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CERTIFICATE OF MORTGAGE OR CONTRACT INDEBTEDNESS
TO BE FILED IN PERSON OR BY MAIL t1 DUPLICATE EACH YEAR BY THE OWNER WITH THE COUNTY AUDITOR
(IN WHICH THE PROPERTY IS IACATED) BETR'EEN MARCH 1 AND MAY 10, INCLUSIVE
� (61.142-1 THROUGH 6-11-12-8) . �
^•QUALIFICATIONS ON BACK°•
STATE OF INDIANA
t, (We)
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COUNTY, ss:\O
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certify that I, (Ne) was/wer egal resident(s) of the State of Indiana and owner(s) of real property on Mareh 1, 19 � and that this
statement is made for the purpose of obtaining a deduction frqtn that real property located in Taxing District (City, Towq Township)
�l.lnR-.il.�l'�w"i-� �T1 Described to wit:
Legal Description/or Key Number �� rv ��I � � �' �) ~' � ` �L
A?e..,e ,. o.r.. �o.r ....d� if diffu.o�t f.nm ahnvo� ' O.J'
� """" __ �'_�__" "__ _"'___ __ __________ ______ _ __ __ —__.
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,� Are you the sole legal or equitable owner of the real estate? S'es No X 7,r �� O�
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a [f no, wha[ is your. exact share of interest in it?
OAssessed value of real estate as of March 1, current year ,�� Q � O`_� `�
� . Amount of Dlortgage or Contract Indebtedness unpaid as of March 1, current year $ �� �J,J '� �� �O/ O�
�, Mortgage or Contrac[ recorded County Recorder's. Office, Record Yo. ��
. �yv _ • _ � .
W Name and address of��� q� eller �
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W Do you know if there is a AP�si�nP,e ��na fide owner or holder ot the mortgage or rnntract? Yes No If yes,
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¢ w•hat is the name and residence? y�'�
C/� - (.�/ti^"'��IT�K ' �
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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(�J Yes No If yes, what County and Taxing District:' �-� • �.�,�, 6l —•g/1
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� Has this deduction been requested on that property for the cunent year? Yes � No � b�
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(fj � Amount Allowed �bO� _/q � .},-{3.� � ��
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,� COUNTY BOARD OF REVIEW �� �See False Statement Penalty el w
,.,,, ACTION i
[.Wy APPROVED IN AMOUNT OF S _ �//v ��� �/ `"` �
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3 REMARKS � _
�PER50\ AUTFiORIZEO BY DULY E%ECIRED POWEN OF ATTOIU:EY)
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SECRETARS' OF BONtU �� � IADDRESS OF AUTNORIZED PERSO�)
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