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1- STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
� FOR DEDUCTION FROM ASSESSED VALUATION
State Form 16-09)
� Presented by Department of L ocal Government Finance F I
L
ED INSTRUCTIONS: tt��11((�� 1 �-nmed
To be filed in person or by mail with the County Auditor or County Recorder of the county where the properly is locatBYM� 1 V nets fi`
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought ❑ County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)mon
before March 31 of each year the deduction a sought rah'Recorder
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See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
Applicant(•rr • or mnhact buyef-see -i.•• on reverse file)
Ii . A__ w G _
Taring D'- / • Key number/legal d-•...T Record number Page number
eddI O. ),(p - o dt - 31 - 3o0 - coo. 0. y 3-o/ F ao 14 4 185
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the applicant the sole
Math 1:one year Mann 1,current year data of application legal or equitable owner?
Y
If no,what is his her exact share of interest? If owned with someone other ma ❑
n spouse;Indicate With whom Yes El No
_
If name on record is afferent than that of applicant,Indicate below. I'-•-.renoe,y m quesiim:Annually Assessed
-----° c°ceed
Name of mortgagee or contract seller 7,-(rat _
•Address of mortgagee or contract seller(number and street,city,stale,and ZIP code) DI'a1y AI' N IO.. ! --
Name of assignee or other owner or holder of mortgage '
Card X10 l.
—
1
Addrem of assignee(number and street � .state,and ZIP code)
. T 5A Fill 3r - 1 - ro Y 4G
Does applicant own property in any other If yes,what county? • What Taxing District? Has this deduction been requested on property
county in Indiana? No for wren year?
ID yes El No
yes Li
COUNTY AUDITOR
Deduction approved in the amount ot. •
20 20 20 20 20 20 20
Signatu County Date(month,day,year)
I/We certify under the penalty of perjury and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed. -
�Sigratum •••• Date(month,day,year)
-II resident....-_ t(number and sleet,city,state,anndd ZIP code)9/ ,/ , // //L
?CIS /L: of/-i 7/ / L2.4 r-, ./ #7600
Person authorized by duly executed Power of Attorney or by IC Sae-7=12-0.7 Date(month,day,year)
Address of aurhwized person (number and street city,state,and ZIP code)
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