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CERTIFICATE OF MORTGAGE OR CONTRACT INDEBTEDNESS �
TO BE FILED IN PERSON OR BY MAIL IN DUPLICATE EACH YEAR BY THE OVYNER R'ITH THE COUNTY AUDITOR�
" (IN WHICH THE PROPERTY IS LOCATED) BETWEEN MARCH 1 AND MAY 1
(6�1.1-12-1 THROUGH 6-1.1-12-8) � n O
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� STATE OF INDIAIVA , �t1.�woa*' COUNTY, ss: �
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certify that I, (\9e) was/were legal resident(s) of the State of Indiana and owneds) of real property on March I, 19 � and that this
statement is made for the purpose of obtaining a�deduction from that real prope.�ilocated in Taxing�District (City, Town, Township)
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\J ���'6� ��' Described to wit:
Legal Description/or Key Number `�-/� �� /4 ' ` "'� �l "e� � � � a • ao� 3 �
� Name on property tas records if different from above?
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z 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 i[?
� Assessed value of real estate as of March 1, cunent year � 3O '. ���
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� Amount of nlortgage or Con[rac[ Indebtedness unpaid as of March 1, current year S «�� • Bv
� Mortgage or Contr�ct recorded County Recorder's Office, Record No. � Page �
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,�� Vame and. address of mortgagee or contract seller IJ��' "V""" ��^"-' -
� Do you know if there is any assignee or bona fide. owner or holder of the mortgage or rnntract?
� what is the name and residence? ��
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No If yes,
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zDoes the owner of the above described real property own real property in any other County in the State of Indiana?}
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� Yes No If yes, what County and TaYing District?
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Qi Has this deduction been requested on that property for the current year? Yes -� No -
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(/j Amount Allawed
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z COUNTY BOARD O R�
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G�Wy APPROVED IN AMOUNT OF S
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SECRETARI' OF
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