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2014 2010 Coit Bond Huntington as successor trustee pay request 5 021915 A011111111 Mr1111111ki■ , 111211 El Bo 0: 111 DI 0., 'Imo GOO um:a A. 1 CITY '0 CARMEL JANIEs 1.3RA1NAItD. MAYOR CITY OF CARMEL,INDIANA LEASE RENTAL REVENUE BONDS OF 2010 CONSTRUCTION FUND DRAW REQUISITION Disbursement Direction No. 5 The Huntington National Bank Corporate Trust Department Attn:Maranda LujaJohnson 45 N.Pennsylvania St.INHP22 Indianapolis,IN 46207 312-229-4039 via email: Maranda.LujaJohnson @huntington.com Date: 18th of February ,2015 RE: City of Carmel (Indiana)Lease Rental Revenue Bonds of 2010—Depository Account Account#4087001459 Dear Maranda: You are hereby authorized and directed as the Depositary under the above-referenced Agreement,to pay the amounts set forth on the attached Register of Claims from the above-referenced Trust account and to overnight the checks to the individual as set forth on the attached register. The undersigned certifies that: (a) The undersigned is an officer of the City of Carmel,Indiana; (b) The amounts set forth on Schedule A are requested to be paid from the City of Carmel(Indiana)Lease Rental Revenue Bonds of 2010—Depository Account(#4087001459) (c) Each obligation as reflected by the amounts set forth on Schedule A has been properly incurred, is a proper charge against the City of Carmel (Indiana)Lease Rental Revenue Bonds of 2010—Depository Account and has not been the basis of any previous withdrawal from the Depository Account; and (d) Supporting information with respect to each payee designated on Schedule A as to the amount owing is attached hereto. CITY OF CARMEL,INDIANA BY: d Diana L. Cordray, Clerk-Treasurer Authorized Officer D::v ii-iNiFi r or E.cnl_eitiNc ONri. Civic SQi ARE.. CARMFI, IN 46032 Orru:r 3 17.571.2441 FAN 317.571.2439 EMAIL cn.iinctgrin,4@e:nreel in.;guP REGISTER OF CLAIMS CITY OF CARMEL, INDIANA LEASE RENTAL REVENUE BONDS OF 2010 CONSTRUCTION FUND PAYMENT REQUISITION DISBURSEMENT DIRECTION NO.5 18-Feb-15 AMOUNTS PAYEE'S NAME&MAILING ADDRESS REQUISITIONED COST ITEMIZATION Anthony Insurance Partnership $22,445.00 Main Street Reconstruction-R/W Acquisition Attn:Tony Schelonka Parcel 15 1919 E. 191st Street Parcel Tax I.D.29-09-26-203-022.000-018 Westfield,IN 46074 Total $22,445.00 ALL CHECKS LISTED HEREON TO BE MAILED TO: CrossRoad Engineers,PC Attn:Jill Newport 3417 Sherman Drive Beech Grove,IN 46107 A-1 Prescribed by State Board of Accounts City Form No.201 (Rev.1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL , INDIANA An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee Anthony Insurance Partnership Purchase Order No. Attn.; Tony Schelonka Terms 1919 E. 191St Street Date Due Westfield, IN 46074 Invoice Invoice Description Date number (or note attached invoice(s) or bill(s)) Amount DES. NO.: 1400673 PROJECT: Main Street Reconstruction PARCEL: 15 COUNTY: Hamilton Compensation for Permanent (Fee Simple) Right-of-Way Total $22,445.00 I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except l ter]b - _, 2014. By: 1 ,714.•iajyiti3 tar "G!/ Signa re: fc.+rtiiT. .9)140 Y Title By: Signature: Title I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance with IC 5-11-10-1.6. , 2014 Clerk-Treasurer I � Form W-9 Request for Taxpayer Give Form to the (Rev.August 2013) Identification Number and Certification requester.Do not Department of the Treasury send to the IRS. Internal Revenue Service Name(as shown on your income tax return) Anthony Insurance Partnership • Business name/disregarded entity name,if different from above w is c • Check appropriate box for federal tax classification: Exemptions(see instructions): ❑Individual/sole proprietor 19 Individual/solietor C Corporation w ❑ S Corporation El Partnership Trust/estate O Exempt payee code(if any) 3 El Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)► Exemption from FATCA reporting code(if any) c H C C E ❑ Other(see instructions)► it Address(number,street,and apt.or suite no.) Requester's name and address(optional) U a 1919 E. 191st Street • City,state,and ZIP code Op Westfield,IN 46074 List account number(s)here(optional) Win Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line I Social security number to avoid backup withholding.For individuals,this is your social security number(SSN).However,for a resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other - - entities,it is your employer identification number(EIN).If you do not have a number,see How to get a TIN on page 3. Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose number to enter. Part II Certification Under penalties of perjury,I certify that: 1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and 2. I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no longer subject to backup withholding,and 3. I am a U.S.citizen or other U.S.person(defined below),and 4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct. Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply. For mortgage interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the instructions on page 3. Sign Signature of — y/ �J y/ Here U.S.person► � Date► �, i �"e // General Instru,do 1 withholding tax on foreign partners'share of effectively connected income,and 4.Certify that FATCA code(s)entered on this form(if any)indicating that you are Section references are to the Internal Revenue Code unless otherwise noted. exempt from the FATCA reporting,is correct. Future developments.The IRS has created a page on IRS.gov for information Note.If you are a U.S.person and a requester gives you a form other than Form about Form W-9,at www.irs.gov/w9.Information about any future developments W-9 to request your TIN,you must use the requester's form if it is substantially affecting Form W-9(such as legislation enacted after we release it)will be posted similar to this Form W-9. on that page. Definition of a U.S.person.For federal tax purposes,you are considered a U.S. Purpose of Form person if you are: A person who is required to file an information return with the IRS must obtain your •An individual who is a U.S.citizen or U.S.resident alien, correct taxpayer identification number(TIN)to report,for example,income paid to •A partnership,corporation,company,or association created or organized in the you,payments made to you in settlement of payment card and third party network United States or under the laws of the United States, transactions,real estate transactions,mortgage interest you paid,acquisition or •An estate(other than a foreign estate),or abandonment of secured property,cancellation of debt,or contributions you made to an IRA. •A domestic trust(as defined in Regulations section 301.7701-7). Use Form W-9 only if you are a U.S.person(including a resident alien),to Special rules for partnerships.Partnerships that conduct a trade or business in provide your correct TIN to the person requesting it(the requester)and,when the United States are generally required to pay a withholding tax under section applicable,to: 1446 on any foreign partners'share of effectively connected taxable income from such business.Further,in certain cases where a Form W-9 has not been received, 1.Certify that the TIN you are giving is correct(or you are waiting for a number the rules under section 1446 require a partnership to presume that a partner is a to be issued), foreign person,and pay the section 1446 withholding tax.Therefore,if you are a 2.Certify that you are not subject to backup withholding,or U.S.person that is a partner in a partnership conducting a trade or business in the 3.Claim exemption from backup withholding if you are a U.S exempt payee.If United States,provide Form W-9 to the partnership to establish your U.S.status applicable,you are also certifying that as a U.S.person,your allocable share of and avoid section 1446 withholding on your share of partnership income. any partnership income from a U.S.trade or business is not subject to the Cat.No.10231X Form W-9(Rev.8-2013) I 1 Form W-9(Rev.8-2013) Page 3 Exempt payee code.Generally,individuals(including sole proprietors)are not G—A real estate investment trust exempt from backup withholding.Corporations are exempt from backup H—A regulated investment company as defined in section 851 or an entity withholding for certain payments,such as interest and dividends.Corporations are registered at all times during the tax year under the Investment Company Act of not exempt from backup withholding for payments made in settlement of payment 1940 card or third party network transactions. Note.If you are exempt from backup withholding, complete this I—A common trust fund as defined in