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CERTIFICATE OF MORTGAGE OR C!�NTRACT INDEBTEDNESS
TO BE FILED IN PERSON OR SY MAIL IN DUPLICATE EACH YEAR BY THE OWNER WITH THE COUNTY AUDITOR
'i "ph WHICH THE PROPERTY IS LOCATED) BE7'R'EEN MARCH 1 AND MAY 10, INCWSIVE
� /�-� (8-1.1-12-I THROUGH 6-1.1-12-8)
��O�t��- � � ^•@UALIFICATIONS ON BACK°• a� •/
Q\� STATE OF INDIANA •�-�-M COUNTY, ss: ifX%it/
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�FU[L NAMEI ,Q
certify that I, (We) was/were legal resident(s) of the State of Indiana�and o eds) ot real property on March 1, 19 �!� and that this
statement is made for the purpose of obtaining a deduction fzom that real property located in Taxing District (City, Town, Township)
�� Described to wit:
Lega] Description/or Key Number�
Name on property tas records if different from above?
Are yov the sole legal or equitable owner of the real estate? Yes _^ No
If no, what is your exact share of interest in it?
Assessed value of real es[ate as of March 1, current year /� o '
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�� Amount ot Mortgage or Contract Indebtedness unpaid as of March 1, current year S � � � O
��o�?gege or Contrac[ recorded County Recorder's Office, Record No. � Page �O�
� Name and address of mortgagee or contract seller v��-�- ��Cn'�v=� �� ��
' W Do you know it there is any assignee or bona fide owner or holder of the mortgage or crontract? Yes No If yes,
Q�Hhat is the name and residence? � � ° ' `� � �/� ' " /
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.I Does the owner of the above. described real property own real property in any other County in the S[ate of Indiana?
Yes � No [f yes, what County and Ta�cing District?
Has this deduction been requested on that property for the cunent year? Yes , No
Amount Allow•ed
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BOARD OF REVIEW
ACTION
APPR�D yN�MO� Ol����
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