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For i Ite.9sed 1%1 , �
Prescrib d by Ne S�av �oerd a( Tex Commissianers
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CERTIFICATE OF MORTGAGE OR CONTRACT INDEBTEDNE
TO BE FILED IN PERSON OR BY MAIL IN DUPLICATE EACH YEAR BY THE OWNER H THE COUNTY
� QN WHICH THE PROPER7'Y IS LOCATED) BETR'EEN MARCH 1 AND Y 10, I\CLUSIVE
� (61.L124 THROUGH 6-11-12-8) � / � � �7
� '•'QUALIFICATIO\S ON BACK^• �D - /i �
`9 if" �
STATE OF INDIANA
COUNTY, ss:
F51ing Fee SI.00
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I� (We) . r � .
IFUIL \AME) Q(�
certify that [, e) was/were legal resident(s) o the State of Indiana and owneds) of real property on March 1, 19 r vand that this
statement is made for the purpose of obtaining a deduction from that real properer�-located in Taxing District (City, Town, Township)
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Legal Description/or Key \'umber
� Name on property tax records i[ dif(erent from above?
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,� Are you the sole legal or equitable owner of the real estate? Yes
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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 _
A
Described W wit:
6S
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W Amount of Mortgage or Contract Indebtedness unpaid as of March 1, current year S
�y �7ortgage or Contract recorded
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��`Name and address of moRgagee or contract seller
Q�r
Rernrder's Office,
�9 �n
Record No. � Page � ��
W Do you know if there is any assignee or bona fide owner or holder ot the mortgage o�tract? Yes
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d what is the name and residence? /�
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No [f yes,
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Does the owner of the above described real property own real property m any other Coun�'n���iana?
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Yes A`o [f yes, what County and Taxing District?
Has this deduction been -requested on that property for the
Amoun[ Allowed
COUNTY BOARD OF REVIEW
ACTION �9q/
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APPROVED IN AMOUNT OF S�__
REMARKS
SECNETARY
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year? Yes No t � � 3 C� 1990
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AUDITOR
"See False Statement Penalty Below�QD� �,q�'�
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ION'RER'S Fll YATIE�
1PERS0\ AU7NORIZED Bl' DULY EXECUTED PoMER OF ATIOR3EY)
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�FIILL RFSIDE�CE ADDRFSS OF ONSER — MUSf BE CR'ES)
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� �ADDRFSS OF AIRHORIZEU PER50\)
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