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P'nnibed by �6e State BoeN ot Tez Commiavonm
CERTIFICATE OF MORTGAGE OR CONTRACT INDEBTEDNESS
TO BE FILED IN PER30N OR 8Y MAIL IN DUPLICATE EACH YEAR BY THE OWNER WITN THE COUNTY AUDITOR
�(IN WHICH THE PROPERTY IS LOCATED) BETWEEN MARCH 1 AND MAY 10, INCLUSNE
(61.1-12-1 THROUGH 6-1142•8) ���
^•QUALIFICATIO.�'S ON BACK•^
ATE OF INDIANA ���---�-�? �� COUNTY, ss: /(/ W
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� I. (We) �>!/G (N-C/z..� v� r�cic-t-C.CiC.��_.
�FU[L NAMEI ��
certify that I, (We) was/were legal resident(s) of the State� of Indiana end owner(s) ot real pzoperty on March 1, 19 ��d that this
statement is made for the purpose of obtaining a dtduction o that real property located in Taxing Distrid (City, Town, Township)
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Legal Description/or Key Number
� Name on pmperty t� records if different from above?
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.7.. Are you the sole legal or equifable owner of the real estate? Yes
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� If no, what is your exact share of interest in it?
� Assessed calue ot real estate as of March 1, current yea�
Described W wit:
� Amount of Mortgage or Contract Indebtedness unpaid as of March 1, current year 3�o� a z�
�� D1ortgage or Contract recorded County Recorder's Office, Record No. � Page �J��
� I Name and address of mortgagee or contract seller
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WDo you know if there is any assignee or bona fide awner or holder of the mortgage or
� what is the name and residence? t
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If yes,
Does the owner of the above. descnbed real pmperty own real property �n any ocner �oun[y in cne �cace o� �namna:
Yes No If yes, what County and Taxing District? /�
Has this deduction been requested on that property for the current year? Yes No
Amount Allowed
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COUNTY
REVIEW
ACTION
AP�V�D �IN .A�U� $
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REMARKS
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SECREI'ARY OF BOAIN
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`See False Sfslement Penalty Below
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IOM'�ER'S ULL NAME�
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