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r INDIANA SALES DISCLOSURE FORM Page 2 <br />`1 <br />Seller I - Name or Entity as appears on deed <br />Citv of South Bend, Board of Public Works <br />Address <br />227 W. Jefferson Blvd., Ste 1300 <br />City, Town. or Post Office State ZIP Code <br />South Bend J.� �, I�!J J6]6]0�1 <br />Seller 2 - Name or Entity as appears on deed <br />Address <br />City, Town- or Post Office State ZIP Code <br />J-1 -1J_j 1-1 - 11 11 <br />Preparer Name and Address Preparer Phone ll <br />t - Name or Entity as appears on deed <br />Will this property be the <br />Halton West <br />buyer's primary <br />Address <br />residence? <br />0Yes 0No <br />225 Donald Street <br />City, Town, or Post Office <br />State <br />�J <br />ZIP Code r l, ' ,. <br />JJJ <br />South Bend <br />3J4 <br />_j_1-1-1 <br />Buver 2 - Name or Entity as appears on deed <br />Address <br />City, Town, or Post OfficeStale <br />ZIP Code <br />1-11-11 <br />Under penalties of perfury, 1 hereby certify that this Sales Disclosure, to lho 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 Properly Sales Disclosure Act". <br />1_� <br />Signature of Seller <br />Signature of Buyer <br />c1 I <br />Seller Sign Date /� <br />/ T <br />2- � (/ I , <br />Buyer Sign Data(MM/DDIYYW) <br />(MM/DDM'W) <br />✓, <br />r2j 1 ���� BuyerJ <br />tiA, J 1 ! JQa PART2- COUNTYAOIDITOR <br />PART 3 -COUNTY OR TOWNSHIP ASSESSOR' <br />County Assessor or other assessing offical must verify and complete the following Information: <br />Significant physical changes to property between March 1 and data of sale <br />�� <br />v <br />�I j�I IIj III ' l�Property dose <br />AV LAND J use cods <br />$ <br />� <br />-- � C.0 <br />L�J�L_.�1 ' • t--�.J <br />Taxing District tDLGF asslgnoc <br />AV IMPV JJJ�J <br />AV TOTAL O Valid Sale <br />Complet}pr J O YesQyU No <br />r: <br />-- i7� J` <br />Date Enterr=.d in Transfer 600Sc <br />m I m I = <br />�-1_j-1�J �J�—JJ NEIGHBORHOOD CODE <br />