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i FORM 5A - IiEVISED 19�) • �
PRESCRIBED BY STATE BOARU OF TAZ COMM13910NER$ �
AFFIDAVIT �F MO TGAGE INDEBTEDNESS .
To Be Filed in Duplicate each year by Lieensed Financial Institutions, Licensed Real Estate '
Broker or Abstract Companies with the county auditor (in which� the property is loeated) be-
tween Diarch 1 and blay 10, inclusive
'•' Qualifications On Back •'• �—�
�ibson /L��/`/
STATE OF INDIANA COUNTY, s9:
I, �we> y ewig s Detivigs Elevator�Qiy�,c_
(FULL NAME)
being duly sworn, upon oath certify that I, (We) was/were legal resident(s) of the State of Indiana and oa-ner(s) of real
property on lfarch 1, 19 82 on which a bona £idc mortgage existed, and that this statement is made for the purpose of
obtaining a mortgage deduetion from that real property located in Taxing District (City, Town, Township)
Haub�tadt
Legal Description/or Kep Number NZ Of CH/4 of 31-3-10 ���A�
Name on property tax records if different from above?
Are you the sole owner of the real estate? Ye� , No ,
If no, what is your exact share of interest in it?
Assessed value of real estate as of Maich 1, cunent year
Amount of Mortgage Indebtedness unpaid as of March 1, Current pear g 46, 394
Described to �cit:
• • -%`� • •
Drawer 4 Card 388
➢Sortgage recorded �ibson County Reeorder's Office, Record No. Page —
Name and address of mortgagee Haub�tadt State Bank
Do Sau know if there is any assignee or bona fide owner or holder of the mortgage? Ye� , A'o , If pes,
what is the name and residence?
Does the owner of the above described rea] property own real property in any other County in the State of
Yes , No , If yes, what County and Taxing District?
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Has an age or mortgage deduc on been requested on that property? Ye� No .
.1CTIOti—COU�TY BOARD OF REVIEW
Approved in amount of
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Date ��! �t�1� i �R � �� f� 1,� O
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— � _ � 6- a,s -�8,, B. �-,�,
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� • See False Statement Penalty�
L� �!!y�,�OWNER'S FULL
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(PEXSON AVTX00.12EO BY �ULY EXECUTEO POWER OF .�TTONNETI
(FULL XESIOENCE �O�RE55 OF OWNER - MUST BE GIVENI
AOONE53 OF AUTHOR�2EO PERSON
Subscribed and sworn to before me, the undersigned
Deni�e A. Taylor -- , in and for said County,
this 29 ay of A �, 19—
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(Sea�: Notarv °ublic - � � �