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Form i Re�ised 19=1 F�R Fee 51-00
Preuribed by tlie 5`a`e Boerd o(Ta: Commiss�onm �
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' � CERTIFICATE OF MORTGAGE OR CONTRACT INDEBTEDNESS
TO BE FILED IN PERSON OR BY MAIL�IN DUPLICATE EACH YEAR BY THE OWNER WITH THE COUNTY AUDITOR
. ph WHICH THE PROPERTY IS LOCATED) BE7'R'EEN MARCH 1 AND MAY 10, INCLUSIVE
(El.l-t2-1 TRROUGH� 6-1.1-12-8)
� ••'QUA�IFICATIONS ON BACK•••
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STATE OF INDIANA
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COUNTY, ss:
I, (We) � - ` �--�
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certify that I, (We) was/were legal resident(s) of the St �e of Indiana and owner(s) of real property on Mazch 1, 1��and that thia
statement is made for the purpose of obtaining a deduction from that real property located in Taxing District (City, Town, Township)
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Legal Description/or Key Number �->"'-F ��/�- � �3 � �
Described to wit: .
� Name on property tar records it difterent from aboce? !
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A I
,Z Are you the sole legal or equitable owner of the rea] estate? Yes No .
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� If no, what is your exact share of interest in it?.
� Assessed value of real estate as o! March 1, current year � � 0 T��0
AAmount o( r7ortgage or Contract Indebtedness unpaid as of Dlarch 1, current year $ � 9 � ��
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- D9ortga�e or Contract recorded ��-+'�//�"' County Recorder's,Office, Record No. _
� Name and address of or contract seller � `
� Do you�o�f�e ignee or bona fide owner or holder of the mortgage o�ntract? Yes
W i.�s�. �+ � R7� h
Qwhat is th@��e �� �nce? �� —� I U- J
Q� '
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I � ' � DITOR
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No If yes,
z Does the owm�tUof the ve described real property own real property in any other County in the State of Indiana?
� 3 �j Yes No If yes, what County and Taxing District?
Q Has this deduction been requested on that property for the current year? Yes No �t��" °w
�
(/1 Amount Allowed
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z COUNTY BOARD OF REVIEW
,,,; ACTION
[.Wy APPROVED IN AD70UNT OF S
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�REMARKS
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- SECRETARY OF BOAftO
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'See False Statement Penalty Belo�d
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�PEH50\ AUTHORIZED BS DULY E%ECVfED PoH'ER OF ATIORNES)
,.,32 / � d���.
IFIiLL RF31DE\CE ADDRF_SS OF ON'1ER - MUST BE GIVEN)