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`I <br />�N6 STArF SALES DISCLOSURE FORM <br />c State Form 46021 (R41904) PRIVACY NOTICE: The telephone <br />A <br />numbers of the parties on this form are <br />[*, jz Prescnbed by Depalmenl of Locat Government Finance I I III II III 111 IN <br />� confidential according to IC 6-1.1-5.5- <br />•:: Pursuant lolC61.7-5.5 3(dr. <br />rA16 <br />Pal of Para <br />Parcel Number(s) (Show additional parcels on separate sheet if necessary) Acreage or Lot Size (sphh <br />JJJJ° 1 7 JJ�JJJJJJJJJJJ JJJJ.JJ • <br />JJ_JJ L-1-i JJJJJJJJJJ JJJJ_J <br />UJ ILIJ-11 -1 J -1 -1 -1 -1 -1 -1 _J _J -1 -1 -1J JJJJJJ 0 <br />Address N of Parcels <br />East side of Olive Road, South of Brick Road J J 1 <br />City, Town. or Post Office state I ZIP Code <br />South Bend l - -- - 1 j NJ 41 6 I6 1 2 18 1I <br />J_J <br />Tax Billing Address (if other than property address) <br />12311 Shoemaker Avenue <br />City, Town, or Post Office _ State ZIP Code <br />Santa Fe Springs 1 JJ JJJJJ JJJJ <br />See Attached Exhibit "A" <br />Identify all conditions/items that apply <br />• 1-Buyer Is an adjacent property owner <br />• 2-Vacant Land <br />O3-Exchange for other real property ("Trade") <br />Q4-Seller Paid Points; amount if applicable <br />$I" FT-T-1,�J <br />(D 5-Change planned In the primary use of the property? Describe In <br />special circumstances. <br />NOTE: If items 12-21 apply, filers are not subject to disclosure <br />filing fee. <br />0 6-Existence of family or buslness relationship between buyer and seller <br />O7- Land Contract Dated: <br />OB-Personal property Included In transfer; amount if applicable <br />ISM00010n <br />O9- Significant physical changes to property between March 1 and date of sale <br />O10- Non -Warranty deed; specify type <br />0 11- Partial Interest. Describe In special circumstances. <br />O12-Security Interest documents such as mortgages or trust deeds. <br />O13-Leases less than 90 years <br />O14-Document resulting from foreclosure, or express <br />threat of foreclosure, divorce court order, condemnatlon, <br />probate or other judicial proceedings. <br />15-Agreements and other documents for <br />mergers, consolidatlons, and Incorporations <br />J16-Quitclaim deeds not serving as a source of title <br />J17-Documents involving the partition of land between <br />tenants In common, joint tenants, or tenants by the <br />entirety. <br />0 18-Transfer to a charity, not -for -profit or government <br />Institution <br />0 19-Transfer for no or discounted consideration, or gift <br />0 20-Rerecording to correct prior recorded document <br />to21-Easements, Right-of-way grants <br />Contract Date (MMIDDIYYYY) Sales Price <br />�a/�U/ [Z as $�J,�,76 1 <br />Describe any unusual or special circumstances related to this sale, including the specification of any less -than -complete ownership interest and terms of seller financing <br />Temporary Right -of -Way Only for Road Construction <br />I <br />