Mortgage_Nossett (2) 5.( t°v STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County I Township I Year
FOR DEDUCTION FROM ASSESSED VALUATION
1 , State Form 43709(R13/10-15) � •Prescribed by Department of Local Government Finance
INSTRUCTIONS: j ; : it..Ma-;
To be filed in person or by mail. Form filed with:
Filing Dates: 1)Real Property:Must be completed and dated in the calendar year for which the deduction is sought. ki Ay 2 5 Z +
Must be filed or postmarked with the County Auditor or County Recorder of the county where the propeny*is' County Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2)Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the co. ty .
where the property is located during the twelve(12)months before March 31 of each year the deduction i Jr r`f .-i 'rat
See reverse side for additional instructions and qualifications. 61�"Otl COI)N,-.• %-I I`!T LlR
Applicant(owner or contract buyer-see restrictions on reverse side)
JEFFREY D. NOSSETT , JAMIE L. NOSSETT
Taxing District Key number/legal description Record(1}�6er P g number
Barton Township I I Pt NW NE Sec 11-T3N-R9W I Y) � ��
Accessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year I assessment date,current year date of application legal or equitable owner?
142,500.00 /S•es No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom [��
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
Beal Property t• nually Assessed
tom obile Home(IC 6-1.1-7)
Name of mortgagee or contract seller 4
Fifth Third Mortgage Company k
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
5001 Kingsley Drive, Cincinnati, OH 45227
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street.city,sate,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county I on property for
in Indiana? Yes ❑No , current year? ❑
❑ a
Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR I
Deduction approved in the amount of:
20 I 20 I 20 I 20 20_ 20 20
Signature of County Auditor County Date(month,day.year)
I/We certify under the penalty of perjury that the above 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.
Signatur (owner's lull name) �L Date(month,day,year)
tads es���FLL %7 /�r S I/1 1 2018
ull dent address of applicant(number and street,city,s, te/and, )
150 E 575 S, Oakland City, IN, 4766047
Person authorized by duly executed Power of Attomey or by IC 6-1.1-12-0.7 I Date(month,day,year)
Address of authorized person(number and street,city,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10.000.
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