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Or INDIANA SALES D[SCLOSURE FORM <br />Page 2 <br />Seller f - Name or Entity as appears on deed <br />Civil City of South Bend <br />Address <br />227 W. Jefferson Blvd., Ste 1316 4 T <br />City, Town, or Post Office Stale ZIP Code <br />South Bend <br />Seller 2 - Name or Entity as aopears on deed <br />Address <br />I <br />ZIP Code <br />City, Town, or Post Office State <br />Title Company Name (if applicable) Title Company Phone <br />t - Name or Entity as appears on deed <br />402 E. South_ Street _ <br />City, Town, or Post Office State <br />South Bend I N_, <br />2 - Name or Entity as appears on deed <br />ZIP Code <br />Will this property be the <br />buyers primary <br />residence? <br />OYes O No <br />Address <br />City, Town, or Post Office <br />State <br />ZtP Code <br />Under penalties of perjury, I hereby certify that this Sales Disclosure, to the best of my knowledge and belie(, is true, correct and complete as required by law, and <br />Is prepared in accordance with IC 6-1.15.5, "Real Property Sales Disclosure Act". <br />Signature of Seller Signature of Buyer <br />I I Lv�� g - <br />Seller Sign Data Buyer Sign Dale <br />(MMIDorn^ry) I U' / i' Z a Cl�7 (MMiDDNYYY) G U 7 <br />Seller Phone Buyer Phone <br />J�-3] �jJ6jJ <br />Z <br />County Assessor or other assessing offical must verify and complete the following information: <br />�?� • <br />Significant physical changes to <br />O <br />property between March i and date <br />of sale <br />,±. <br />\ J <br />$ <br />1�� <br />AV LAND <br />I Property class <br />J use code <br />v <br />Taxing District (OLGF assignee <br />Completion <br />No <br />Date Entered in Transfer Book <br />LI ;!f 1J!I I 1 11 <br />AV TOTAL O Valid Sale <br />NEIGHBORHOOD CODE <br />