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CERTIFIC� O OR G E O dONTR�/AC�T INDEB EDNESS
TO BE FILED IN PERSON OR BY MAIL IN DUPLICATE EACH YEAR BY TNE OWNER WITH THE COUNTY AUDITOR
(IN WHICH THE PROPERTY IS LOCATED) BETWEEN MARCH 1 AND MAY 10, INCLUSIVE
' �n (6-11-12-1 THROUGH 6-1.1-12-8)
' �� � -� °•QUALIFICATIONS O.�` BACK••• M � (�
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►i S�ATE OF INDIANA ���'1, COUNTY, ss:
I, (Ne) 'v T n.• i r o� �
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certify that I, (R'e) was/were legal resid t(s) of the State of [ndiana and owner(s) of real property on March 1, 19 and that this
statement is made for the purpose of obtaining a deduction from that real property located in Taxing District (City, Town, Township)
Legal Descrip[ion/or Key Number
� Name on property tax records i( difterent 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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� [f no, what is your exact share of interest in it? �
�� . Assess�a�e�pi j� te s ot March 1, current�year
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W _ Amount o( Mortgage �yQAntract Indebtedness unpaid as of D9arch 1, current year S
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�,00�
f/i�
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Described ta wit:
R? Mortga�eor�C nt(s�recorded County Recordeis Office, Record No. -7 Page �(533
� �, ,,,�,'J� Q��s � ��1 � � � cz� � � �.
�" �Nam�G�A�aeqr�d6 o agee or contract seller �'`i i .
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W� Do you know if there is any assignee or bona Ede owner or holder of the mortgage or contract? Yes
Qwhat is the name and residence7 �� ��/�-
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No If yes,
I Does the owner of the above described real property own rea] property in any other County'in the S te of Indiana?
Yes No If yes, what�County and Taxing District?
Has this deductian been requested on that propedy for the current year? Yes
Amount Allowed
COUNTY BOARb OF REVIEW
ACTION /�! Y/
APPROVED IN AB40UNT OF S �d�%
No ��oa-�3,/��`l
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jC' p'b� 'See False Statement Penalty Below a�� �� �'
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REMARKS �
�PEItiO\ AUTHORIZED BY OULY E%ECU'fED PoWEft OF ATTOR4EY)
� b l� �FfiLL RFSiDE\CE ADDRFSS OF OR'\ER — MUSf 8E GIVEN�
SECRETARY OF BOARD �� �\ ^ f/�ORE55 OF AUTHORIZED PER50\)
DATE �