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Page 2 <br />Pr INDIANA SALES DISCLOSURE FORM <br />Seller 1 - Name or Entity as appears on deed <br />CITY OF SOUTH BEND <br />Address <br />1400 COUNTY —CITY BUILDING, 227 WEST JEFFERSON <br />State ZIP Code <br />City, Town, or Post Office <br />SOUTH BEND �JI lc�_li Snul <br />Seller 2 - Name or Entity as appears on deed <br />Address <br />Crty. Town, or Post Of(ce <br />State <br />�� <br />ZIP Code <br />I �� JI <br />preparer Name and Address <br />PreparerPhone <br />Buyer 1 - Name or Entity as appears on deed <br />Will this property be the <br />HABITAT FOR HUMANITY, INC. <br />buyers primary <br />residence? <br />ss <br />AddL402 <br />O Yes No <br />EAST SOUTH STREET <br />City. Town. or Post Office <br />state <br />I <br />IN <br />ZIP code ` <br />f n ,1 I _ <br />y�1I—tl <br />SOUTH BEND <br />J JI J J <br />Buyer 2 - Name or Entity as appears on deed <br />Address <br />Stale ZIPCode <br />City. Town, or Post Office <br />Under penalties of perjury, I hereby certify that this Safes isriosure. to the <br />s DisclosureAt1^of my knowledge and belief, is true, correct and complete as required by law, and <br />is prepared in accordance with IC 6-1.1-5.5,"Real PropertySignature of Buyer <br />Signature of Seller } , <br />Buyer Stgn Date IJ L <br />• Seller Sign Date (MMID6IYYYY) <br />(MMfDDNYYY) Buyer Pnone Seller Phone <br />..- <br />,� County Assessor or other assessing oNtcal most verity and complete the following information: <br />between March 1 and date of sale <br />Significant physical changes to property <br />pe class <br />Pro m <br />AV LAND J J J use code <br />iR n � Tarin Dlslrict(DLGF assigner <br />`\\\Cli <br />6`���r 1 I l LL�� AV IMPV <br />L� <br />Completion O Yes O No O Valyd Sale <br />AV TOTAL <br />Date Entered in Transfer Book ` <br />NEIGHBORHOOD CODE <br />