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CERTIFICATE OF MORTGAGE OR CONTRACT INDEBTEDNESS
TO BE FILED IN PERSON OR BY MAIL IN DUPLICATE EACH YEAR BY THE OR'NER WITH THE COUNTY AUDITOR
pN R'HICH THE PROPERTY IS LOCATED) BETR'EEN MARCH 1 AND MAY 1Q INCLUSIVE �'
.D�q 0 v� v�— O O • QUALIFICATIONS ON'BACKB'' ' �
I D
�T1�TE OF INDIANA COUNTY, ss: � D�
1, (we)
certify chat [, (R'e) was/were legal re=
statement is made for the purpose of
the State of Indiana and owneds) of real property on Diarch 1, 19 ( J 1 and that this
a deduction from t�t real property located in Taxing District (City, Town, Township)
1
Legal Description/or Key Number
� Name on property tax records if different from above?
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A
,Z Are you the sole legal or equitable owner of the real estate? Yes
�
�Q
� It no, what is your exact share of interest in it?
� Assessed value of real estate as of March�l, current year
� Amount of Mongage or Contract Indebtedness unpaid as of Maah 1, current year $
�. Moaga�e or Con[ract recorded
�� Name and address of mortgagee or contract seller
No
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Y
County
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W � _
WDo you know if there is any assignee or bona fide owner or holder of the mortgage or
Qwhat is the name and residence?
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Yes No If yes,
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I �lncc thn nw�ner nf the a6ove described real nronert" v o��al nrooertv in anv other County in the State of Indiana?
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A
Yes No It yes, what County and Taxing District?
Has this deduction been requested on that property for the current year? Yes No
Amount Allowed
ACTION
APPROVED IN AMOUNT_ OF S
REbtARKS
DATE
' SECRETARY OF BOAM
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