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INDIANA SALES DISCLOSURE FORM <br />Seller 1 - Name or Entity as appears on <br />GVW Realty, LLC, an Indiana limited liability company <br />4411 Quality Drive <br />Ciry, Town, or Post Office State <br />South Bend I I N <br />Seller 2 - Name or Entity as appears an deed -J <br />Page 2 <br />ZIP Code <br />2 J -JJJ <br />Address <br />City, Town, or Post Office State ZIP Code <br />_71 _J JJJ - i I I I <br />Title Company Name (if applicable) Title Company Phone <br />- <br />Buyer 1 - Name or Enlily as appears on deed <br />The City of South Bend, State of Indiana Community & Economic Development Wilt [his properly be the <br />- buyer's primary <br />Address <br />residence? <br />1200 County -City Building, 227 W. Jefferson Boulevard O Yes O No <br />City, Tovm• or Post Office State ZIP Code <br />South Bend JJ JJJ 1- 1 1J0 1 <br />Buyer 2 - Name or Entity as appears on deed <br />Address <br />City, Town, or Post Office Stale ZIP Cade <br />JJ 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 />Signatuc of Iter <br />Signature of Buyer <br />rg <br />Si n Dale <br />g ® <br />/ <br />/ ` <br />B er Sin Date(MMIDDIYYYI) MMIDDIYYYY <br />f� <br />) <br />FL17_1 1 1Seller <br />O O <br />Seller Phone <br />JJJ - JJJ - <br />41JJJ <br />Buyer Phone <br />County Assessor or other assessing offical must verify and complete the following Information: <br />OSignificant physical changes to property between March 11 and dale of sale <br />$ = , I <br />' AV LAND JJJ ...pony class <br />uaa codo <br />Taxing DWrlct (DLGF aeaignec <br />$ JJ ' f �=J AV IMPV JJJJJ <br />1pletion O Yes 0 No <br />Date Entered in Transfer Book <br />CJJ AV TOTAL O Valid Sale <br />J / J I I I LIE—] NEIGHBORHOOD CODE <br />A <br />