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STAT IU Et'T QP MOVEMENTS <br />' '" <br />REA1. ESTATE 1M <br />3taie i orni 61787'(84 / 2:13) <br />p,;scdbed by 1. eparlrneent of Loopi Ggvemment Finance <br />Thi§ s(ateir)enl is being coCppleted'for real property that 0yalrfies under the following I'ndiana.0 ode (check one imx): <br />Re0evelopmen1 or rehabilitation of real e¢ta[e.(mprovemenW' (I d G•1.1= 12.1 -4) <br />Ci Re5ldenlially aistres'?ei area (iG 6- 1.:i- '12. -4.1j <br />INSTRUCTIONS. <br />9 Thfs ta(emenf plot he s#binffted to thg bi aly flesI4tra#ng tht Economic Rev(talfzatlan Area pr3orfo.i(re ptfb!lc.he <br />InforMatfon frbm the app9piIntIn ij aW fts clgctsion.abpfit'wfietherto destgnafe an Et onomlcRevRaGzafiogAre, <br />'?�iojects "planned or d, , - ftteit fo afferJuly 1 9987, end area's desfgifl3ted afteriJuly 1., 19B7; require a STATf_JtQF_N7 (7F BENf_Fi7S {10 <br />2 Approval of the designating body (CQy Cpuricil, Tawn Boani, County Col ndl, ate) m. uet be abtafned prlorto infittfon of the tedewlopmerrt b <br />rahab111taBon, BEFORE a dedtfcfit3h may be approved <br />3 76 obUtt a deafuctfon, a Form g2WRL )hb# be filed 4iilth fiig GountyAu lbihefore lblay 10 In the year In whlgh the addNrbn to assessed Gslirfitlon s. <br />mgde'of hot Ili "t hahtrifrty'(? OJ haysaY; ertheassess7nenfnoticelsolar! edto3lfeproperiyowner kk was niailedafterAprilIa. ffthepro/iertiowv e( <br />tnlsses the May 1Q deadline ln'thq.ljigi6l yearof oc'cripatfon fie can apply between March 1 and May 10'pf a subsequent year. <br />4 1'mpe Y o"am Whose 5tatem'bnt bf Beneilts was approved iterJune:30 9991, m/rst.atjach'a Form C� 7 /Rea% Pxoperty annually to tale ApUcaflo i to <br />shottigomltllailca wltjr t jle 3taterrleYit of Benefits (lC tj- 14 -72.1v ltbj ehd 7C ¢9, j J 3({)) <br />Tile sghedu {es established ander lC E y >�2 f -?!(dJ fotfehabtlftated grope r1y aply to any economic fevftalizatlon crass designated airteerJtftie 30� 200p, <br />unties* an alterilative detluctron sc/r d i§ adopted by the desfgnatrnp body {I 8-1.1 121 -i7J, 7ne schedules.etfective prior to July 1; 2000 *!tall. <br />coiftir►ue to apply fo ecoriomlc revJtalT {atlon,aieas designated before July 1,.;2p00; <br />SECTION •- A • <br />Niim6ofta)payer <br />South Bond Form Tool Co., Inc. <br />P.,ddress of tokpayer (agmberand *freer; city, state, and jZIP'dode) <br />408 W. Indiana Ave., South Bend, IN 46813 <br />Name o[ conlactpersoo Telephone nainber <br />E map address <br />Herb Eggers (674 ) 289 -2441 <br />heggers@sbform.com <br />SECTION 2 LOCATION AND DESCRIPTION OF PROPOSED Przbj�df. <br />Name of designating twdy <br />Resolution _number <br />City of South Bend <br />Cgcation of property <br />County <br />DLGF faxing district number <br />1619 & 1623 Franklin St, South Band, IN 46613 <br />St Joseph <br />Description of real propg4yimprovemenig. redevelopment, orrehab8itation' tfse adaggruifsheets l(necessary) <br />EsGmaled'stari date-1-11A day, yeai) <br />4!1)2016 <br />Construction of approximately 3,000 additional square feet of manufacturing space and improvements to existing building <br />'02pated cotrtpkil) dale (MMM, day, year) <br />12/112016 <br />Currenlnumber Salaries Nuniberretained Salaries Numberaddiijonal tielOdes* <br />17 $785,000 17 $785,000 8 $378,560 <br />SECTION 4 ESTIMATED TOTAL COSTAND VALUE,OF PROPOSED PROJECT <br />REAL tcSTgTE IM ROVEMENTS .. ' <br />COS C - ASSESSED VALUE <br />Gs�rreril values- <br />$10,000 <br />$31,000 <br />Plus estimated' yalues of; ro` osgd 0 r: egt <br />$222,166 <br />Len.vatyes•gfan ro e.4.;treihi replaced <br />$o <br />$o <br />fJetesliinafed'.Yalues upotj'a2[npijtion APpr.'o act <br />$232,166 <br />$253,166 . <br />SECTION OTHER.BENEFJTS <br />PRON11SED BY THETAXPAYER <br />Estirliaied solid waste cortvetled ( pounds) <br />Ealiinated-hazardous wastg converted. (pounds) <br />Otherbeneets <br />SECTION • <br />I hereby certify, that the representa0pne in #his'statement are true; <br />Signature orauthc , ►presentative Digitally signed by Kyle Harbison <br />TIOU <br />day,•yeo <br />Date: 1016.03.0311:30:24 - 05'00' <br />Protect Manager <br />03/03/2018 <br />Page i of 2 <br />