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Farm' Reriad 19e1
FilinR Fee SI.00
Pmcribed by Ne Su�e Bm�d of Taa Cammis.sioum �O �� ^
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CERTIFICATE OF MORTGAGE OR CONTRACT INDEBTEDNESS
TO BE N7LED IN PERSON OR SY MAIL IN DUPLICATE EACH YEAR BY THE OWNER R'ITH THE COUNTY AUDITOR
�(IN WHICH THE PROPERTY IS LOCATED) BETWEEN MARCH I AND MAY 10, INCLUSIVE
(611-12-1 THROUGH 64.1-12-8) ��
^•QUALIFICATiONS ON BACK^•
STATE OF INDIANA /�.G.arx COUNTY, ss: ��
�I. (We) / �_ �
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certify that I, (Ne) was/were legal resident(s) of the State of I iana and o eHs) of real property on March 1, 19 �� and that this
statement is made for the purpose of obtaining a deduction from that real property loca xmg i ity, Town, Township)
Legal Description/or Key Number
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� Name on property taac records if different from above?
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A
z Are you the sole legal or equitable owner of the real estate? Yes _, ho
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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 � ' O` �`%�'— /��
� Amount of D7ortgage or Contract Indebtedness unpaid as of March 1, current year S � D O O
�D1ortgage or Contract recorded County Recordei s Office, Record No. �� 3 Page %7 b
� Name 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 rnntract? Yes
�what is the name and residence? C
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wit:
No If yes,
z Does the owner of the abave. described real property own real property in any olher County in the Stace of Indiana?
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(,�} Yes No If yes, what County and Taxing District?
Qi Has this deduction been requested on that property for the current year? Yes No ���s—p
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(fj Amount Allowed
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F COUNTY BOARD OF REVIEW
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(.W.i APPROV��A�UUSa�I
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� REMARKS �
F ; t,�AR 16 �982
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O AUDITO
A� SECRETARS OF BOARD
DATE
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� •See False Statement Penalty Below
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, , IOW\ER'S FUIL \AMEI �
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' a �J� % AUTNORIZEO BY 0�LY{ E%ECUTED PoWER $1�ATIOR\EY�
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(FULL RFSIDEYCE ADORCSS OF ON'YER — MUST 8E GIVEN�
200 9
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�' � Q, IADDRFSS OF AUTHORI D PERSO\)
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9-9-98