section 584(a) y p p g,you should still corn form to avoid possible erroneous backup withholding. J—A bank as defined in section 581 The following codes identify payees that are exempt from backup withholding: K—A broker 1—An organization exempt from tax under section 501(a),any IRA,or a L—A trust exempt from tax under section 664 or described in section 4947)a)(1) custodial account under section 403(b)(7)if the account satisfies the requirements M—A tax exempt trust under a section 403(b)plan or section 457(g)plan of section 401(f)(2) 2—The United States or any of its agencies or instrumentalities Part I.Taxpayer Identification Number(TIN) 3—A state,the District of Columbia,a possession of the United States,or any of Enter your TIN in the appropriate box.If you are a resident alien and you do not their political subdivisions or instrumentalities have and are not eligible to get an SSN,your TIN is your IRS individual taxpayer 4—A foreign government or any of its political subdivisions,agencies,or identification number(ITIN).Enter it in the social security number box.If you do not nstrumenta€hies have an ITIN,see How to get a TIN below. 5—A corporation If you are a sole proprietor and you have an EIN,you may enter either your SSN or EIN.However,the IRS prefers that you use your SSN. 6—A dealer in securities or commodities required to register in the United If you are a single-member LLC that is disregarded as an entity separate from its States,the District of Columbia,or a possession of the United States owner(see Limited Liability Company(LLC)on page 2),enter the owner's SSN(or 7—A futures commission merchant registered with the Commodity Futures EIN,if the owner has one).Do not enter the disregarded entity's EIN.If the LLC is Trading Commission classified as a corporation or partnership,enter the entity's EIN. 8—A real estate investment trust Note.See the chart on page 4 for further clarification of name and TIN 9—An entity registered at all times during the tax year under the Investment combinations. Company Act of 1940 How to get a TIN.If you do not have a TIN,apply for one immediately.To apply 10—A common trust fund operated by a bank under section 584(a) for an SSN,get Form SS-5,Application for a Social Security Card,from your local 11—A financial institution Social Security Administration office or get this form online at www.ssa.gov.You may also get this form by calling 1-800-772-1213.Use Form W-7,Application for 12—A middleman known in the investment community as a nominee or IRS Individual Taxpayer Identification Number,to apply for an ITIN,or Form SS-4, custodian Application for Employer Identification Number,to apply for an EIN.You can apply 13—A trust exempt from tax under section 664 or described in section 4947 for an EIN online by accessing the IRS website at www.irs.govlbusinesses and clicking on Employer Identification Number(EIN)under Starting a Business.You The following chart shows types of payments that may be exempt from backup can get.Forms W-7 and SS-4 from the IRS by visiting IRS.gov or by calling 1-800- withholding.The chart applies to the exempt payees listed above,1 through 13. TAX-FORM(1-800-829-3676). IF the payment is for... THEN the payment is exempt for... If you are asked to complete Form W-9 but do not have a TIN,apply for a TIN and write"Applied For"in the space for the TIN,sign and date the form,and give it to the requester.For interest and dividend payments,and certain payments made Interest and dividend payments All exempt payees except with respect to readily tradable instruments,generally you will have 60 days to get for 7 a TIN and give it to the requester before you are subject to backup withholding on payments.The 60-day rule does not apply to other types of payments.You will be Broker transactions Exempt payees 1 through 4 and 6 subject to backup withholding on all such payments until you provide your TIN to through 11 and all C corporations.S the requester. corporations must not enter an exempt Note.Entering"Applied For"means that you have already applied for a TIN or that payee code because they are exempt you intend to apply for one soon. only for sales of noncovered securities acquired prior to 2012. Caution:A disregarded U.S.entity that has a foreign owner must use the appropriate Form W-8. Barter exchange transactions