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STATEMENT OF BENEFITS <br />REAL ESTATE IMPROVEMENTS <br />State Form 51767 (R3112 -11) <br />Prescribed by the Department of Local Government Finance <br />This statement is being completed for real property that qualities under the following Indiana Code (check one box): <br />❑V Redevelopment or rehabilitation of real estate improvements (IC 6.1.1- 12.1 -4) <br />❑ Eligible vacant building (IC 6- 1.1- 12.1 -4.8) <br />2014 PAY2015 <br />FORM SB -1 I Real Property <br />INSTRUCTIONS., <br />1. This statement must be submitted to the body designating the Economic Revitalization Area prior to the public hearing if the designating body requires <br />information from the applicant in making its decision about whether to designate an Economic Revitalization Area. Otherwise this statement must be <br />submitted to the designating body BEFORE the redevelopment or rehabilitation of real property for which the person wishes to claim 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 prior to initiation of the redevelopment or rehabilitation, <br />BEFORE a deduction may be approved. <br />3. To obtain a deduction, application Form 322 ERA/RE or Form 322 ERA/VBD, Whichever is applicable, must be riled with the County Auditor by the later <br />of.- (1) May 10, or (2) thirty (30) days after the notice of addition to assessed valuation ornew, assessment is mailed to the property owner at the address <br />shown on the records of the township assessor, if any, or the county assessor. <br />4. Property owners whose Statement of Benefits was approved after June 30, 1991, must attach a Form CF -1 /Real Property annually to the application to <br />show compliance with the 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) for vacant buildings apply to any statement <br />of benefits approved on or after July 1, 2000, unless an alternative deduction schedule is adopted by the designating body (IC 6- 1.1- 12.1 -17). The <br />schedules effective prior to July 1, 2000, shall continue to apply to a statement of benefits riled before July 1, 2000. <br />to•�ew•e� <br />••r. <br />Name of taxpayer <br />5024 Western LLC <br />Address of taxpayer (numberand street, city, state, and ZIP code) <br />8833 Gross Point Road, Suite 308, Skokie, IL 60077 <br />Name of contact person Telephone number <br />E -mail address <br />Shalom Menora (847) 679 -6200 <br />Shalom menorafinancial. <br />Name of designating body <br />Resolution number <br />Common Council of the City of South Bend <br />Location of property - <br />County <br />DLGF taxing district number <br />5024 West Western Avenue <br />St. Joseph <br />Description of real property improvements, redevelopment, or rehabilitation (use addition / sheets ifnecessary) <br />Estimated start date (month, day, year) <br />The company will complete demolition in the facility to create a "white box" in order to build <br />04/01/2014 <br />out the space into a modern healthcare facility. In addition, the developer will make <br />Estimated completion date (month, day, year) <br />siantficant electrical and mechanical uDarades to the facilitv. O <br />12/31/2018 <br />retained S <br />Current number Saiades Number Salaries Numberadditional Salaries <br />0.00 $0.00 0.00 $0.00 80.00 $2,476,032.00 <br />NOTE: Pursuant to IC 6 -1.1- 12.1.5.1 (d) (2) the COST of the property <br />REAL ESTATE IMPROVEMENTS <br />is confidential. <br />COST <br />ASSESSED VALUE <br />Current values <br />Plus estimated values of proposed project <br />3.263.722.00 <br />Less values of any property being replaced <br />Net estimated values upon completion of project <br />3.263.722.00 <br />Estimated solid waste converted (pounds) <br />Estimated hazardous waste converted (pounds) <br />Other benefits <br />The proposed project will result in the redevelopment of an economically obsolete building in the community. The project <br />would provide the community with a state -of- the -art skilled nursing facility in South Bend to serve the Michiana region. The <br />facility would have 80 beds and employ approximately 80 full -time associates. There is a significant unmet need in the <br />community for this type of healthcare facility. <br />SECT16N 6 TAXPAYER CERTIFICATION <br />I hereby certify that the representations in this statement are true. <br />Signature of authorized representative <br />Title <br />Date signed (month, day, year) <br />Manager <br />01129/2014 <br />Page 1 of 2 <br />