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INDIANA SALES DISCLOSURE FORM Page 2 <br />feller 1 - Name or Entity as appears on deed <br />David P. Koehler and Pauline R. Koehler <br />Address <br />51933 Orange Road <br />City, Tmvn, or Post Office State ZIP Code <br />South Bend <br />Setter 2 - Name or Entily as appears ort deed <br />City, Town. or Post Office State ZIP Code <br />Title Company Name of applicable) Title Company Phone <br />Buyer 1 - Name or Entity as appears on deed <br />The City of South Bend, State of Indiana Community & Economic Development VOIIthis 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 Slate ZIP Code <br />South Bend JJ J��JJ 1 J_� 3 1J <br />Buyer 2 - Name or Entity as appears on deed _ <br />Address <br />City. Town, or Post Office State ZIP Code <br />J JJJJJ - JJJ <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 6.1.1-5,5, "Real Property Sales Disclosure Act". <br />signeluie oJ.SqII,11 1Signature of Buyer <br />Seiler Sign Dale / Buyer Sign Date <br />(MM/DDNYYY) f � �, O (MM1DDlYYYY) <br />SelIe <br />ne BuyerPhone <br />JJJ 2 1 7 7 3 A.1J - --kl is-�� <br />County Assessor or other assessing ofrcal must verify and complete the following Information: <br />0I�`' `Significant physical changes to property between March 1 and date of sale <br />,t1;111'+ ST;17::P I Propariyclass <br />$ E �� AV LAND �J usacoao <br />Taxing District(DLGF asslgnec <br />$ AV IMPV _1JJ <br />J J <br />pletion O Yes O No j <br />DJ JD AV TOTAL 0 Valid Sala <br />Date Entered in Transfer Book <br />M/Fl-1/1 LF-P -1�IIJ-1Ji.JJ JJ NEIGHBORHOOD CODE <br />