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2 SALES DISCLOSURE FORM <br />a t <br />State Form 46021 (R3t1-00) <br />Approved by State Board of Accounts, 2000 <br />• • Prescribed by the State Board of Tax Commissioners, 1999 <br />Pursuant to IC 6-1.1-5.5 <br />First name(s) <br />+ City of South Bend, Indiana <br />M.I.(s) <br />Last name(s) <br />Address (number and street) <br />Primary residenc!�Ve <br />1400 — C i t Bldg. <br />City, Town or Post office <br />❑ Yes KI No <br />South Bend <br />State 1 N 6601 <br />First name(s) <br />South Bend Heritage <br />Foundation <br />M.1.(s) <br />Last name(s) <br />Address (number and street) <br />914 L i nco 1 nway West <br />Primary residenc <br />❑Yes (lNo <br />City Town qqr Post Office <br />Soutrl Bend <br />Stat <br />Send tax bills and notices to this address? <br />If no, provide mailing address (number and street, city, state, ZIP code) <br />k1 Yes ❑ No <br />Street address <br />1227 West Colfax <br />' City, Town or Post Office <br />State <br />ZIP code <br />South Bend <br />IN <br />46601 <br />County <br />Township <br />School Corporation Name <br />St. Joseph <br />Portage <br />EXEMPT TRANSACTIONS (see instructions on reverse side) <br />Exempt Transaction? <br />If yes, specify the number of the exemption. (see "Exempt Transactions" on reverse side) <br />6Yes ❑ No <br />SALES INFORMATION <br />1. Total sales price <br />$ 1 . 00 <br />DATE OF SALE <br />2. Seller paid points <br />$ ) <br />Month Day <br />Year <br />3. Net sales price (line 1 minus line 2) <br />$ 1 . 00 <br />Check ALL of the following conditions that apply to this sale. <br />D Transfer of entire parcel ❑ Purchase of adjoining land ❑ Vacant land a Exchange for oth Trade') <br />❑ Seller provided financing ❑ Mobile home <br />rd <br />❑ Condominium ❑ Split(s) �t ) 4 <br />' i? rG <br />❑ Existence of family or business relationship between buyer and seller <br />: <br />4'S <br />❑ Personal property included in transfer (Ps4mated.vafi 4 c-. ) <br />ci <br />Describe any unusual or special circumstances related to this sale, including the specification of any less -than -co ete°own'rshI A rest, <br />the terms of any seller financing. <br />completed , <br />.-side) <br />County Auditor must verify and complete the following information: <br />❑ Buyer and Seller information ❑ Sales price <br />❑ Parcel I Key number <br />❑Address of property transferred ❑ Conditions of sale <br />❑ School corporation number <br />❑ Date of saleltransfer <br />O Warranty deed? ❑ YES ❑ NO <br />-T 3 - To be completed by COUNTY <br />ASSESSOR .- <br />County Assessor must verify and complete the following Information: <br />ASSESSED VALUE (AV) INFORMATION <br />❑ Significant physical changes to property between March 1 and date of sale <br />AV LAND $ <br />Cl Current property record card attached <br />AV IMPROVEMENT(S) $ <br />❑ Properly class I use code <br />AV TOTAL $ <br />PART 4 - SiaPatwe ai�d Verificptlon Section (see instructipps on.reverse side) <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 <br />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 <br />Disclosure Act." <br />Sign t r , of Seller or rep entative <br />Telephone number <br />(month, day, year) <br />Dat�77 <br />219-235-924I <br />Signature of uyer or repre entative <br />Telephone number <br />Dale signed (month, day, year) <br />