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o STATEMENT OF BENEFITS <br />REAL ESTATE IMPROVEMENTS <br />State Form 61767 (8219.07) <br />Prescribed by the Department of Local Government Finance <br />This statement Is being completed for real property that qualifies under the following Indiana Code (check one box): <br />❑ Redevelopment or rehabilitation of real estate Improvements QC 6-1.1- 12.1 -4) <br />❑ Eligible vacant building (IC 6-1.1- 12.1 -4.8) <br />20_•• -. PAY 20_ <br />FORM 88.11 Real Property <br />INSTRUCTIONS: <br />1. This statement must be submitted to the bodydeslgnating the Economlc ReWalizollpnArea prior to the pubAc hearing If the designating body requires <br />Information from the applicant in making its'decision about whether to designate an Economic ReWallzation Area. Otherwise this statement must be <br />submitted to the deslgnating body BEFORE the redevelopment orrehablPtatlon of real proportyfor which the person wlshes to claim a deduction. <br />'projects' planned or committed to after July 1, 1967, and areas designated after July 1, 1987, require a STATEMENT OF BENEFITS. <br />2. Approval of the designating body (City Council, Town Board, County Council, etc.) must be obtained prior to Initiation of the redevelopment or rehabEltaflon, <br />BEFORE deduction maybe approved. <br />3. To obtain a deduction, application Form 322 ERA/RE or Fort 322 ERA/VBD, Whichever Is applicable, must be filed with the County Auditor by the later <br />of (1) May 10,• or (2) thirty (30) days after the notice of addition to assessed valuation or new assessment is mailed to the properly owner at the address <br />shown on the records of the township assessor. <br />4. Property owners whose Statement of Benefits was approved after June 30, 1901, must attach a Form CF -VReal Property annually to the application to <br />Mow compliance with the SYatementofBanefftt (IC and IC &1.142.1.5.30)) <br />5. The schedules established under 10 6- 1.1-1214(o for rehabilitated proportyand underIG 6- 1.1- 12.1 - 4.8(1) for vacant bulldbVs apply to any statement. <br />ofbanefits approved on orafterJuly 1, 2000. The schedules effective prior to July 1, 2000, shag continue to apply to a statement o1 benaflts filed before <br />_ uh, -t onnn <br />• r • <br />Name of taxpayer <br />C. Leo <br />Address of taxpayer (number and stmar, dry, state, and rPcoda) <br />3 yn - c C7 <br />Name of contact person 1 <br />Tel tone number <br />E ma9 addre <br />SECTION LOCATION r DESCRIPTION OF -.•. , PROJECT <br />Name of deslgnatrng body <br />G 177 • o r '5o r-Th �JEn) Q vv.or Q•t-(.vt -c-t <br />Resolution number <br />Location of Rjyperty <br />�>7a� <br />County r( <br />157• IS <br />DLGFtextng dlsbid number <br />1%AW4-67 <br />'FP <br />Description of real property Improvements, redevelopment, or rehablitanon (use addiWnaf sheats ftneeessmy) <br />Estimate date (month, day, year) <br />/o8 <br />7- /+rEn�T �nMDt �X SEE e><tgt.8rT "�'." (1694— v. <br />/D r <br />Estlmat w letlon date (month, dayyearj <br />,4PA�- i <br />/o�r��I <br />SECTION OF • AND SALARIES AS RESUILTOF • • • • r PROJECT <br />Current number Salads Numberretolned Salaries Number additional Salaries <br />W Q yg'Sf btu d <br />D o <br />SECTION 4 TOTAL COSTAND VALUE <br />OF PROPOSED PROJECT <br />NOTE: Pursuant to IC 6.1.1- 12.15.1 (d) (2) the COST of the-property <br />REAL ESTATE IMPROVEMENTS <br />COST <br />ASSESSED VALUE <br />Is confidential. <br />Current values <br />O <br />/ IoGD o1v0 <br />Plus estimated values of proposed project <br />% q61 <br />1/1 ,7.;R y! 1 <br />Less values of any property being replaced <br />$ <br />516 <br />Net estimated values upon completton of project <br />SECTION • r AND OTHER BENEFITS PROMISED <br />Estimated solid waste converted (pounds) A11A <br />Esttma u s <br />Other benefits ( i6r <br />AN 2 9 2008 <br />JOHN VOORDE <br />CITY CLERK, S0. BEND, IN. <br />SECTION 6 TAXPAYER CERTIFICATION <br />I hereby certify that the representations in this statement are true.# o ' A <br />Signature of euftrized representative <br />Tate <br />Date signed (month, day, year] <br />V r' Pe'�izAv'Y <br />1, y " CJ <br />Page 1 of 2 <br />