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ram~ rxRp use inSSA cPhONSty (8193) <br />PART I - TO BE COMPLETED <br />=first name HY BUYER AND SELLER <br />lR r <br />f� Alliance Associates <br />Social Security number or Federal 1D number (optional) <br />a <br />Gr7 <br />Address (number and street) <br />City, <br />First name <br />ct; he Civil Cxt of South Bend, <br />Social Security number or Federal ID number {optional) <br />q <br />Address (nutttber Wand <br />Address (number and street) <br />�FW <br />Parcel or Key number <br />Ao 25; 1014 023804, 023832 <br />`AQC4O County <br />- I ;-ast name <br />Town or Post Office <br />:7=$1 <br />Town or Pos[ Office <br />Ciry, Town or Post Office <br />Township name <br />Property class code (check one) <br />❑Residential ❑Commercial <br />Mineral ❑ Agricultural <br />Ll Industrial <br />Other (specify) <br />PRIVACY NOTICE Notwithstanding IC 5-14-3, a sales disclo- <br />sure form is not a public record and ma <br />only be used by the State Board of Tax y <br />Commissioners or per <br />acting on behalf <br />of the State Board of Tax Commissioners. <br />State ZIP code <br />rate ZIP code <br />ET AL <br />1VIYE 'TRANSACTIONS <br />oes the transaction qualify as an exempt transaction? If Yes, specify the number of the exemption and skip to the signature section on page 2. <br />exemption see section entitled "Exempt Transactions belosv) <br />® Yes ❑ No P g (TO determine the number of rite <br />Exempt Transactions Reason number: <br />The Declaration of Value section of this form does not have to be completed for any document presented for recording which clearly indicates on such document that it is an <br />exempt transaction. If the transaction meets one of the conditions listed below, please indicate that the transaction is exempt and provide the reason number. <br />I. Security interest document such as mortgage and trust deeds <br />2. Leases that are for a term of less than ninety <br />90 7. Transfer for no consideration or gift <br />3. Document for compulsory transactions as result of foreclosure or express <br />8. Documents involving the partition of land tenants in common, joint tenants <br />threat er foreclosure, divorce, court order, condemnation or probate or tenants by the entirety <br />4. Transfer t a charity 9. Re-recording to correct prior recorded document <br />5. Agreements and other documents for mergers, consolidations and <br />10. Deeds placed in escrow prior to July 1, 1993 <br />incorporations involving soley nonlisted stock 11. Easemems/Right of Way Grants for no consideration <br />6- Quitclaim deeds not serving as a source of title 12. Documents executed prior to July 1, 1993, but not previously recorded <br />atgnature and Verification Section <br />The parries to a real property conveyance document are required to file this form and attest in writing and under die penalties of perjury that the information is true <br />contained herein <br />and correct. A persoa who knowingly and intentionally falsifies anyinformation required on this form commits a Class C misdemeanor, <br />Uuder Penalties of Perjury, I hereby certify that this Sales Disclosure, to fhe hest of my lutowledge and belief, is true, correct and complete as <br />required by law, and is prepared in accordance with IC ti-1.I-5.5, "Real Property Sales DiscIoslrre Act . <br />Signature of buyer or representative P <br />Telephone number <br />Signature, f seller or <br />day, year) <br />TO BE COMPLETED BY THE AUDITOR AND R <br />This instrument prepared by: Louis Klatch, Attorney at Law 11004665 <br />