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Statement for Public Disclosure <br />Address: —_ Z Z 7 S. /Ylo:., Sf o f <br />S" ,-fe _766 <br />_�O ate, <br />TaxpayerID #: <br />1. Applicant proposes to enter into contract for the purchase or lease of land from the <br />South Bend Redevelopment Commission. Said land is more accurately described in <br />Exhibit "A." <br />2. Organizational Status of Applicant: <br />❑ An individual <br />❑ A corporation <br />❑ A not - for - profit corporation or charitable institution <br />A partnership known as: P/ouu ; L. P. <br />❑ A business association or a joint venture known as: <br />❑ A Federal, State or Local government or instrument thereof <br />❑ Other (explain): <br />3. Organized and operating under the laws of S„ o% it,na <br />4. Date of Organization: Z- —' _I <br />5. Names, addresses, and title of principal officers, investors, members or shareholders <br />of Applicant, as follows: (attach additional sheets if necessary) <br />a. CORPORATION: the officers, directors or trustees, and each stockholder <br />owning more than 10% of any class stock <br />b. NOT - FOR - PROFIT: the members who constitute the board of trustees or <br />board of directors or similar governing body <br />C. PARTNERSHIP: each partner, whether a general or limited partner, and the <br />nature and percent of interest <br />d. BUSINESS ASSOCIATION OR JOINT VENTURE: each participant and the <br />nature and percent of interest <br />e. OTHER ENTITY: the officers, the members of the governing body, and each <br />person having an interest of more than 10% <br />47 <br />