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FORM 5 Reviaed 1981 l,� ^ u U
Prexrihed by the State Board o[ Tss Commivionen 0 O `�' _ v� `� 1� O FILING FEE $1.00
CERTIFICATE OF MORTGAGE OR, CONTRACT INDEBTEDNESS
To Be Filed In Pereon Or By Mail In Duplicate Euh Year By The Owner With The County AudiWr
(in which the property u localed) beta�een March 1 and Nay 10, incluaive.
(61.1-12-1 through 6L412-8)
"'QUALIFICATIONS ON BACK^• �I � �
� $ q�������1� J
STATE OF INDIANA "► ���' -' V COUNTY, ss: �
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I, �We) —� f}-GL QhL�i..G� "
(Full Name)
certify �pt I, (We) was/were legal resident(s) of the State of Indiana and owner(s) of real property on March
1, 19 �o and that this statement is made for the purpose of obtaining a deduction from that real
property locate�d � ax g Dist,r/�c�t� (City, Town, Township)
�"/��– �1-�� Described to wit:
Legal Description/or Key Number
Name on property tax records if different from above?
Are you the sole legal or equitable owner of the reai estate? Yes � No
If no, �ahat is your exact share of interest in it?
Assessed value of real estate as of D4arch 1, current year 3�Eo �`��G-� 3 ago =���
Amount of Mortgage or Contract Inyd,eb�tqedn�es_s� un,paid as of March 1, current year $�
Mortgage or Contract recorded ,/v-�-O � County Recorder's Office, Record No. 5
Page —LQ� . n . n .
Name and address of mortgagee or contract seller ���• �O� �'�'�'�
Do you know if there is anv assignee or bona fide o«�ner or holder of the mortgage or contract?
1 es � No ✓ If yes, what is the name and residence? � A��,,,g�la
Does the owner of the above described real property o�vn real property� in any other County in the State of
Indiana? Yes No � If yes, what county and Taxing District?
Has this deduction been requested on that property for the current year? Yes % No ���
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COUNTY BOARD OF REVIE�V
ACTION
APPRO\'EU IN A\fOUNT OF $
REMARKS
Da[e
Secre[ary of Board
Amount Allowed
' False Statement Penalty Below �` I/`5 / '��/
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Authorized Person
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