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aE• ^.4 SALES DISCLOSURE <br />4 L State Form 46021 (A2 / 9-98) Notsure f h ri is not <br />iG public <br />record <br />a sates ai only _ sure form is not a public recortl and may only <br />r Prescribed by the State Board of Tax Commissioners 1996 be used by the State Board of Tax <br />�� J�. Pursuant to IC 6.1.1.5.5 Commissioners, persons acting on its behall. <br />Approved by State Board of Accounts, 199E or officials acting under the aulhonzation of <br />P.L. 84.1995 Sec. 7. <br />names) <br />First name(s) �Last <br />City of South Bend <br />'Address (number and street) <br />1400 County -City Building <br />ZIP code <br />City, Town or Post Office <br />:�:A]SJa,.,e <br />4660: <br />South Bend <br />mes) M.I.(s) Last name(s)ghborhood <br />Housing Services, Inc <br />(number and street). <br />Box 1972 803 N. Notre Dame Avenuewn <br />[Address <br />State <br />ZIP code <br />or Post Office <br />46634 <br />th BendIN <br />tax bilks and notices to this If no, provide mailing address:ss' <br />® Yes ❑ No <br />and sfree!)2 <br />East Sorin Street <br />Post OfficeState <br />Z!P code <br />1,ITownship <br />VAddressmber <br />th Bend <br />ZN <br />School corporation <br />Joseph <br />EXEMPT TRANSACTIONS see instructions on reverse side <br />Exempt transaction? II Yes, specify the exemption number L�Yes ❑ No (see 'Exempt Transactions" on other side) 4 <br />SALES INFORMATION <br />1. Total Sales Price $ 10.00 <br />DATE OF SALE <br />2. Seller Paid Points $ } <br />Month Day Year <br />i F7-- E�2� 4J `/ � 3. Net Sales Price (item 1 minus item 2) $ 10.00 <br />Check ALL of the following conditions that apply to this sale: <br />❑ Transfer of entire parcel ©- vacant Land ❑ Exchange for other Real ❑ Purchase of adjoining land <br />Property ('Tradel <br />❑ Existence of a family or business ❑ Personal Property included in ❑ Condominium ❑ Split(s) <br />relationship between buyer and seller transfer (estimated value <br />0 Seller provided financing $ ) ❑ Mobile Home <br />Describe any unusual or special circumstances related to this sale, including the specification of any less than complete ownership interest, and <br />the terms of any seller lnancing: <br />County Auditor must verify and complete the following information: <br />❑ Buyer and Seller Information ❑ Sales Price <br />❑ Address of Property Transferred ❑ Conditions of Sale <br />❑ Date of Sale / Transfer <br />County Assessor must verity and complete the following information <br />❑ Significant physical changes to property Between March 1 and <br />date of sale <br />❑ Current Property Record Card Attached <br />Property Class / Use Code: <br />Parcel / Key Number: <br />Warranty Deed? ❑ Yes ❑ No <br />ASSESSED VALUE AV INFORMATION <br />AV Land: $ <br />AV Improvement(s): I $ <br />AV Total: i s <br />The parties to a real property conveyance are regwred to file this form and attest in writing and under the penalties of perjury that the information contained <br />herein is true and correct. A person who knowingly and intentionally falsifies or omits any information required on this form commits a Class A infraction. <br />Under Penalties of Perjury, I hereby certify that this Sales Disclosure, to the best of my knowledge and belief, is true, correct and complete <br />as required by law, and is prepared in accordance with IC 6-1.1-5.5, "Real Property Sales Disclosure Act". <br />Signatur I �o sent ttv Telephone number Date signed (month, day, year) <br />lle L. Lng�l, Assistant City Att (21.9) 235-9241 12/16/99 <br />signature at buyer or repreisentatwo Totophone number Date signed (month, day, yca,) <br />Anrtc T3oc�ccn]camla ( ) <br />