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City of South Bend, Indiana <br />Valuable Metal /Scrap Metal Transaction Report <br />(As Required by South Bend Municipal Code § 4-51 <br />Firm Name of Buyer <br />Address of Buyer_ <br />Date of Transaction <br />Zip Code. <br />Time: <br />Name of Seller <br />Driver's License # or Govt. ID# <br />Address of Seller Zip. <br />Motor Vehicle License # of Seller <br />Telephone #'s <br />Make <br />Street Address & Zip Code where metal was located prior to transaction <br />Description of Metal <br />Weight of Metal Price Paid <br />The Seller affirms under pains and penalties of perjury that the above information is true and <br />correct. <br />Signature of Person Completing Form as Seller <br />Right Thumbprint of Seller Left Thumbprint of Seller <br />Buyer is attaching a copy of the driver's license or other government issued identification card which has <br />a picture of the Seller who completed this form. <br />Cell <br />Model Year <br />Buyer shall retain this form for a period of two (2) years. <br />