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sALES DISCLOSURE FORM <br />State 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 />First name(s) <br />C i t Of South Bend Inca i an <br />Address (number and street) <br />1400 County-CityB.1d <br />City, Town or Post Office <br />First name(s) <br />South Bend Heritage Foun <br />Address (number and street) <br />914 Lincoinway West <br />City, Town or Post Office <br />South Bend <br />Send Fax bills and notices to this address? <br />❑ Yes IKNo <br />Street address <br />1209 West Colfax <br />City, Town or Post Office <br />South Bend <br />County <br />M.I.(s) Last names) <br />Primary residence? <br />Cl Yes Q�No <br />State Z1P code <br />tion I <br />Last <br />A^.I.(s) name(s) <br />Primary residence? <br />❑ Yes >C No <br />!S!tat�e�ZiP <br />It no, provide mailing address (number and street, city, state, ZIP code) <br />ZIP code <br />46601 <br />School Corporation Name <br />S.. 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 />SALES INFORMATION <br />1. Total sales price <br />DATE OF SALE <br />Month Day Year 2. Seller paid points <br />Township <br />State <br />IN <br />3. Net sales price (line 1 minus line 2) 1 $ <br />1.00 <br />Check ALL of the following conditions that apply to this sale.;,' <br />❑ Transfer of entire parcel ❑ Purchase of adjoining land ❑ Vacant land ❑ Exchange OPP the* real proper 'Trade') <br />❑ Seller provided financing ❑ Mobile home P 9 ❑Condominium ❑Split(s)"�` <br />❑ Existence of family or business relationship between buyer and seller ❑ Personal property included in transf �>y(,Est'm' aiedValue �r <br />Describe any unusual or special circumstances related to this sale, including the specification of any less -than- gplelp of 6rsfilp interest,,and <br />the terms of any seller financing. <br />County Auditor must verify and complete the following information: <br />❑ Buyer and Seller information ❑ Sales price ❑ Parcel / Key number <br />❑ Address of property transferred ❑ Conditions of sale ❑ School corporation number <br />❑ Date of sale/transfer ❑ Warranty deed? ❑ YES ❑ NO <br />County Assessor must verify and complete the following information: ASSESSED VALUE (AV) INFORMATION <br />❑ Significant physical changes to property between March 1 and date of sale <br />AV LAND $ <br />❑ Current property record card attached <br />❑ Property class / use code <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 />SigrANre of Seller or representative I Telephone number Date signed (month day year) <br />�� <br />Signature of -Buyer or representative <br />219-235-9241 <br />Telephone number <br />Dale signed (month, day, year) <br />