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Farm.i fle.iaed 19%;1 O/ P — R Fee SI.00
Prescribed by �e Smu B�rd of Taz Commissioners � � 2 7 7��
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
(IN WHICH THE PROPERTY IS LOCATED) BETWEEN MARCH 1 AND MAY 30, INCLUSIVE
(6-11-12-1 THROUGH 64.1-12-8) �
� "'QUALIFICATIONS ON BACK°•
STATE OF INDIANA J�J�-�-� T, CO I NTY, ss: .� ,/
n . o .. � �._ n L `f
I, (1Ve) � `
IFULL \AMEI �
certity that I, (\Ve) wa /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 for the purpose of obtaining a deduction from [hat real property Iceated in Taxing District (City, Town, Township)
Described to wit:
C,egal Description/or Key A`umber
�� Name on property tax records if different from above? _
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z Are you the sole legal or equitable owner of the real estate? Fes No
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Q� .
� If no, what is your exaci share of interest in it?
� Assessed value of real estace as of March I, cuaent year �+�� �� 31 D
� . Amount of Mortgage or Contract Indebtedness unpaid as of March 1, current year S ��j—(J�/v
, Mortgage or Contract recorded Coun[y Recorder's Office, Record No. � Page ��—
� �'�. `Name and address gy�' Qee� r � setler �d ��• �V��
� Do you know if ther��y ass�g� or1�bona fide owner or holder of the mortgage or rnntract? Yes No It yes,
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U what is the name and�stde�lie4 1909 ` 73 21- �
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� AUDITOR
�il�>s thr nwner� nf the ahove described real oronertv own real orooertv in anv other County in the State of [ndiana?
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Yes No If yes, what County and Taxing Districl?
Has this deduction been requested on that property for the cunent year? Yes No
Amount Allawed
COUNTY BOARD C
ACTION
APPROVED IN AMOUNT OF S
REMARKS
OF BOARD .
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�dD� � 'See False Statement Penalty Below
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�OH'YER'S FUIl SMIE�
^�{ �PF.RSO\ AUTHORIZED BY DULS E%ECUTED PoR'ER OF A9'IORNEY)
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/] �( 1/� . (FULL RFSIDESCE ADDRFSS OF OWSER — MUSI' BE GR'E1�
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�0� ` 0 a
/,.O �ADDRE55 OF AVI'HORIZED PER50\�
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