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A <br />INDIANA SALES DISCLOSURE FORM Page 2 <br />n i <br />Seller I - Name or Entity as appears on deed <br />City_ -of South Bend <br />Address <br />227 West Jefferson Blvd., Ste 130.0 <br />City- Town, or Post Office Stall a ZIP Code j <br />South Bend �IJ N1 ���_j� I I I <br />Salley 2 -Name pr Entity as appears on deed <br />Address <br />City, Town, or Post office State ZIP Code <br />Tice Company Name (if applicable) Tile Company Phone <br />Buyer I- Name or Entity as appears on deed <br />lWilt this property be the <br />South Bend Heritage Foundation I buyer's primary <br />Address residence? <br />803 Lincoln Clay West <br />O Yes O No <br />City, Town, or Post Office _l State ZIP Code <br />f South Bend 1 -LU -J16 16J, U - JJ-J-J <br />Buyer 2. Name or Entity as aooears on deed <br />Address <br />C,y, Town, or Post Office State ZIP Code <br />11 _ f 1 L1 I I I - III J <br />Under penalties of perjury, I hereoy certify that this Sates Disclosure, to the best of my knowledge and belief, is true, correct and complete as required by law, and <br />,s prepared in accordance with IC fi-1.1S.5, "Real Property Sales Disclosure Act". <br />Signature of Seller Signature of Buyer <br />G <br />Seller Sign Date y IJ Buyer Sign Dale <br />(MMJDO YYYY) U ! I / Z I L U U I G (MMIDOrr—) / I (/121 Of O <br />Seller Phone Buyer Phone <br />�iTZ S—Jd—��J- ?JK�V —)J(g I& IL01 <br />County Assessor or other assessing offlcai must verify and complete the following information: <br />OSignificant physical changes to property between March 1 and dale of sale <br />AU01TOFd S FqX 5TAIS4P f I ! ©AV LAND —J—J-1 Property class <br />use code <br />Taxing District (DLGF assigned <br />I <br />I I I I AV IMPV <br />Completion O Yes ONO <br />I j�_I� J I <br />Date Entered in Transfer Book + I '�—J__-_.J AV TOTAL O Valid Sale <br />/ =1 /—��� �_U_ U-11 NEIGHBORHOOD CODE <br />