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0 STATEMENT OF BENEFITS <br />PERSONAL PROPERTY <br />dicta For hWeA (114./ 11=15) <br />Prescribed by the Depadmenl of Local Oovemmerit <br />hi(e�rnr rnriiaere <br />h. <br />Filets in Clark"i tike <br />FORM SB 1 / PP. <br />Any Infametlon ooaoi:r�Ing.the, cost <br />o! the ptupergw and gperflfc solstice paid <br />to Rrdlvldual em braes try.ihe arty <br />ewaeris can Adsplbl per10 B l.7 2"-5.1. <br />2. The sletantent ofbersetits form mustbb adhmNted to the desigpaHng body tW Me of be. desCgnated an 0Dom 010 WVuauzaaon Me DOW me utsraueu0n <br />ofquo*kgsbatable aqulpment rorwhkh the per$6n desfms ibdalm o deducfion. <br />3. To obbsbt.e dttdua4lon, a person rust Ne atodkled deducton schedule wXh the person's personal property m&n on a cerNed didrrct(op schedule <br />(form 1OUM) Koh—me own sh essessorpfthe township Wherethepropeltylsaltuafod brwO thv wwlyassessor frtjrera is rw towx shipassessor <br />for the tcwnshfp•. The 103 -B must be fled between January f and May 15 of rho• assessment yeas• In which now manu%aclut equlpmint <br />8nd1or reseercvt and development equipment and/or ffiq flcai.&dd rulfo{t sq*nvat dmftb kepanadat teclmorogy equipjpenn( h Mstabd an8 f* <br />functlanal anless @ fiiV "nslon hasboon obtainod APOM04 typo obhabrs a tilhtgoxtensibn Mud Ai the form behveen January• d slid the exlendad <br />duo date ofthat ywir. <br />4 PlvpmW owners wlfose Statement openafus was pppmved, must submh form CF-1/PP emual yto show complA wce wltlt the Statement of tdenefffs. <br />(IQ 8•�1.t- t2.1d.8J • <br />3 Fare Faro SB -142P thatis appmuedefiarJund 30, 2013, the des��,et/ngrbodty, Is ra4h t4d to estabKsh anobab anent schedule Areach deduction aAowed. <br />FarbFft88. 1/ PPihatl aapprovldprforf0Julyli2013.Meab mantsdiedtQe'appmvedbYNteda aUli9kQd1' 1x14% (lC6- 1.1- ft'l -179 <br />SECTION <br />• <br />N @me of Iaxpeyer <br />N•trro of ootttect person <br />INDUSTRIAL METAL FAB, .INC. <br />PATRICK FOX -OR- KYLE BEAUDWAY <br />Address oftaWyer (aumbarerdsheet d(W stater grid ZW=*) <br />Iblephone mrm6er <br />2866 WFST :SAMPLE, SOUTH BEND, )N 46618 <br />( 574•) 288,8368 <br />SECTION LOCATION AND DESCRIPTION <br />OF PROPOSED PROJECT <br />Name otdaeleraangbody <br />R•eolutbrtnumber ( s) <br />taae6on�o�fp� rb <br />2806 WE T SAMPLE, SOUTH BEND, IN 46619 <br />County DLW tabil dMW number <br />Sr. absEpN <br />Description ofmanulbeturlttg Iptt W1 and/or research and development equ�ptndnt E3YNff® <br />/oi htfomlaUon tttdtrtofogy equipment. <br />andloi I Istical distribution equipment end <br />lorraf ltnecessarKj <br />STAN7 BATE CobgPL"ON DATE <br />(Usg ad sheets <br />Mimaadt m Equipmeni 10 -15 -16 3 -15 -17 <br />(4pAeria(' I/iocNdit„9 t°.gvlpNUr�t �Patk3nWirTM <br />R &D,Equipment <br />too f .. 1 e js welt H+ 'Slow iwrit ii►venfo r� . Cagier Est EgtrIpmant <br />ITEgWpmtrtf <br />SECTION OF <br />Conantnumber Selman uumber"dow <br />PROPOSED <br />Saq•tes Nurhberaddrdl <br />Saladea <br />SECTION • <br />NOTEe Pursuant to IC 5-1.7 -12.1 1(d) (2) Ilm MANt1FACTUfi�Ia <br />R&D Egt11P�1�IT DIS* <br />fT EQUIPMENT <br />CM AW <br />COST ofthe property is cmftrdtal. do# AW <br />CAST � ® cos'r AW <br />0wrent tiaWs <br />Pkiiiillmated vakies ofpmosed eel <br />Loss vahres of behVieploced <br />tJet es�teled u o0 on ttf <br />CONVERTED AND OTHER <br />Edmeled wpd waste corwerted (corms) <br />FonaledWwrdoW waste 4onvaried.(pound.) -- - <br />ollierbaoelix <br />SECTION G, TAXPAYER CERTI71CATiON <br />t tiara certify that the ieRtesenietions into italement aie into. <br />s otetabedthdrepret•n1aUro <br />Dele Stood h adaltY�O <br />lidnMd iM,II� of zed representslw <br />�e <br />�rntcid ^w>z <br />�• m <br />Page 7 of 2 <br />