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y INDIANA SALES DISCLOSURE FORM Page 2 � <br />Seller 1 - Name or Entity as appears on deed <br />Patterson Dental Supply, Inc., a Minnesota corporation <br />Address 1 <br />1031 Mendota Heights Road - <br />City, Town, or Post Office Slate ZIP Code <br />St. Paul <br />Seller 2 - Name or Entity as appears on deed <br />City, Town, or Post Office Slate ZIP CodeI l I <br />i _J_1 _1JJJJ ��JI <br />Title Company Name (ilapplicable) Title Company Phone <br />3uyer 1 - Name or Entity as appears on deed <br />The City of South Bend, State of Indiana Community & Economic Development I Wiillthis property bethe <br />buyer's primary <br />Address residence? <br />1200 County -City Building, 227 W. Jefferson Boulevard 0 yes .No <br />City, Town, or Post Office State ZIP Code <br />South Bend J0 1J <br />Buyer 2 - Name or Entity as appears on deed <br />Address <br />City, Town, or Post office Slate ZIP Code <br />Under penalties of perjury, I hereby certify t this Sales D <br />is prepared in accordance with IC 6-1.1-9 , "Real Property, <br />Sign of Seller <br />Seller Sign Date Moq <br />(MM/DD/YYY1n U <br />Seller Phone <br />losure, to the best of my knowledge and belief, is true, correct and complete as required by law, and <br />es Disclosure Act". <br />Sicinature of Buver <br />J I <br />I <br />Buyer Sign Dale F/ <br />(MM/DpW /YI) � <br />8uyerPhone <br />5.� .l, L1-3 IS 1 15 �A- <br />runty Assessor or other assessing offical must verify and complete the following Information: <br />OSignificant physical changes to property between March 1 and date of sale <br />AIJniTOR'S Ptf,t: STA;,tF- � AV LAND —iii property class <br />use code <br />Taxing District (DLGIF assigned <br />AV IMPV <br />mpletion 0 Yes ONO <br />Date Entered in Transfer Book $ E�J AV TOTAL O valid Sale <br />m' F—P I LLIJ� -1-1-1- 1JU IU.—._l-1 NEIGHBORHOOD CODE <br />kills, 'A <br />