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Filed ill C:Ierk's Office <br /> �.:. STATEMENT OF BENEFITS f - FORM SB-1 /PP <br /> PERSONAL PROPERTY r ) <br /> State Form 51764(R4/11-16) SEP 2 G L0 I t <br /> Prescribed by the Department of Local Government Fine ce PRIVACY NOTICE <br /> I<IIi�EEN1AH FOWLER Any Information concorning the cost <br /> of the properly and specific salaries paid <br /> CITY CLERK,SOUTI iFND,iN to Individual employees by the property <br /> ND,.IN ovmer Is confidential per IC 6-1.1-12.1.5.1. <br /> INSTRUCTIONS <br /> y, This statement must be submitted to the body designating the Economic Revitalization Area prior to the public hearing if the designating body requires <br /> information from the applicant In making its decision about whether to designate an Economic Revitalization Area. Otherwise this statement must be <br /> submitted to the designating body BEFORE a person installs tire new manufacturing equipment and/or research and development equipment,and/or <br /> logistical distribution equipment and/or information technology equipment for which the person wishes to claim a deduction. <br /> 2. The statement of benefits form must be submitted to the designating body and the area designated an economic revitalization area before the installation <br /> of qualifying abatable equipment for which the person desires to claim a deduction. <br /> 3. To obtain a deduction, a person must file a certified deduction schedule with the person's personal property return on a certified deduction schedule <br /> (Form 103-ERA)with the township assessor of the township where the property is situated or with the county assessor if there is no township assessor <br /> for the township. The 103-ERA must be filed between January 1 and May 15 of the assessment year in which new manufacturing equipment <br /> and/or research and development equipment and/or logistical distribution equipment and/or Information technology equipment is installed and fully <br /> functional,unless a filing extension has been obtained. A person who obtains a filing extension must file the form between January 1 and the extended <br /> due date of that year <br /> 4. Property owners whose Statement of Benefits was approved,must submit Form CF-1 1PP annually to show compliance with the Statement of Benefits. <br /> (IC 6-1.1-12.1-5.6) <br /> 5. For a Form SB-1 1PP that is approved after June 30,2013,the designating body is required to establish an abatement schedule for each deduction allowed. <br /> For a Form SB-l1PP that is approved prior to July 1,2013,the abatement schedule approved by the designating body remains in effect. (IC 6-1.1-12.1-17) <br /> SECTION TAXPAYER INFORMATION <br /> Name of taxpayer Name of contact person <br /> Tri-Pac, Inc. Vikram Shah <br /> Address of taxpayer(number end street,city,slate,and ZIP code) Telephone number <br /> 3333 N Kenmore St,South Bend,IN 46628 ( 269 ) 476-2303 <br /> SECTION 2 LOCATION AND DESCRIPTION OF PROPOSED PROJECT <br /> Name of designating body Resolution number(s) <br /> South Bend City Council <br /> Location of property County DLGF taxing district number <br /> 3333 N Kenmore St,South Bend,IN 46628 St Joseph 009/003 <br /> Description of manufacturing equipment and/or research and development equipment ESTIMATED <br /> and/or logistical distribution equipment and/or information technology equipment. START DATE COMPLETION DATE <br /> (Use additional sheets if necessary) <br /> Manufacturing equipment Manufacturing Equipment 11/15/2017 12/31/2019 <br /> R&D Equipment <br /> Loglst Dist Equipment <br /> IT Equipment <br /> Current number Salaries - Number retained Salaries Number addalonal Salaries <br /> 7 $495000 7 $495000 20 $748,800 <br /> MANUFACTURING R&D EQUIPMENT LOGIST DIST IT EQUIPMENT <br /> NOTE:Pursuant to IC 6-1.1-12.1-5.1 (d)(2)the EQUIPMENT EQUIPMENT <br /> COST of the property is confidential. COST ASSESSED COST ASSESSED COST ASSESSED COST ASSESSED <br /> VALUE VALUE VALUE VALUE <br /> Current values I _ <br /> Plus estimated values of proposed project 1.500,0001 450,000 <br /> Less values of any property being replaced I — <br /> Net estimated values upon completion of project 450,000 <br /> Estimated solid waste converted(pounds) Estimated hazardous waste converted(pounds) <br /> Other benefits: <br /> SECTION • <br /> I hereby certify t at the representations In t atemenl are true. _ <br /> Signature f aulh ze representative �� Date signed(month,day,year) <br /> L'—L- _. September 21, 2017 <br /> Printed name of authorized representative Title <br /> Vikram Shah President _ <br /> Page 1 of 2 <br />