERTIFICATE OF MORTGAGE OR CONTRACT INDEBTEDNESS
TO BE FILED IN PERSON OR SY MAIL IN DUPLICATE EACH YEAR BY THE OWNER WITH THE COUNTY AUDITOR
"(IN WHICH THE PROPERTY IS LOCATED) BE"I'NEEN MARCH 1 AND MAY 10, INCLUSIVE . .
(61.1-12-1 THROUGH 6-1.1-12-8)
� "•QUALIFICATIONS ON BACK•'• � �
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STATE OF INDIANA %��� COUNTY, ss: ���
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�FUIl NAMEI (J�
certify that I, (We) was/were legal resident(s) of the State of Indiana and owneds) of real property on March 1, 19 � and that this
statement is made for the purpose of obisining a deduction from that real property Iceated in Taxing District (City, Town, Township)
Legal Description/or Key Number
Name on property tan records if different &om above? �
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A �
,� Are you the sole legal or equitable owner of the real estate? Yes � No -
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� If no, what is your exact share of interest in it? .
�. � Assessed value of real estate as of March 1, current year ?�7� _7� ��
� Amount of D9ortgage or Contract Indebtedness unpaid as of March 1, current year S �� � � �
�� 'tilortgage or Con[ract recorded County Recorder's Office, Record A`a. _
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me and address ot mortgagee or contract seller ''-/'�' '�� �-�+�-
�- � Do you know if there is any assignee or bona fide owner or holder of the mortgage or mntract? Yes
. Q�hat is the name and residence? � O�
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Described to wit:
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_� No If yes,
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I Does the owner of the above- described real property own real property in any other Counry .in the State of [ndiana?
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(� Yes No If yes, what County and Taxing District? 6�
Q Has this deduction been requested on that propeAy for the current year? Yes � No ��
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Cf� Amount Allowed — �Ld�T/ �
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z COUNTY BOARD O REVIEW � 'See False Statement Penatty Below
�„i ACTION (� � Q, � (�� /,�,U;.Y� /\GU%Gd.
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w REMARKS
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