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pv(�C <br />Slate Form 46021 (R311-00) <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 />r , <br />name(s) <br />M.1.(s) <br />Last name(s) <br />City of South Bend, Indiana <br />JFirst <br />Address (number and street) <br />Primary residence? <br />1300 County -City Bldg. <br />El Yes ❑No <br />City, Town or Post Office <br />State <br />ZIP code <br />South Bend <br />IN <br />46601 <br />s) <br />M.I.(s) <br />Last name(s) <br />Bend Heritage Foundation <br />mber and street) <br />Primary residence? <br />' incolnway West <br />Yes ❑No <br />or Post Office <br />Ltaxtbills <br />Statel N <br />ZIP code <br />46601 <br />Bend <br />ills and notices to thls address? <br />If no, provide mailing address (number and street, city, state, ZIP code) <br />No <br />Street address <br />1227 West Colfax <br />City Town or Post Office StIN ZIP code 46616 <br />youth Bend <br />' County South Bend YtnsfF�jE <br />t ag e School Corporation Name <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 />SALES INFORMATION <br />1. TotaI sales price $ 1 .00 <br />DATE OF SALE <br />Month I Day I Year 12. Seller paid points $ <br />1 I I I I I 13. Net sales price (fine I minus line 2) $ 1. 0 0 <br />T Check ALL of the following conditions that apply to this sale. <br />❑ Transfer of entire parcel ❑ Purchase of adjoining land ❑ Vacant land Cl Exchange for other real property ("Trade') <br />❑ Seller provided financing ❑ Mobile home ❑ Condominium Cl Split(s) <br />❑ Existence of family or business relationship between buyer and seller ❑ Personal property included In transfer (PONATal1 ) <br />Describe any unusual or special circumstances related to this sale, Including the specification of any a s-tha C��Tnpldtm o8-nership In t, and <br />the terms of any seller financing. N a-U <br />a s.. M N V <br />r-- a ' 0 o A <br />o 'rt ti <br />County Auditor must verify and complete the following Information: <br />❑ Buyer and Seller information 0 Sales price <br />❑ Address of property transferred 0 Conditions of sale <br />❑ Dale of sale/transfer <br />County Assessor must verify and complete the following Information: <br />❑ Significant physical changes to property between March 1 and dale of sale <br />❑ Current property record card attached <br />❑ Parcel I Key number <br />❑ School corporation number_ <br />❑ Warranty deed? ❑ YES ❑ NO <br />ASSESSED VALUE (AV) INFORMATION <br />AV LAND $ <br />AV IMPROVEMENT(S) $ <br />❑Property class /use code <br />AV TOTAL $ <br />Tha parties to a real property conveyance are required to rile 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 />Sion -attire of Seller or reoresentative Telephone number Dale signed (month da e <br />574-235-9241 <br />Telephone number <br />fly <br />� ar) <br />Signature of Buyer or represen <br />Dale signed (month, day, year) <br />