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DocuSign Envelope ID: DBF1C726-DE71-4282-AE01-AD6D18F646AD <br /> C-0, STATEMENT OF BENEFITS zo Pqy zo_REAL ESTATE IMPROVEMENTS State Form 51767(R2/1-07) FORM 58-1/Real Property Prescribed by the Department of Local Government Finance <br /> This statement is being completed for real property that qualifies under the following Indiana Code(check one box). <br /> B Redevelopment or rehabilitation of peal estate imprcvements(IC 6-1.1-12.14) <br /> ❑ Eligible vacant building(IC 6-1.1-12.1-4.8) <br /> INSTRUCTIONS: <br /> 1. This statement must be submittod t0 the body designating the Economic Revitalization Area prior to the public hearing irlhe designating body requires <br /> information from the applicant in making its decision about whether to designate an Economic Revitalization Area. O!hery ise this sta!enlent must be <br /> submitted to the designating body BEFORE the redevelopment or mhabiolalion of real property for which the person wishes to clam a deduction. <br /> 'Projects-planned Or committed to after July 1. 1987,and areas designated after July 1, 1987.require a STATEMENT OF BENEFITS. (IC 6-1.1-12.1) <br /> 2 Approval of the designating body(City Council, Town Board, County Council,etc.)must be obtained poor to initiation of the redevelopment or rehabilitation, <br /> BEFORE.1 deduction may be approved <br /> 3. To obtain a deduction.application Form 322 ERA/RE or Form 322 ERA1/60. Whichever is applicable,must be filed with the CounlyAuditor by the later <br /> of(1)May 10:or(2)thidy(30)days after the notice of addition to assessed valuation or new assessment is mailed to the properly owner el the address <br /> shown On the records or Ibe township assessor <br /> 4. Property owners whose Statement or Benefits was approved efter June 30, 1991. must If a Fomt CF-1/Reat Property annually to(ho application 10 <br /> show compliance with Iha Statement of Benefits. (IC 6-1.1-12.1-5.1(b)and IC 6-1.1-12.1-,5.36)] <br /> 5. The schedules established under IC 6-1.1.12.1-4(d)for rehabilitated property and under IC 6-1.1-12.1-4.8(1)nor vacant buildings apply to any statement <br /> Or tenefits approved on Or after July 1,2000. The schedules efreclive prior to July 1.2000,shall continue to apply to a statement of benefits filed before <br /> July 1.2000. <br /> Na pie of is=p yen <br /> I AMress of taxpayer(num icr and street.city stare.and lip cope) <br /> I10 toll ial(-air ZI 5cath & <br /> Napa,M I CI person t Telephone number - <br /> =6; <br /> r cl T c c.�<er 57N -7 9 DJ c rz�� w Cr cu . ,e „ <br /> _ .,.. . <br /> Name of designating body Resolution pumper <br /> LoGltion of property -- <br /> County DLGC,a:,ng msf1C ni—In' <br /> :. ! Sr. y(,t I F' o.ept <br /> Description,of real ptppprly linprpvm cols.rCdev((IOpmC'nl,or rehab lilalipn(uSn.Mdihpnal shpNS d neeesan/y1 Est malon,sttan dale(month,day year) <br /> c I IJ <br /> Estim,!ed cemplelion date(nwnlh.pay,ycaQ <br /> (Current number yes • h p1 ia;,Cd :;ala (Number addil rill <br /> `1 (Salaries <br /> 315, c0o c p <br /> • -.r . <br /> NOTE:Pursuant to IC 6-1.1•-121 5.1 !di 121 Ine COST of li. prcpe,;y REAL ESTATE IMPROVEMENTS <br /> is confidential. COST <br /> ASSESSED VALUE <br /> Current values i <br /> Plus estimated values of proposed project t1 �`3 7 o T( 10 i <br /> Less values of any property being replaced r <br /> Net estimated values upon completion of project ( J f <br /> Estimated solid waste convened(poenos) Estimated hazaldo w s e Convene IDOtm(/s <br /> Other benefits <br /> I ? 2013 <br /> SECTION 6 TAXPAYER CERTIFICATION <br /> I hereby certify that the representations in this statement are true. <br /> S.grattur, - Yicpresenlauve Tile Dale signed(niona, day yon') <br /> �lI"r`• �_ managing member I 8/8/2013 <br /> 31A2CD0DE2a046F Page 1 of 2 <br />