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I 14 <br />INDIANA SALES DISCLOSURE FORM Page2 <br />Buyer I - Name or Entity as appears on deed <br />City of South Bend, Indiana _ Will this property be the buyers primary <br />Address - residence? <br />1,100 County -City building <br />Yes No <br />City, Town, or Post Office State ZIP Code <br />South Bend / 111, 1 � � U <br />Buyer 2 - Name or Entity as appears on deed <br />1—J <br />Address <br />City, Town or Post Office State ZIP Code <br />Under penalties of perjury, I hereby certify that this Sales Disclosure, to the best of my knowledge and belief, is true, correct and <br />complete as required by law, and is prepared in accordance with IC 6-1.1-5.5, "Real Property Sales Disclosure Act". <br />Signa" of Seller Sigpajure of Buyer ,-- <br />Seller Sign Date Buyer n Date <br />(MM/DD/YYYY) Z d (MM/DD/YYYY) <br />Seller Phone Buyer Phone <br />?� ► D �o Z 2�35-q <br />1r County Assessor or other assessing official must verify and complete the following information. <br />,t <br />t 0 Significant physical changes to property between March 1 and date of sale <br />AUDITOR'S FILE STAMP <br />t AV LAND � Property das./use <br />crate <br />$ AV IMPV <br />Taxinn District (MGF asslarted) <br />i � � <br />I <br />It Completion 0 Yes 0 No $ AV TOTAL O Valid Sale <br />I Date Entered in Transfer Book <br />II NEIGHBORHOOD CODE <br />