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1 M <br />SALES DISCLOSURE FORM <br />State Form 46021 (R3/1-00) <br />Approved by State Board of Accounts, 2000 <br />Prescribed by the Slate Board of Tax Commissioners, 1999 <br />Pursuant to 1C 6-1.1-5.5 <br />r <br />irst names) <br />City of South Bend, Indiana M.I_(s) Lastname(s) <br />ddress (number and street) <br />1 4 0 0 C o u n t y — C i t y B l d Primary residence? <br />City. Town or Post office g ❑ Yes CR No <br />South Send State ]NJ ZIP code <br />First name(s) <br />South Bend Heritage Foundation M.I.{s) Lastname(s) <br />Addr�esls (number and street) <br />Lincoln Way West [MILY <br />ary residence? <br />es alloCity, Town or Post offcetate <br />46601 <br />ZIP code <br />h Bend IN 46616 <br />Send tax bills and notices to this address? If no, provide mailing address (number and street, city, state, ZIP cads) <br />ayes ❑ No <br />Street address <br />1316 Liston Street <br />City, Town or Post Office State ZIP code <br />South Bend IN 46601 <br />County Township School Corporation Name <br />St. Joseph Portage <br />EXEMPT TRANSACTIONS (see instructions on reverse side) <br />Exempt Transaction? If yes, specify the number of the exemption. (see "Exempt Transactions" on reverse side) <br />❑>Yes ❑ No <br />DATE OF SALE <br />Month <br />SALES INFORMATION <br />1. Total sales price $ 1.00 <br />Year 1 2. Seller paid points <br />3. Net sales price (line 1 minus line 2) $ 1 . 0 0 <br />Check ALL of the following conditions that apply to this sale, <br />❑ Transfer of entire parcel Q Purchase of adjoining land ❑ Vacant land ❑ Exchange fo p ;ii ('Trade') <br />❑ Seller provided financing ❑ Mobile home ❑ Condominium ❑ Split(s) <br />❑ Existence of family or business relationship between buyer and seller ❑ Personal property included in transf gpa�gd V0111 <br />r-zs <br />Describe any unusual or special circumstances related to this sale, including the specification of any less -than omplet6,:q ershil�-fhtere nd <br />the terms of any seller financing. <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 />l ao—ty Assessor must verrfy and complete the following information: <br />❑ Significant physical changes to property between March 1 and date of sale <br />❑ Current property record card attached <br />❑ Property class 1 use code <br />❑ Parcel / Key number <br />❑ School corporation number <br />❑ Warranty deed? ❑ YES ❑ NO <br />ASSESSED VALUE (AV) INFORMATION <br />AV LAND $ <br />AV IMPROVEMENT(S) $ <br />AV TOTAL $ <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 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 as required <br />by law, and is prepared in accordance with IC 6-1.1-5.5, "Real Property Sales Disclosure Act." <br />Sign to a of Seller or re p re t C <br />sen a i Telephone number Date sig ed (month, day, year) <br />219-235-9241 ��c��� <br />Signature of uyer or representative Telephone number p Date signed (month, day, year) <br />