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S7•ATEMF.t�ti OF BENEFITS <br />PERSONAL PROPERTY <br />State FbTM.51764 00111=96) <br />Piescdbed by the Department of LOCO <br />INSTRU07IONS <br />Y, This statement must be sdbnOW1 to the body d"JW <br />WgfMafioq %tom the appN t ki inafdng no dediston <br />itibmNted to the desWathrg bbdy BEFORE a parso, <br />iogidNcal distdbatfen equtpnfentondlorinformatlartb <br />g. The smtentantofb9naffis lgnn mustbe submttted10 L <br />of gdalffying abatable equipment far Wift the parsdtr <br />Filed in Clerlr'i office. <br />SEP 61 t 10 <br />to <br />L1t, J <br />FORM S84 t PP <br />UVACY NOTICE. <br />idon <br />""W 7nC . Ipe, wat <br />ty and ip salarkS paid <br />mpwtypatisj.:; a� <br />0agrigrbody regctires <br />a*eft AArea. Otderwlse this statement must be <br />Varteseamh and development egi*meni, and/or <br />r to orahn a dedaoft. <br />ownatnfcrovNafhalknarea befom tha instaNRffM <br />a. 7b obtain a deduction, o pe(son Ausl Nee certh7ed daduclron soneaure wsn we persona persoutar P/opm1Y MWT" on a ceded deduction schadule <br />(Fam► f03 ERA) with'fha tuivnsb 'asbessot of lownshlp whbra the propetiyls situated or the aountyasseawrrifMom Is no towpsmp Assessor <br />far !h8 township. The 103-ER, be hied between January f and'May 15 of the assessment year In whkh bow menuract101 egdIpment <br />andlornrsesrdh end devekpa equlp_ment ondkrAIWOW Osf W00 egplpment epol0r tklowellon Pochnnoo/foop�yy equlpme»!It IWO W and fu0y <br />funclknal, unleas a (Ring axionslop has been obtained, 74 <br />person whoobfabLt a filing eztenslonmust6 the form }. oM*en January 1 andthe extended <br />due date ofthat year. <br />4. Property owners whose Statement of Benefits was approved, must subma Form CF -11PP ennuaftyto show crorn/lllance with Me Statement of 9eneks. <br />(1C 6-1.1 -12. lgrt _ <br />� »�r�„�aa&. boar% ii: apopm�� 'dntJnuJalv4�2013,1thesbaiime� dbYthedesaigpst (rlgbgdyreelnalnsl�fiect. (!C$ -�i2 -17j <br />INFORMATION <br />SECTION <br />Npmeofteveyst Name ofcoraactperson <br />I INDUSTRIAL METAL FAB, .INC. PATRICK FOX -OR- KYLE 13EAUDWAY <br />Mdmu orlaxpayar(kniMberandshee4 c* data, WWZI'oods) <br />Wephone number <br />2866 WEST SAMPLE, SOUTH 136M IN 46619 <br />( 574) 288 78368 <br />SECTION 2 LOCATION AND DEscmpiioN or PROPOSED PROJECT <br />flame gfderfnnounpbody <br />— <br />ke oiugmnumber(a) <br />Location of rN <br />2806 rEN SAMPLE, SOUTH BEND, IN 46619 <br />County <br />ST. 3bwpli <br />DLGF Wang dtetdatnumber <br />Description ofinenufactud►ig ufpmentand /or research and devekWasnCoqui fndnt <br />dtstribulton �mmt and /or Infonnagon todtoology equipment. <br />ESTIMATrED <br />DATE <br />andior toggtsttcai a <br />(Usp addflllehal sheets Ifnecessary•J <br />START PATE <br />coMPLETiON <br />Mehyfactudng Equipment <br />10 -15-16 <br />3 -16 -17 <br />(A qhar)ct( ka .41 t n Pty �� prtM1 ee ►t fa elr .� t,1 i�4M <br />R 8 D Equipment <br />roof . To ,ye- v"A •}. 540- .P Wt lnvinfo <br />1 ogist Dist Equipment <br />IT Equipment <br />SECT ION 3 ESTIMATE • • PROPOSED <br />Currentnumber 8aterNs , Numberrel teed Goodes Numbera"donel Salaries <br />18 $161hr. I. to $16 /hr <br />OF • . <br />SECTION <br />NOTEi Pursuant to IC 6.1.1 -12. 5.1 (d) seethe <br />MANUFACTUNNG <br />R & D 9401PMENT <br />I.O u11ST 818T IT EQli1PMENT <br />BosT of the property Is confidential. <br />dOgT AssE D <br />cosr <br />t� ED <br />cosy <br />��ED co'sr ASSESSED <br />CuhgntWiles <br />Plus iegung ted values or pmposed project <br />Less Values of arpj pr.ogft bekv mplaced <br />I Iet estimated values Kc o bon ofprojeet <br />SIC FION 5' WASTE CONVERTED AND OTHER BENEFITS <br />PROMISED BYTHE TAXPAYER <br />Estimated solid waste converted (Bounds) <br />Estimated hazardoys waste converled(pounds) <br />Olhgr1 -trews <br />TAXPAYER CERTIFICATION <br />SECTION 6 <br />I hereby cerUfy thallow fepresenlatione In the statement are true. <br />ti ofaulhorh4dreprossn'talhe Dale sgned {nronNb dir2'yoa►7 <br />pdntgd name of a. th zed represintativa <br />due <br />rue " Y, <br />M <br />Page 1 012 <br />