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Form a Re.iaed IA51 . �O� �� FJine Fee 51.00
Prescnb d by Ne Siaie Flonrd ofTex Commissianers
CERTIFICATE OF MORTGAGE OR CONTRACT INDEBTEDNESS
TO BE FILED IN PERSON OR BY MAIL IN DUPLICATE EACH YEAR BY THE OWNER WTTH THE COUNTY AUD[TOR
(IN WHICH TNE PROPERTY IS LOCATED) BETWEEN MARCH 1 AND MAY 1Q INCLUSIVE
(61.]-124 THROUGH 6-1.1-12-8)
"'QUAI.IFICATIO\S Oh BACK•'• /
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STATE OF INDIANA _�d� )6.l�� COUNTY, ss: ' D�
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I, (We) ��/A A v�v ivc� t� •� �•x.v t7 rv r�. � i. i�.�.�-c�v�
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certify that I, (\Ve) was/were legal resident(s) of the State of Indiana and owner(s) of real property on Mazch 1, 19 �b and that this
statement is made for the purpose of obtaining �deduction from that real property located in Taxing District (City, Town, Township)
�' /\NY�C..C/1 VW � Described to wit:
Legal Description/or Key Number �1 / �/' �" � �/ �/ v I �� / ✓� �
� Name on property tar records if difterent &om above?
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,Z Are you the sole legal or equitable owner of the real estate? Yes � No I/Q._ ���
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� If no, what is your exact share of interest in it? _ _ �
� Assessed value of real estate as of March 1, cuaent year
� . Amount ot Mortgage or Conhac[ Indebtedness unpaid as of March I, current year $ �T�l J� l J
� D7oRgaRe or Convact recorded �A! Y�/� County Recordei s Office, Record Na � Page �—
�� Name and address of mortgagee or contract seller _L(L.ldl_1�LLA-^ Q� C�J� YI�IJ.AC .
WDo you know if there is any assignee or bona fide� owner or holder of the mortgage or mntract? Yes No If yes,
Qwhat is the name and residence? - ���
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Do���e� he bo��e descnbed real property own real property m any other County m the State of Indiana?
Yes No If yes, what County and Taxing District?
Has FEB�u�i19b en requested on that property for the current year? Yes � No
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BOARD OF
ACTION
APPROVED IN AMOUNT OF S �D� �
REMARKS w ADO �
DATE
SECREI'ARY OF 80ARD
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5��e False Statement Penalty Below �
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IPEH50\ AUiHOftIZED BY DULY ERECITi'ED PoWER OF ATTORFEY)
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�FULL RFSIDENCE ADD� ON:CER — M1tUST BE GIVEN�
(ADDRESS OF AUTHOAIZED PER50\)
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