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Form.i Reai�e+l t%1
Presmib d bY �e State BoeN of Taa Commi�ionera
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CERTIFICATE OF MORTGAGE OR CONTRACT INDEBTEDNESS
TO BE FILED IN PERSO\ OR BY MAIL IN DUPLICATE� EACH� YEAR BY THE Ow'NER R'ITH THE COUNTY AUDITOR
(IN WHICH THE PROPERTY IS LOCATED) BETR'EEN MARCH 1 AND MAY 10, INCLUSIVE �
(6-1.1-12-1 THROUGH 8-1.1-12-8)
�a g .q� '••QUALIFICATIONS O,�' BACK•'•
STATE OF INDIANA
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COUNTY, ss: �
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• IPUfL SAMEI
certify that I, (Ne) was/were legal resident(s) of the�State of Indiana and owner(s) of real property on March 1, 19 � � and that this
statement is made Coz the purpose of obtaining a deduction Crom that real property located in Taxing District (City, Town, Township)
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Legal Description/or Key Number
�'' �/S�- d'a2-/D
Described to wit:
� A`ame on property ta�c records if different from above?
z
�
A
Z Are you the sole legal or equitable owner of the real estate? Yes No
N
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� If no, wha[ is your exact share of interest in it?
OAssessed value of real estate as of March 1, current year
WAmount o( D7ortgage or Contract Indebtedness unpaid as of Mazch 1, current year S ��� 0 O O
,'_ " J
� �7ortgaKe or Contract recorded ' County Recorder's Of� Recor� Page,L�
� Name and address of mortgagee or.contract seller �r•
WDo you know if there is any assignee or bona fide owner or holdez of the mortgage or mntract? Yes A'o If yes,
Qwhat is the name and residence? ��/��/ � " —/
� '� ,� n�_L, /�-/ 9� O� ,�i'i/�
zDoes the owner of the above described real property own rea� o� y in any other County in the State of Indiana?
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� Yes No If yes,.what County and Taxing District?
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Has this deduction been requested on that properly for the current year? Yes No
� � FEB 23 1990
Amount Allowed
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APPROVED IN AMOUNT OF S
REMARKS
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SECNETARY OF BOARU
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b'�is � �' � A�IDITOR
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V IOW6ER'S FUll. \AME�
�^PERSO\ AUTFiORIZED BS OULI' EYECUTED POWER OF ATIC11tNEY1
xo /�. /C d �O�L �i( X I
( �FULL IiE51DESCE e{DDRGSS OF O'NEft — MUST BE GR'EM
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O `Y (AUDRESS OF AUTHOAIZEO PERSOI:� /