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Pr INDIANA SALES DISCLOSURE FORM Page 2 11 <br />t - Name or Entity 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 Slate ZIP Coda <br />South Bend JJ JJJJJ JJJJ <br />Seller 2 - Name or Entity as appears on deed _ <br />j Address <br />City, Town, or Post Office Slate ZIP Code <br />JJ JJJJ JJJ <br />Preparer Name and Address Preparer Phone <br />JJJ -JJJ JJJJ <br />1 - Name or Entily 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 />1JJ <br />ZIP Code <br />JJJJ <br />-JJJJ <br />South Bend <br />Buver 2 - Name or Enlily as appears on deed <br />Address <br />City, Town, or Post Office State ZIP Code <br />JJ JJJJ-JJJJ <br />Under penalties of perjury, I hereby certify that this Sales Disclosure, to the 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 />Signature of Seller <br />Seller Sign Data <br />Seller.S; - JJJ -JJJ <br />� <br />W- <br />-Q <br />Completion v�� �� e� o <br />Date Entered in Transfer Book <br />EEI / JJ /JJJJ <br />of <br />Buyer Sign Dale <br />(MM/DD/YYYY) <br />JBuye-JJr-JJJ JJJJ <br />County Assessor or other assessing offical must verify and complete the following information: <br />OSignificant physical changes to property between March 1 and date of sale <br />AV LAND JJJ PBro PertY class <br />uU cOdo <br />Taming District IDLGF a,signoc <br />AV IMPV <br />y� I I J ❑J � AV TOTAL O Valid Sale <br />JJJJJJJJJJJJ NEIGHBORHOOD CODE <br />