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xC' SALES DISCLOSURE FORM <br />46021 (R3/1-0o) <br />e roved by State Board of Accounts, 2000 <br />Pies y 1 <br />Cribed b the Stale Hoard of Tax Commissioners, 1999 <br />pursuant to IC 6-1.1-5.5 <br />m- <br />na e(s) <br />Civil <br />t <br />_ - - - - - - <br />Last name(s) c' _.. �.,; l L. <br />C i ty-,of South <br />Address <br />Bend <br />4 <br />(number and street) <br />Primary residence'?,.-. <br />227 W- Jefferson Blvd.r Ste. 1400 0Yes QNo �' J: <br />City, Town or Post Office <br />State ZIP code �— <br />46601 <br />South Bend <br />1N <br />First name(s) <br />M.1.(s) Last name(s) <br />South Bend Heritage <br />Foundation, 1 <br />c <br />Primary residence? <br />Address (number and street) <br />0 Yes to No <br />803 L i nco l nway West <br />state ZIP code - <br />4 6 6 1 6 <br />City, Town or Post Of r-e <br />IN <br />South Bend <br />and street, city, state, ZIP code) <br />this address? <br />If no, provide mailing address (number <br />Send tax bills and notices o <br />6 Yes Q No <br />Street address <br />1o1D West Jefferson <br />City, Town or Post Office State ZIP code <br />South Bend IN 46601 <br />County Township School Corporation Name <br />St. Joseph <br />EXEMPT TRANSACTIONS (see instructions on reverse side) <br />:xempt Transaction? If yes, specify the number of the exemption. (see "Exempt Transactions" on reverse side) <br />% Yes a No 4 <br />SALES INFORMATION <br />1. Total sales price <br />DATE OF SALE <br />Month <br />Day Year 2. Seller paid points L— <br />C) 3. Net sales price (Gne I minus line 2) <br />V O <br />Check ALL of the following conditions that apply to this sale. <br />o-transfer of entire parcel ❑ Purchase of adjoining land p Vacant land ❑ Exchange for other real property ("Trade') <br />`❑ Seller provided financing o Mobile home ❑ Condominium ❑ Split(s) <br />1 o Existence of family or business relationship between buyer and seller ❑ Personal property included in transfer (Estimated value $ ) <br />Describe any unusual or special circumstances related to this sale, Including the specification of any less -than -complete ownership 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 <br />❑ Address of property transferred ❑ Conditions of sale <br />❑ Date of sale/transfer <br />County Assessor must verify 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 />O Property class I use code <br />❑ Parcel I Key number <br />❑ School corporation number_ <br />❑ Warranty deed? O YES ❑ NO <br />ASSESSED VALUE (AV) INFORMATION <br />AV LAND $ <br />AV IMPROVEMENTS) $ <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 loTm y mrnh e i r-%r s Gon iF— <br />therein is true and correct- A person who knowingly and intentionally falsifies or omits any information requiredon this form commits a Class AUnder penalties of perjury, I hereby Certify that this Sales Disclosure, to the besof my knowledge and belief, is true, correct and complete as �equtted <br />by taw, and is prepared in accordance with IC 6-1.1-5.5, "Real Property Sales Disclosure Act:' <br />Dale signed (month, day, years <br />ignptdre of Seller or represenlative <br />✓I <br />Signature of bu' er or representative <br />'telephone number <br />Telephone number Date signed month, day, Years <br />