4811-19 Confirming Real Property Tax Abatement for Five Corners, LLC

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1-61- 4. COMPLIANCE WITH STATEMENT OF BENEFITS 2023 PAY 2024 i�� ,•= REAL ESTATE IMPROVEMENTS `-.a State Form 51766(R5 i 12-21) FORM CF-1/Real Property MI6 Prescribed by the Department of Local Government Finance PRIVACY NOTICE INSTRUCTIONS: The cost and any specific individual's 1. This form does not apply to property located in a residentially distressed area or any deduction for which the salary information is confidential;the Statement of Benefits was approved before July 1, 1991. balance of the filing is public record 2. Property owners must file this form with the county auditor and the designating body for their review reganjpp per IC 6-1.1-12.1-5.3(k)and(I). the compliance of the project with the Statement of Benefits (Form SB-1/Real Property). �us 3.. This form must accompany the initial deduction application(Form 322/RE)that is filed with the county audtor. Filed In C.lerk'S Office 4. This form must also be updated each year in which the deduction is applicable. It is filed with the county auditor and the designating body before May 16 or by the due date of the real property owner's personal property return that is filed in the township where the property is located. (IC 6-1.1-12.1-5.30) APR 17 2023 5. With the approval of the designating body,compliance information for multiple projects maybe consolidated on one(1)compliance form(Form CF-1/Real Property). DAWN M.JONES SECTION 1 TAXPAYER INFORMATION Name of taxpayer County Five Corners LLC St. Joseph Address of taxpayer p }} DLGF taxing district number Number and Street:814 Marietta St. City: So. Bend State: IN zip:46601 - Name of contact person Email Telephone number First Name: Anne Last Name: Hayes Address: ahayes@telecompark.com (574) 233-1296 SECTION 2 LOCATION AND DESCRIPTION OF PROPERTY Name of designating body Resolution number Estimated start date(month,day,year) Common Council of the City of South Bend 4811-19 11/1/2019 Location of property Actual start date(month,day,year) Number and Street: 1130 S B Ave City:S o. Bend State: IN ZIP:46617 3/1/2020 Description of real property improvements Estimated completion date(month,day,year) Construction and development of a 28,000 SF 5/1/2021 mixed use building. Actual completion date(month,day,year) TBD-still under construction SECTION 3 EMPLOYEES AND SALARIES EMPLOYEES AND SALARIES AS ESTIMATED ON SB-1 ACTUAL Current number of employees 0 0 Salaries 0 0 Number of employees retained 0 0 Salaries 0 0 Number of additional employees 87(indirect) 35 Salaries $65,000 $70,000 SECTION 4 COST AND VALUES COST AND VALUES REAL ESTATE IMPROVEMENTS AS ESTIMATED ON SB-1 COST ASSESSED VALUE Values before project $49,100 Plus: Values of proposed project $4,315,000 Less: Values of any property being replaced Net values upon completion of project $4,315,000 $49,100 ACTUAL COST ASSESSED VALUE Values before project $0 $ Plus: Values of proposed project $4,300,000 $4,222,200 Less: Values of any property being replaced Net values upon completion of project $4,300,000 $4,222,200 SECTION 5 WASTE CONVERTED AND OTHER BENEFITS PROMISED BY THE TAXPAYER WASTE CONVERTED AND OTHER BENEFITS AS ESTIMATED ON SB-1 ACTUAL Amount of solid waste converted 0 0 Amount of hazardous waste converted 0 0 Other benefits: SECTION 6 TAXPAYER CERTIFICATION I hereby certify that the representations in this statement are true. Signature f authorized representative Title Date$ign d(month,day,year) 0i),x. I-16-110 Member, Five Corners fi 7 /3 coa Page 1 of 2