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~" ~ STATEMENT OF BENEFITS
<br />a ~ "' ,,r PERSONAL PROPERTY
<br />•y ~ ~ `p Slate Form 51764 (R! 1-06)
<br />' Prescribed by the Department of Local Government Finance
<br />INSTRtIC710NS:
<br />FORM SB-1 1 PP
<br />PRNACY NOTICE
<br />The cost and any specific individuals
<br />salary information Is conriden4al; the
<br />balance of the filingg is public record
<br />erlC 6-1.1-12.1-S.t c and d .
<br />1. This statement must be submitted to the body designating the Economic RevitaJlzation Area prior to the public hearing if the designating body requires
<br />information from the applicant in making !ts declslon about whether to designate an Economic Revitalization Area. Otherwise this statement must be submitted
<br />to the deslgnaling body BEFORE a person lnsta!!s the new manufacturing equtpment and/or research and development equipment, and/or togtsticat distribution
<br />oqulpment and/or lnfonnatlon tochnology equtpment for which the person wkhes to claim a deduction. Projects° planned or committed to aRer July 1, 1987,
<br />and areas designated aRerJuly 1, 1987, require a STATEMENT OF BENEFITS. (/C ti-i. f-12. i) '
<br />2. Approval of the designating body (CRy Council, Town Board, County Council, etc.) must be obtained error fo installation of the new manufacturing equipment
<br />and/orresearch and development equipment and/or logistical distribution equipment and/or information technology equtpment, BEFORE a deduction may
<br />be approved
<br />3. To obtain a deduction, a person must file a certrf/ed deduction schedule with the person's personal property return on a ceriifred deduction schedule (Form
<br />103-ERA) with the township assessor of the township where the property is situated. The 103-ERA must be fled between March i and May 15 of the
<br />assessment year In which new manufacturing equtpment and/or research and development equtpment and/or logistical distributton equtpment and/or
<br />information technology equipment is installed and fully functional, unless a filing extension has been obtained. A person who obtains a filing extension must
<br />fife the form between March 1 and the extended due date of that yeas
<br />4. Property owners whose Statement of Benefits was approved after June 30, 1991, must su6mtt Form CF-1 / PP annually to show compliance wtth the
<br />Statement of Benefits. (lC 6-1.1-i2. J-5.6)
<br />5. The schedules established underlC 6-1.i-i2.1-4.5(d) and {e) apply to equipment installed after March 1, 2001. For equtpment installed prior to March 2,
<br />2001, die schedules and statutes in eNect at the (Ime shaft con6'nue to apply. (IC6-1.1-12,1-4.5(f) and (g))
<br />• •• •
<br />Name of taxpayer
<br />Fortis Plastics, LLC.
<br />Address of taxpayer (ntxnner and street, city, stare, and ZfP case)
<br />2965 LaVanture Place, Elkhart, {N 46514
<br />Name of contact person Telephone number
<br />Lisa Makowski, Corporate Treasures (574) 970-6477
<br />
<br />Name of designating body
<br />Resolutbn number (s)
<br />Cit of South Bend
<br />Location of proporty County DLGF taxing disU'tcl number
<br />3615 Voorde Dr, South Bend, IN st. Joseph 026
<br />Description of manufacturing equipment and/or research and development equipment ESTIMATED
<br />and/or logistical dlStfitKltlOn equtpment and/or InfoRnatlOn technology equipment. START DATE COMPLETION DATE
<br />(use additional sheets if necessary)
<br />Plastic injection mold machines and extruders. ManufacturingEqu;pmer,t otiotj2oos 06/01/2010
<br />Computers, IT infrastructure and servers for R & D Equipment
<br />Headquarters OperatlOnS. Logtst Dist Equipment
<br />IT Equipment 02/01/2009 06/01!2010
<br />•.•. •.
<br />Current number Salaries Number retained Salaries Number additional Salaries
<br />126 3,925,900.00 126 3,925,900.00 20 1,620,000.00
<br />
<br />NOTE: Pursuant to IC6-1.1-12.1-5.1 (d) (2) the MANUFACTURING R & D EQUIPMENT LOGIST DIST IT EQUIPMENT
<br />E UIPMENT E UtPMENT
<br />COST of the property is confidential. COST ASSESSED COST ASSESSED COST ASSESSED COST ASSESSED
<br />VALUE VALUE VALUE VALUE
<br />Current values
<br />Plus estimated values of proposed project 2,170,900.00 48,000.OD
<br />Less values of any property being replaced 0.00 0.00
<br />Net estimated values upon completion of project 2,170,900.00 48,000.00
<br />
<br />Estimated solid waste converted (pounds) Estimated hazardous waste converted (pounds)
<br />Other benefAs:
<br />Rehabilitation of vacant facility, new and used equipment installation, new production and Headquarters operations
<br />
<br />
<br />hereby certify that the representations in this statement are true,
<br />Signature of euth ed reprgg~~rOlativ
<br />- Tdle Date signed {month, day, yeah
<br />~1V ULi Corporate Treasurer 12/16/2008
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