18-44 Modifying and Reconfirming Resolution for JSK Development-Southhold- Courtyard Marriott Downtown

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�e4 STATEMENT OF BENEFITS 20_PAY 20_ REAL ESTATE IMPROVEMENTS State Form 51767(R6110-14) FORM SBA i Real Property a e' Prescribed by the Department of Local Government Finance PRIVACY NOTICE This statement is being completed for real property that qualifies under the following Indiana Code(check one box): Any information concerning the cost of the property and specific salaries ❑Redevelopment or rehabilitation of real estate improvements(IC 6-1.1-12.1-4) paid to individual employees by the ❑Residentially distressed area(IC 6-1.1-12.1-4.1) property owner is confidential per IC 6-1.1-12.1-5.1. INSTRUCTIONS. 1. This statement must be submitted to the body designating the Economic Revitalization Area prior to the public hearing if the designating body requires information from the applicant in making its decision about whether to designate an Economic Revitalization Area. Otherwise,this statement must be submitted to the designating body BEFORE the redevelopment or rehabilitation of real property for which the person wishes to claim a deduction. 2. The statement of benefits form must be submitted to the designating body and the area designated an economic revitalization area before the initiation of the redevelopment or rehabilitation for which the person desires to claim a deduction. 3. To obtain a deduction,a Form 3221RE must be filed with the County Auditor before May 10 in the year in which the addition to assessed valuation is made or not later than thirty(30)days after the assessment notice is mailed to the property owner if it was mailed after April 10. A property owner who failed to file a deduction application within the prescribed deadline may file an application between March 1 and May 10 of a subsequent year 4. A property owner who files for the deduction must provide the County Auditor and designating body with a Form CF-1lReal Property. The Form CF-1lReal Property should be attached to the Form 3221RE when the deduction is first claimed and then updated annually for each year the deduction is`applicable. iC 6-1.1-12.1-5.1(b) 5. For a Form SB-1 1Real Property that is approved after June 30, 2013, the designating body is required to establish an abatement schedule for each deduction allowed. For a Form SB-11Real Property 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 i SECTION I TAXPAYER '" • Name of taxpayer 5S K IJEVEL OP/'�EtiTr.,n —�oNT/z'y0 GLG Address of taxpayer(number and street,city,state,and ZIP code) 247 North Dixieway, South Bend, IN 46637 Name of contact person Telephone number E-mail address AJ Patel ( 574 ) 387-4467 info @'skhotel.com SECTION DESCRIPTION OF PROPOSED PROJECT Name of designating body Resolution number South Bend Common Council 4 S I - I S" Location of property County DLGF taxing district number 121 St. Joseph St., South Bend, IN 46601 St. Joseph Description of real property improvements,redevelopment,or rehabilitation(use additional sheets if necessary) Estimated start date(month,day,year, Construction of 120 room hotel August 1, 2015 Estimated completion date(month,day,year) March 1, 201.7 Current number Salaries Number retained Salaries Number additional Salaries 0.00 $0.00 0.00 $0.00 38.00 $1,108,723.20 REAL ESTATE IMPROVEMENTS COST ASSESSED VALUE Current values 0'00 Plus estimated values of proposed project 6,750,000-00 Less values of any property being replaced 0.09 Net estimated values upon completion of project 8,750,000.00 . . • • Estimated solid waste converted(pounds) Estimated hazardous waste converted(pounds) Other benefits SECTION • I hereby certify that the representations in this statement are true. Signature of authorized represen ' Date signed(month,day,year) May 12, 2015 Printed name of authorized representative Title Page 1 of 2