and Exempt payees 1 through 4 Part II. Certification patronage dividends Payments over$600 required to be Generally,exempt payees To establish to the withholding agent that you are a U.S.person,or resident alien, sign Form W-9.You may be requested to sign by the withholding agent even if reported and direct sales over$5,0001 1 through 52 items 1,4,or 5 below indicate otherwise. For a joint account,only the person whose TIN is shown in Part I should sign Payments made in settlement of Exempt payees 1 through 4 (when required).In the case of a disregarded entity,the person identified on the payment card or third party network "Name"line must sign.Exempt payees,see Exempt payee code earlier. transactions Signature requirements.Complete the certification as indicated in items 1 'See Form 1099-MISC,Miscellaneous Income,and its instructions. through 5 below. However,the following payments made to a corporation and reportable on Form 1.Interest,dividend,and barter exchange accounts opened before 1984 1099-MISC are not exempt,from backup withholding:medical and health care and broker accounts considered active during 1983.You must give your payments,attorneys'fees,gross proceeds paid to an attorney,and payments for correct TIN,but you do not have to sign the certification. services paid by a federal executive agency. 2.Interest,dividend,broker,and barter exchange accounts opened after Exemption from FATCA reporting code.The following codes identify payees 1983 and broker accounts considered inactive during 1983.You must sign the that are exempt from reporting under FATCA.These codes apply to persons certification or backup withholding will apply.If you are subject to backup submitting this form for accounts maintained outside of the United States by withholding and you are merely providing your correct TIN to the requester,you certain foreign financial institutions.Therefore,if you are only submitting this form must cross out item 2 in the certification before signing the form. for an account you hold in the United States,you may leave this field blank. 3.Real estate transactions.You must sign the certification.You may cross out Consult with the person requesting this form if you are uncertain if the financial item 2 of the certification. institution is subject to these requirements. 4.Other payments.You must give your correct TIN,but you do not have to sign A—An organization exempt from tax under section 501(a)or any individual the certification unless you have been notified that you have previously given an retirement plan as defined in section 7701(a)(37) incorrect TIN."Other payments"include payments made in the course of the B—The United States or any of its agencies or instrumentalities requester's trade or business for rents,royalties,goods(other than bills for merchandise),medical and health care services(including payments to C—A state,the District of Columbia,a possession of the United States,or any corporations),payments to a nonemployee for services,payments made in of their political subdivisions or instrumentalities settlement of payment card and third party network transactions,payments to D—A corporation the stock of which is regularly traded on one or more certain fishing boat crew members and fishermen,and gross proceeds paid to established securities markets,as described in Reg.section 1.1472-1(c)(1)(i) attorneys(including payments to corporations). E—A corporation that is a member of the same expanded affiliated group as a 5.Mortgage interest paid by you,acquisition or abandonment of secured corporation described in Reg.section 1.1472-1(c)(1)(i) property,cancellation of debt,qualified tuition program payments(under section 529),IRA,Coverdell ESA,Archer MSA or HSA contributions or F—A dealer in securities,commodities,or derivative financial instruments distributions,and pension distributions.You must give your correct TIN,but you (including notional principal contracts,futures,forwards,and options)that is do not have to sign the certification. registered as such under the laws of the United States or any state i 1 Page 4 DES. NO. / PROJECT 1400673; Main Street Reconstruction PARCEL 15 If you decide to accept the offer of$22,445.00 made by the City of Carmel, Indiana, sign your name(s) below and mail this form to the address indicated above. An additional