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® INDIANA SALES DISCLOSURE FORM <br />Page 2 <br />Seller 1 - Name or Entny as appears on deed <br />City of South Bend, Board of Public Works <br />Address <br />227 W. Jefferson Blvd., Ste 1300 <br />City, Town, or Post Office State 'I <br />ZIP Codeff I <br />South Bend JN ���0JJII <br />Seller 2 - Name or Entity as appears on deed <br />Address <br />City, Town, or Post Office Slate ZIP Coce <br />I == -� -J � I <br />Preparer Name and Address Preparer Phone II ii <br />1 -Name or Entity as appears on deed <br />Halton West <br />Will this property be the <br />buyers primary <br />Address <br />residence? <br />225 Donald Street <br />Oyes ONo <br />City, Town, or Post Office <br />Slate <br />]N <br />ZIP Code <br />4 6�JJ4 - J J,-J <br />South Bend <br />I <br />Buyer 2 - Name or Entity as appears on deed <br />.: tmp l ete <br />Address <br />YJAU�•!!y� <br />51:de ZIP Code`�e6rU� <br />City. Town, or Post Office <br />Under penalties of perjury, 1 hereby certify that this Sales Disclosure, to the best of my knowledge and belief, is true, correct and Complete as r0, w—Cd by law, and <br />is prepared in accordance with IC 6.1.1-5.5, "Real Property Sales Disclosure Act". <br />Signature of Seller <br />ignature of Buyer <br />MIw ONY-try) r Sign D <br />EP / <br />Setter Sign Date U T <br />(MM/DDlYYYY) <br />P-L <br />Sailor Phone <br />Buyer <br />Phohe <br />V. , <br />1. t,-.r.•,urr i <br />"\._ - • J,�/ County Assessor or other assessing offical must verify and complete the fallowing information: <br />Significant physical changes to property between March 1 and dale of sale <br />r� <br />h'^., I� party doss <br />. .. j•^ �� ', AV LAND use <br />J use coda <br />Taxing Dii1strictlI(DLGF asstgnuc <br />' r $ AV IMPV <br />Cornpleiion.,r-;, `-Or Ye5r'" O No <br />Date Entered in Transfer Book <br />AV TOTAL O Valid Sale <br />___J.__J-1—J NEIGHBORHOOD CODE <br />