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°` -a�� STATEMENT OF BENEFITS <br />aA REAL ESTATE IMPROVEMENTS <br />d State Form 51767 (RS 112 -13) <br />Prescribed by the Department of Loral Government Finance <br />This statement is being completed for real property that qualifies under the following Indiana Code (check one box): <br />® Redevelopment or rehabilitation of real estate improvements (IC 6- 1.1- 12.1 -4) <br />❑ Residentially distressed area (IC 6 -1.1- 12.1 -4.1) <br />20yry_ PAY 201¢_ <br />FORM SB -1 / Real Property <br />PRIVACY NOTICE <br />Any information concerning the cost <br />of the property and specific salaries <br />paid to individual employyees by the <br />roperty owner is wnfdential per <br />INSTRUCTIONS: <br />PC e-1.1- 12.1 -5.1. <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 />2. The statement of benefits form must be submitted to the designating body and the area designated an economic revitalization area before the initiation of <br />the redevelopment or rehabilitation for which the person desires to claim a deduction. <br />3. To obtain a deduction, a Form 3221RE must be filed with the County Auditor before May 10 in the year in which the addition to assessed valuation is <br />made or not later than thirty (30) days after the assessment notice is mailed to the property owner if it was mailed afterApol 10. A property owner who <br />failed to file a deduction application within the prescribed deadline may file an application between March 1 and May 10 of a subsequent year <br />4. A property owner who files for the deduction must provide the County Auditor and designating body with a Form CF -1 /Real Property. The Form CF- 1/Real <br />Property should be attached to the Form 3221RE when the deduction is firet claimed and then updated annually for each year the deduction is applicable. <br />IC 6-1.1- 12.1- 5.1(b) <br />5. For a Form SB- 1/Real Property that is approved after June 30, 2013, the designating body is required to establish an abatement schedule for each <br />deduction allowed. For a Form SB- 1/Real Property that is approved prior to July 1, 2013, the abatement schedule approved by the designating body <br />remains in effect. IC 6- 1.1-12.1 -17 <br />SECTION <br />•- <br />Name of taxpayer <br />Address of taxpayer (number and street, city, state, and ZlPcode) <br />1115 Burns Avenue South Bend Indiana 46617 <br />Name of contact person <br />Telephone number <br />E -mail address <br />(773 ) <br />SECTION 2 LOCATION AND DESCRIPTION <br />Name of designating body <br />OF PROPOSED PROJECT <br />Resolution number <br />Common Council of City of South Bend <br />Location of property, <br />County <br />DLGF taxing district number <br />Descripaon of real property impr vements, re eve pment, or rehabilitation (use additonal sheets ne ssary) <br />71 -026 <br />Estimated start date (month, day, year) <br />Colfax Hill Partners, LLC proposes to make an investment of at least $3,000,000 in the development <br />and construction of a – 23,000 square foot mixed use builicing, including <br />approximately 4,725SF of <br />Jigly 1 2014 <br />Estimated completion date (month, day, yeari <br />ground floor retail together with – 18,275SF of space for residential apartments. <br />JUN 1 2015 <br />Current number Salaries Number retained <br />Salaries Number additional Salaries <br />0 N/A <br />I I N/A <br />SECTION 4 ESTIMATED TOTAL COST AND <br />VALUE OF PROPOSED PROJECT <br />REAL ESTATE IMPROVEMENTS <br />COST ASSESSED VALUE <br />Current values <br />20,000 <br />60,000 <br />Plus estimated values of proposed project <br />3,000,000 <br />Det . under Reg 17 <br />Less values of any property being replaced <br />N/A <br />N/A <br />Net estimated values upon completion of project <br />3,020,000 <br />Det. under Reg 17 <br />Estimated solid waste converted (pounds) <br />Estimated ;h��i a gveetl�(pou�,pr-- <br />Other benefits <br />..o �— <br />.r, Ze014 <br />f•i f'4 (j <br />r. <br />Ik <br />JO I, VOI ,h,.." <br />CITY CLERK, Sota;I' eirw <br />rra <br />SECTION 6 TAXPAYER CERTIFICATION <br />I hereby certify that the representations in this statement are true. <br />Ompresentative sentative <br />Date signed (month, day, year) <br />A rll 25 2014 <br />Ttlle <br />Page 1 of 2 <br />