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—,'''!',-,\ STATEMENT OF BENEFITS <br /> q PERSONAL PROPERTY FORM SB-1 /PP <br /> • 1"• 't , Slate Form 51764(R4!11-15) <br /> r Prescribed by the Department of Local Government Finance PRIVACY NOTICE <br /> Any Information concerning the cast <br /> of the property and specific salaries paid <br /> to individual employees by the property <br /> owner is confidential per IC e-1 1-12.1.5 1. <br /> INSTRUCTIONS <br /> 7. 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 the 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-I/PP 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/PP that is approved after June 30,2013,the designating body is required to establish an abatement schedule for each deduction allowed. <br /> Fora Form SB-1/PP 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 1 TAXPAYER INFORMATION <br /> Name of taxpayer Name of contact person <br /> WSJM-INC Dave Doetsch <br /> Address of taxpayer(number and street,city slate,and ZIP code) Tatephone number <br /> 1301 East Douglas Road,Mishawaka, IN 46545 269-925-1111 <br /> SECTION 2 LOCATION AND DESCRIPTION OF PROPOSED PROJECT <br /> Name of designating body Resorul on number(s) <br /> City of South Bend <br /> Location of property County DLGF taxing district number <br /> 316 East Monroe Street St.Joseph County . <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 <br /> . <br /> R&D Equipment <br /> Logist Dist Equipment <br /> IT Equipment 12/7/20 2/12/21 <br /> SECTION 3 ESTIMATE OF EMPLOYEES AND SALARIES AS RESULT OF PROPOSED PROJECT <br /> Current number Salaries Number retained Salaries Number additional Salaries <br /> 23 $1,040,520 23 $1,040,520 l S104,957 <br /> SECTION 4 ESTIMATED TOTAL COST AND VALUE OF PROPOSED PROJECT <br /> NOTE Pursuant to IC 6-1.1-12.1-5.1(d)(2)the MANUFACTURING R&D EQUIPMENT LOGIST DIST IT EQUIPMENT • <br /> EQUIPMENT EQUIPMENT <br /> COST of the property is confidential. COST COST ASSESSED ASSESSED ASSESSED ASSESSED <br /> COST VALUE VALUE VALUE COST VALUE . <br /> Current values <br /> Plus estimated values of proposed project $50,000 SBCD,000 • <br /> Less values of any property being replaced 0 <br /> Net estimated values upon completion of project r <br /> SECTION 5 WASTE CONVERTED AND OTHER BENEFITS PROMISED BY THE TAXPAYER <br /> Estimated solid waste converted(pounds) Estimated hazardous waste converted(pounds) . <br /> Other benefits. <br /> SECTION 6 TAXPAYER CERTIFICATION <br /> I hereby certify that the representations in ttys}statement are true. <br /> Si nature of authrxiz re - ntative / Dela signed(month,day.year) <br /> f April 8, 2020 <br /> Print name of authorized representafive I Title <br /> Dave Doetsch President <br /> Page 1 of 2 <br />