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STATEMENT OF BENEFITS <br />REAL ESTATE IMPROVEMENTS <br />Stale 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 />INSTRUCT IONS: <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 />Projects "planned or commlted to aiterJuly 1, 1987, and areas designated afterJuty 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 of the redevelopment or <br />rehabilitation, BEFORE a deduction may be approved <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 alter the assessment notice is malted to the property owner If it was mailed afterApril 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- 11Real Property annualty to the application to <br />show compliance with the Statement of Benefits. 11C 6- 1.1- 12.1- 5.1(b) and IC 6-1.1- 12.1- 5.30)j. <br />5. The schedules established under IC 6- 1.1- 12.1 -4(d) for rehabilitated property apply to any economic revitalization areas designated alter 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 prior to July 1. 2000, shall <br />continue to apply to economic revitalization areas designated before July 1, 2000. <br />Page 1 of 2 <br />SECTION •- • <br />Name of taxpayer <br />County Development LLC <br />Address of taxpayer (number and street, city, state. and ZIP code) <br />P. O. Box 2709, South Bend, IN 46680 <br />Name of contact person Telephone number <br />E -mail address <br />Gregory L. Freehauf ( 574 )239 -1818 <br />gfreehauf @martins- supermarkets.com <br />SECTION 2 LOCATION AND DESCRIPTION OF PROPOSED PROJECT <br />Name of designating body <br />Resolution number <br />Common Council of South Bend <br />Location of property <br />County <br />DLGF taxing district number <br />Mayflower Road & Western Avenue <br />SL Joseph <br />Description of real property improvements. redevelopment, or rehabilitation (use addiffonaf sheets If necessary) <br />Estimated start date (month. day, year) <br />May 1, 2016 <br />40,000 square foot supermarket store and 4,000 square foot convenience store and fuel center business <br />Estimated completion dale (month, day, year) <br />April 1, 2017 <br />SECTION OF • AND SALARIES AS RESULTOF '••• PROJECT <br />Current number Salaries Numberretatned Salaries Number additional Salaries <br />98 $1,440,000 30 $936,000 13 $453,440 <br />SECTION 4 ESTIMATED TOTAL COST AND VALUE OF PROPOSED PROJECT <br />REAL ESTATE IMPROVEMENTS <br />COST ASSESSED VALUE <br />Current values <br />o <br />Plus estimated values of proposed project <br />$9,207.178 <br />Less values of any property being replaced <br />0 <br />Net estimated values upon completion of pro ect <br />$9,207,179 <br />SECTION • D AND O '• <br />1 1 <br />Estimated solid waste converted (pounds) Estimated hazard as re <br />Other be <br />MAR 2 3 2016 <br />KgREEMS � <br />CITY CLERK, EB NJIN <br />SECTION CERTIFICATION <br />I hereby certify that the representations in this statement are true. <br />daigoalpaolwbald (aodmtudaepreserdative <br />Title <br />Data signed (month, day, year) <br />DN:m- &agml'LFreahw%o-Maen's Super Makels,o MartWs Supra Ma*.Ia,ameilVrnhaf@m Mr m" ikels. .B=US <br />Vice President Finance, CFO <br />03/18/16 <br />Dar« 2016.03.1816:11:58 -04W <br />Page 1 of 2 <br />