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� 'Y INDIANA SALES DISCLOSURE FORM Page <br />Seller 1 - Name or Entity as appears on deed <br />ACRI, Inc., an Indiana corporation <br />Address <br />12311 Shoemaker Avenue <br />City. Town, or Post Office State ZIP Code <br />Santa Fe Springs —_ C 9 0 16 <br />__JJ _�JI <br />Seller <br />� Name or Entity as appears on deed — <br />Address <br />City, Town, or Post Office 1 State ZIP (Code <br />Title Company Name {if applicable) Title Company Phone <br />! J-1i - -1l] - ��JJ <br />1 - Name or Entity as appears on deed <br />i The City of South Bend, State of Indiana Community & Economic Development Will this property be the <br />buyers primary <br />Address residence? <br />1200 County -City Building, 227 W. Jefferson Bouievard O Yes No <br />City, Town, or Post Office State ZIP Code <br />South Bend 1 18J J <br />Buyer 2 - Name or Entily as appears on deed <br />Address <br />City, Town, or Post Office Slate ZIPCode <br />Under penalties of perjury, I hereby certify that this Sales Disclosure, to the best of my knowledge and belief, is true, correct and complete as required by law, and <br />is prepared in accordance with IC -1. - "Real Property Sales Disclosure Act". <br />Signature of ter /" Signature of Buyer <br />it I Buyer Sign Dale ✓'Seller S D I��' Iy <br />O( YYYY) (MMDDYYYSeller Phone Buyer Phone <br />5 1 6 1 2 9 0 12] 0] _0] 9 7] 9�] S' <br />Completion ()Yes <br />County Assessor or other assessing offical must verify and complete the following information: <br />0 Significant physical changes to property between March 1 and date of sale <br />' w L I t I �� AV LAND use codeerty ass <br />use code <br />�l Taxiing District (DLG Ir assig <br />ned <br />AViMPV I INoJ <br />Date Entered in Transfer Book <br />y^ AV TOTAL O Valid Sale <br />JJJ J�J-1 <br />I ` JJ <br />NEIGHBORHOOD CODE <br />14 <br />