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b <br />0W... <br />SALES DISCLOSURE <br />State Form 45021 (R219.98) <br />1998 <br />Prescribed by the State Board of Tax Commissioners <br />Pursuant to IC6-1.1-5.5 <br />Approved by State Board of Accounts, 1996 <br />Last <br />First name(s) <br />City of South Bend <br />Address (numberandstrPLV <br />1400 county -city Buildi <br />City, Town or Post Office <br />South Bend <br />First namets) <br />Solon <br />Address (number and street) <br />308 N. Cushing Street <br />City, Town or Post Office <br />South Bend <br />San2i rax bills and notices To rn19 1 no <br />iddress7 Yes ❑ Yes ❑ No <br />Address (number and street) <br />r 714 Oak Street <br />City, Town or Post Otftce <br />South Bend <br />County <br />St, 3oseph <br />Notwithstanding IG 5.14-3c re, a safes d'Iy onl <br />sure form is not h0ubStateoBoard mo{ T 1, <br />be used by arsons acting on Its behalf, <br />Commissioners, P <br />or officials acting under the authorization o <br />P.L. 84-1995 Sec. 7• <br />State <br />Orfanos <br />EXEMPT TRANSAGTIUNtp seems: <br />xempt transaction? �(see��Ex-empt <br />�exemplton number <br />(� Ye�D�& ns' on other side) <br />SALES INFORMAT <br />1. Total Sales Price <br />DATE OF SALE <br />Month Day Year <br />0'- 9 3 0 1 9 <br />❑ Transfer of entire parcel <br />❑ Existence of a family or business <br />relationship between buyer and seller <br />❑ Setter provided financing <br />Describe any unusual or special circumt <br />the terms of any seller financing: <br />2. Seller Paid Points <br />on reverse side <br />:9D 3. Net Sales Price {item 1 minus item 2)Chck ALL of the following conditions that apply to this sale: <br />❑ Vacant Land ❑ Exchange for other Real <br />Property ('Trade <br />❑ Personal Property included in ❑ Condominium <br />transfer (estimated value <br />a. ) ❑ Mobile Home <br />County Auditor must verify and complete the following information: <br />❑ Buyer and Seller Information ❑ Sates Price <br />❑ Address of Property Transferred ❑ Conditions of Sale <br />❑ Date of Sale ! Transfer <br />ust verify and complete the following information <br />County Assessor m <br />❑ Significant physical changes to property between March 1 and <br />date of sale <br />Current Property Record Card Attached <br />Property Gtass / use Code: <br />ng the specitication of any <br />Parcel / Key Number: <br />Warranty Deed? ❑ Yes ❑ No <br />ASSESSED V <br />AV Land: <br />AV Improvement(s): <br />AV Total: <br />code <br />code <br />.6616 <br />State r4660101 <br />code <br />IN <br />School corporation <br />$ 150.00 11 <br />$ � 1 <br />$ 150-00 <br />❑ Purchase of adjoining land <br />❑ Split(s) <br />mmnlete ownership istterest, a <br />AV INFORMATION <br />$ <br />The parties to a real property conveyance are required 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 Ciass 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 re d by law, and is prep accordance with IC 6-1.1-5.5, Real Property Sales Disclosure Act". <br />9n e s er or r Telephone number Date signed (month, day, year) <br />Michelle L. Engel (219) 235-9241 9 30 99 <br />Signature of buyer or representative Telephone number Date signed (month, day, Year) <br />