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<br /> 6 <br /> <br />12. Does any member of the South Bend Redevelopment Commission or any officer or employee of the City of South Bend Department of Redevelopment have any direct or indirect personal interest in the Applicant or the development of the land as proposed? <br /> Yes <br /> No <br /> If yes, explain: <br /> <br /> 13. Does any member of the governing body of the City of South Bend or any public official or employee of the City of South Bend have any direct or indirect personal interest in the applicant or the development of the land as proposed? <br /> If yes, explain: <br /> <br /> <br /> 14. Statements and other evidence of the Applicant’s qualifications and financial responsibilities (other than the financial statement referred to above) are attached hereto and hereby made a part hereof as follows: <br /> <br /> <br /> <br /> Certification <br /> I (We), Certify that this Statement of Qualifications and Financial Responsibility and the attached evidence of the Applicant’s qualifications and financial responsibility, including financial statements, are true and correct to the best of my (our) knowledge and belief. <br /> <br /> <br /> Name Name <br /> <br /> <br />Signature Signature <br /> <br /> <br />Title Title <br /> <br /> <br />Date Date <br /> <br />(If the Applicant is an individual, this statement should be signed by such individual; if a partnership, by one of the partners; if a <br />corporation or other entity, by one of its chief officers having knowledge of the facts required by this statement) <br />