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STATEMENT OF BENEFITS 20 PAY 20 i 1, REAL ESTATE IMPROVEMENTS Slate Form 51767(R6110-14) FORM SB-1/Real Property L.1. Prescribed by the Department of Local Government Finance PRIVACY NOTICE This statement is being completed for real property that qualities under the following Indiana Code(check one box): Any information concerning the cost Redevelopment or rehabilitation of real estate improvements(IC 6-1. 1-12.1-4) or the property and speclfc salaries Residential) distressed area(IC 6-1.1-12.1-4.1) prop to individuali confidemploentiall p theResidentiallypropertyowneris confidentlal per INSTRUCTIONS: IC 6-1 1-12.1.5.1 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 322/RE 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 afterApril 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 CountyAuditor and designating body with a Form CF-1/Real Property. The Form CF-1/Real Property should be attached to the Form 322/RE when the deduction is first claimed and then updated annually for each year the deduction is applicable. lC 6-1.1-12.1-5.1(b) 5. For a Form SE-1/Real 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-1/Real 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 SECTION 1 TAXPAYER INFORMATION Name of taxpayer IWSJM-INC Address of taxpayer(number end street,city state,and ZIP code) 1301 East Douglas Road, Mishawaka, IN 46545 Name of contact person Telephone number E-mail address Dave Doetsch 269-925-1111ved@midwestfamilyswmi.com SECTION 2 LOCATION AND DESCRIPTION OF PROPOSED PROJECT Name of designating body Resdutton number City of South Bend, IN Location of property County DLGF taxing district number 316 East Monroe Street St.Joseph Description of real property Improvements,redevelopment,or rehabditabon(use additional sheets if necessary) Estimated start date(month,day,year) July 1,2020 The 18,185sf building was built in 1985. It is a vacant 2 story building. It will re renovated to Estimated completion dab(month,day,yea' February 26,2021 SECTION 3 ESTIMATE OF EMPLOYEES AND SALARIES AS RESULT OF PROPOSED PROJECT Current number Salaries Number retained Salaries Number additional Salaries 23 1,028,560 23 1,028,560 3 SECTION 4 ESTIMATED TOTAL COST AND VALUE OF PROPOSED PROJECT REAL ESTATE IMPROVEMENTS COST I ASSESSED VALUE Current values 235,000 Plus estimated values of proposed project 3,100,600 Less values of any property being replaced 0 Net estimated values upon completion of project SECTION 5 WASTE CONVERTED AND OTHER BENEFITS PROMISED BY THE TAXPAYER n/a Estimated solid waste converted(pounds) Estimated hazardous waste converted(pounds) Other benefits SECTION 6 TAXPAYER CERTIFICATION I hereby certify that the representations in this statement are true. Signature of authorized pre niative Date signed(month,day,year) 14/8120 Prin a of authorized rep n aloe tie Dave Doetsch President Page 1 of 2