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DOcuSign Envelope ID: DBF1C 726- DE7lA2B2- AE01-AD6D18F646AD <br />.:STATEMENT OF BENEFITS <br />REAL ESTATE IMPROVEMENTS <br />SIM Form 51057 (¢2 / 1.07) <br />% Prescribed by the Department of Loral GOVemment Finance <br />This Statement is being Completed formal properly that qualifies under the following Indiana Code (chock One box): <br />9 Redevelopment or rehabiliteen of real estate improvements (IC 51.1. 12.14) <br />O Eligible vacant building (IC 51.1 - 12.1 4.8) <br />INSTRUCTIONS: <br />1. This&element mull be submllodto the body designating the Economic <br />inlortnati0n lmm the aPPIlcsnl in making its dedslon about whalherf0 de <br />20 PAY 20_ <br />FORM SB -1 / Real Property <br />hearing ffthe des,gnatu,, body =,,I,, <br />ea. Olhemnse this statement use be <br />Oman wishes to claim a deduclinn <br />3. TO Obtain a daduchim,applicalson F. 322 ERAJ RE or Form 322 ERAIVBO. Whlchaver la applicable, muel belled will the CounlyAed,lor by the let., <br />oP (1) May 10; or (2) thirty (30) days after the series ofeddition to assessed valuation w new assessment is maAed to the properly, Owner el the address <br />shown on the records of fire fownshtp awass,.. <br />4. Property owners whose Sfatemenf o[ Benefits was oppmvedafter Juno 30, 1991. must attach a Foan CFC/Real pmpony annually fo the opplicmlonW <br />show comphanca with the Statement of Benefits. (IC 6 -1.1- 12.1- 5.1(b) and IC 6- 1.142.13.30) <br />5. The schedules established under IC 6- 1. 1. 12. 14(d)Iorrahabll,luediampedyand under C64.f•f2.1- 4.6(1)IOry -Cant build,ngs appty to any slaNmer, <br />ofborefits approved on or after July 1, 2000. The schedWes ef/ecum priorto July 1, 2000, shell continue to app1Y to a statemenl ofbanofils r✓edbo/ere <br />July 1. 2000, <br />age r of a <br />Neme onnpeyer - _ <br />1 <br />Adre9a al td[p3yel mem bo rOndblmIN, see, super, AIM ZIPpQS) <br />_ <br />f1 I Ny v <br />Namofwbe rsw <br />hlepM1One number <br />E- mailaWross <br />� d TGC e,�C¢r 574 -Z51•�j DJ <br />bfaTl.nktr rew }IeQu ia; ,c <br />Name atdesgmdng body <br />Re eluaan number <br />Leedom of propaM <br />cmMy <br />DLGF tming deIrct numpv <br />DeFNplian of rent aopanv lma nts. race bpmem, or rena Ibn (vu aldifbx /snncls! /rcccmaw <br />Bimetal Ned OMe(mmlh. dq. Hall <br />i 113 <br />EsNmteda "Istion one(nq.YM1. dry, yxafi <br />Z Z3 IS <br />Lurcent numaer Saban Number retuned Sabna a Number addlbnal $ibMi <br />H 3(S ooc I, 31s oao c p <br />NOTE: Pursuant to IC 6-1.1. 12.1- 5.1(d)(2) the COST of the property FLEAL ESTATE IMPROVEMENTS <br />is. ddnlial. COST ASSESSEDVALUE <br />Current values Z O <br />Plus estimated values of proposed proled [ r• '� O <br />Less values or any property being replaced <br />Net delinealM values upon completion of project <br />Estimated solid waste convened (pounds) Estimated h..rdo semnve a vn <br />Omer morns - T <br />(U3, 2 1 2013 <br />I hereby cerlify that the representations in this statement are true. <br />icpexnbuw <br />Tnle <br />Date sgnaa (mmin, day lead <br />managing member <br />8/8/2013 <br />age r of a <br />