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Prescribed by the State Board of Tax Commissioners 1998 <br />Pursuant to 1C 6-1.1-5.5 <br />'°• Approved by State Board of Accounts, 1998 <br />First name(s) <br />1--CitY of South Bend <br />1400 Count -Cit Building <br />City, Town or Post Office <br />South Bend <br />First names) <br />Nei hborhood Housing Services <br />Address (number and street) <br />803 N. Notre Dame Ave. <br />City, Town or Post Otlice <br />South Bend, <br />Send tax bills and notices to this <br />address? If no, <br />® Yes ❑ No <br />UA(numberandsreet)6 Arthur Street <br />n or Post Office <br />uth Bend <br />W-(s) Last— n1 <br />f.(s) Last <br />(P-0- BOX 1972) <br />address: <br />St. JOse h Township <br />EXempt transaction? EXEMPT TRANSACTIONS see instructions on reverse; <br />If Yes, spec+fy the exemption number <br />® Yes ❑ No (see 'Exempt transactions' on other side) <br />SALES INFORMAT(ON <br />DATE OF SALE I. Total Sales Price <br />Month Day Year 2. Seller Paid Points <br />1 0 1 8 1 g 9 3. Net Sales Price (item 1 minus item 2) <br />Transfer of entire parcel Check ALL of the following conditions that apply to this sale: <br />❑ <br />❑ Vacant Land <br />❑ Exchange for other Real <br />❑ Existence of a family or business Property ('Trade'} <br />relationship between buyer and seller Personal Property included in <br />transfer (estimated value El Condominium <br />❑ Seller provided financing <br />Describe any unusual or special circumstances <br />the terms of any seller financing: <br />County Auditor must 0 <br />verify and complete the following information: <br />' <br />Buyer and Seller Information <br />❑ Safes Price <br />❑ Address of Property Transferred <br />❑ Conditions of Sale <br />❑ Date of Sale / Transfer <br />❑ Mobile Nome <br />uding <br />any <br />Notwithstanding IC 5-14-3, a sales disclo- <br />sure form is not a public record and may only <br />be used by the State Board of lax <br />ommissners, on its <br />OrOfficials acting understheta 9hori2abeh llf, <br />P.L. 84-1995 Sec. 7. <br />State —7ZIP code <br />IN 4660I <br />IN 1ZIP code <br />46634 <br />State ZlPcode <br />School corp- <br />Oration <br />$ t0.00 <br />$10.00 <br />❑ Purchase of adjoining land <br />❑ Split(s) <br />complete ownership interPcr <br />Parcel / Key Number: 18 - 5 0 7 8- 2 7 3 2 <br />Warranty Deed? <br />[]Yes []No <br />County Assessor must verify and complete the following information: <br />s- <br />❑ Significant physical changes to grope ASSESSED VALUE AV INFORMATION <br />date of sale dl' between March 1 and <br />Current Property AV Land: <br />p trty Record Card Attached $ <br />Property Class / Use Code: <br />AV Improverniant(s): r$ <br />wgr. AV Total: $ ------ <br />The parties to a real Proper <br />ty conveyance are required to file this form and attest in writing and under the penalties of per'u t <br />herein is true and correct. A person who knowingly and intentionally falsifies or omits any information <br />Under Penalties of Perjury, I hereby certify that this Sales Disclosure, to the best of m <br />as required by law, and is prepared in accordance with 1C 6-1,1-5-g, . 1 ry that the information contained <br />n required on this form commits a Class A infraction. <br />Signature Y his <br />and belief, is true, correct and complete <br />r repre tativ Real Property Sales Disclosure Act", <br />Telephone number <br />signature of bu 141 the l l e Date Signed (month, <br />ycr or representauvo Engel 1 It 1 9) tlaY, year) ' <br />235-9241 <br />Telephono numbor <br />( <br />