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STATEMENT OF BENEFITS <br />REAL ESTATE IMPROVEMENTS <br />State Form 61767 (R412.13) <br />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 />❑ 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 />INSTRUCTIONS: <br />1. This statement must be submitted to the body designating the Economic Revitalization Area poor 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 Jury 1, 1987, and areas designated sfterJuly 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 otthe redevelopment or <br />rehabilitation, BEFORE a deduction may be approved. <br />3. To obtain a deduction, .a Font 322/RE must be filed with the County Auditor before May 10 in the year in which the addition to assessed valuation Is <br />made ornot later than thirty (30) days afterthe assessment notice is mailed to the property owner if N was mailed after April 10. if the property owner <br />misses the May 10 deadline in the initial year of occupation, he can apply between March 1 and May 10 of a subsequent year <br />4. Property owners whose Statement of Benefits was approved after June 30, 1991, must attach a Form CF- IlReai Property annually to the application to <br />show compliance with the Statement of Senefts. (IC ti•1 -1- 72.1- 5.1(b) and IC 6 -1.1- 12.1- 6.3Q)j. <br />5. The schedules established under IC 6 -1.1- 12.1 -4(d) for rehabilitated properly apply to any economic revitalization areas designated after June 30, 2000, <br />unless an alternative deduction schedule is adopted by the designating body (IC 6-1.1- 12.1 -17). The schedules effective priorlo July 1, 2000, shall <br />continue to apply to economic revitalization areas designated before July 1, 2000. <br />SECTIOA I TAXPAYER INFORMATION <br />Name of taxpayer <br />JSK Development or LLC to be named later <br />Address of taxpayer (number and street, city, slate, and ZIP code) <br />247 North Dixleway, South Bend IN 46637 <br />Name of contact person Telephone number <br />E -mail address <br />AJ Patel $74-397 -0566 <br />mailQskhotel.com <br />SECTION • • AND DESCRIPTION OF •OP • PROJECT <br />Name of designating body <br />Resolution number <br />Location of property <br />County <br />DLGF taxing district number <br />Description of real property improvements. redevelopment, or rehabilitation (use addisona /sheers ilnecessary) <br />Estimated start data (month. day, year) <br />W112015 <br />Construction of 120 room hotel <br />Estimated completion date (month, day, yea) <br />3nnon <br />Current number Salaries Number retained Salaries Numberadditional Salaries <br />0 42 1254000 <br />SECTION • TOTAL COSTAND VALUE OF •••• • PROJECT <br />REAL ESTATE IMPROVEMENTS <br />COST ASSESSED VALUE <br />Current values <br />Plus estimated values of proposed project <br />Less values of any property being replaced <br />Net estimated values upon completion of project <br />SECTION 5 WASTE CONVERTED AND OTHER <br />BENEFITS PROMISED BY THE TAXPAYER <br />Estimated solid waste convened (pounds) <br />Estimated hazardous waste converted (pounds) <br />Other benefits Filed ill - _- Office <br />SECTION - <br />I hereby certify that the representations in this statement are true. <br />Signature of authorized repress <br />7Ue <br />Date signed (month, day. year) <br />President <br />4112n015 <br />Page 1 of 2 <br />