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tE..sraTF D <br />opt.: �ii� � : ~`,� SALES DISCLOSURE FORM <br />State Form 46021 (R419Z4) <br />W: �- <br />N` f �� Prescribed by Department of Local Government Finance <br />Pursuant to IC 8-1.1-5.5 <br />r816 � <br />PRIVACY NOTICE: The telephone <br />numbers <br />onf d nt all a coarding to IC 6S1€1-5.5 re111111111 111111111 <br />3(d). <br />Parcel Numbers Show additional parcels on separate sheet if necessary <br />O ( P P r5') Fcreage Or Lot Size <br />JJJ o Q JJ_ J JJ IJ JJJJJJJ J J o J J a J <br />�JJJJ JJJJJJJJ IJJJJ__I JJ <br />__JJ 1--- LJ._ iJr J JJJJ JJLLIUULLI_1�1 JJ J . 1 i! o <br />AcrrLf so( a <br />1arcels <br />121 Duey _ J <br />—11 <br />City. Town. or Post Office State Zip Code <br />South Bend JJ JJ6�_J11JJJJJ <br />Tax eilltng Address (if other than property address) <br />i <br />Lincoln belay West <br />City, Town, or Past Office _ <br />State <br />Z�-IIP Code <br />iLegSot-thalotscnptonBend <br />I'I� <br />6 <br />JJ�J <br />_J�J1 <br />Lot 112 Hartman's and Miller's Addition <br />I .. <br />Identify all conditions/items that apply NOTE: If items 12-21 apply, filers are not subject to disclosure <br />, 11inq fee. <br />O1-Buyer is an adjacent property owner <br />n2-Vacant Land <br />0 3-Exchange for other real property <br />01 4-Seller Paid Points; amount if applicable <br />$JIF-T-T-7 <br />O5-Change planned in the primary use of the property? Describe In <br />special circumstances. <br />O6-F ttstence of family or business relationship between buyer and seller <br />0 7- Land Contract Dated: <br />O8-Personal property Included in transfer; amount if applicable <br />g❑. Jl .QJ� J <br />0 9- Significant physical changes to property between March 1 and data of sale <br />@ 10- Non -Warranty deed; specify type Quit Claim <br />011-Partlal interest Describe in special circumstances. <br />Contract Date (MMlDolyyyy) <br />Desc be any unusual or specaI circumstances related to this sale, ind <br />O12-Secunty Interest documents such a] mortgages or trust deeds. <br />O13-Leases less than 94 years <br />O14-Document resulting from forectosure, o <br />r express <br />threat of foreclosure, divorce court order, condemnation, <br />probate or other judicial proceedings. <br />O15-Agreements and other documents For <br />mergers, consolidations, and incorporations <br />O16-Cuitclaim deeds not serving as a sourca of title <br />O17-Documents involving the partitlon of land between <br />tenants in common, joint tenants, or tenants by the <br />entirety, <br />® 18-Transfer to a charity, not -for -profit or government <br />institution <br />O19•Transfer For no or discounted consideration, or gift <br />0 20•Rerecording to tarred prior recorded document <br />O21-Easements, Rfght�of way grants <br />Sales Pnce <br />$O O.0 <br />rding the specification of any less -Than -complete <br />and terms of seller <br />i, <br />Id <br />