copy of this offer has been provided for your file. ACCEPTANCE OF OFFER Anthony Insurance Partnership owner of the above described property or interest in property, hereby accept the offer of $ 22,445.00 made by the City of Carmel, Indiana, on this ,25— day of /00lier_ir h C — , 2014. Anthony Insurance Partnership By: By: Sign ure: Signature: NOTARY'S CERTIFICATE STATE OF TnOlk;Q,nQ ) ) SS: COUNTY OF 1-10.x,; 14-or‘ ) Subscribed and sworn to before me this S day of A.)ouer,b( , 2014. My Commission Expires: GI L;-5 My County of Residence is: o ry• 110n (Sig Ieture) (Printed) NOTARY PUBLIC 10/08 STATEMENT OF THE BASIS FOR JUST COMPENSATION Code N/A REV-29 1. This is a written statement of, and summary of the basis for, the establishment of the amount believed to be, through a valuation process,just compensation for the purchase of this right-of-way for highway purposes. The amount set forth in Item 5 below is not less than the approved estimate of value. In accordance with Public Law 91-646 as amended, the "Uniform Act", and as codified in Indiana at IC 8-23-17-1 through 8-23-17-35, this value disregards any decrease or increase in fair market value of the property prior to the date of valuation caused by the public improvement for which the property is acquired other than physical deterioration within reasonable control of the owner. 2.The legal description of this acquisition is set forth in the instrument of conveyance in the following identified parcel and this acquisition is identified in the Acquiring Agency's records as: Des.# N/A Parcel 15 Road Main Street County Hamilton Owner(s) Anthony Insurance Partnership, L.P. 3.The area and type of interest being acquired: 0.077 Acres of Fee Simple and 0.022 Acres of Temporary R/W The amount in item 5 below includes payment for the purchase of all interests in the real property and no separately held interest is being acquired separately in whole or part, except as may be explained in Item 8 below. 4.This acquisition is(Check one): a. ❑ A total acquisition of the real property. b. ® A partial acquisition of the real property. 5. The Agency's Offer: Just compensation has been determined to be and the Acquiring Agency's offer for the purchase of this real property is as follows: a. Total Land, Land Improvements and Buildings $20,645.00 b. Severance Damages(i.e.: Setback, Loss in Value to the Residues, etc) $ 0.00 c. Other Damages(Itemize) Cost-To-Cure estimates: Relocate two post sign $ 200.00 Temporary R/W $1,600.00 Total Damages $ 1,800.00 d. Perpetual Easement $ 0.00 Total amount believed to be Just Compensation offered for this Acquisition is: $22,445.00 6. The amount in Item 5 above may include payment for the purchase of certain buildings and improvements and their ownership shall pass to the Acquiring Agency. These buildings and improvements are identified as follows: None 7. The amount in Item 5 above may include payment for the purchase of certain Land Improvements, Fixtures, Equipment, Machinery, Signs, Etc., and their ownership shall pass to the Acquiring Agency. These items are identified as follows: Lawn and a landscape rock. 8. Items owned by others(i.e.: lessee, tenants, etc.) included in Item 5 above are identified as follows: 9. Remarks: A cost-to-cure is included to relocate a two post sign. Acquiring Agency Approval: Reviewer: Signature: j Signature: 4 _ �. Name Printed: S� , 199.2 ,(/ Name Printed: Julie M.West �� n Title: Y/"� J� +'U'L" , Company: Appraising I iana 11[ 11 k �J \Y7 / Date: a(d 11 /re7 Date: 9/8/2014 5,44r, SALES DISCLOSURE FORM 4 State Form 461121(811/12-11) 'it "• SDF ID 1,,k.' kt\i Prescribed by Department of Local Government Finance �+a County Pursuant tolC6-l.]-5.5 Year Unique ID SDF Date: tb'a PRIVACY NOTICE:The telephone numbers and Social Security numbers of the parties on this form are confidential accordlne to IC 6-1.1-5.5-31d1. INDIANA SALES DISCLOSURE FORM SDF ID SDO ID 1804617 Page 1 PART 1-To be completed by BUYER/GRANTEE and SELLER/GRANTOR A.PROPERTY TRANSFERRED-MUST.BE CONVEYED ON A SINGLE CONVEYANCE DOCUMENT 1•Property Number Check box if applicable to 5.Complete Address of Property 6.Complete Tax Billing Address(if different from parcel property address) © 2.Split 0 Old Meridian Street One Civic Square 29-09-26-203-022.000-018 ® 3.Land Carmel,IN 46032 Carmel, IN 46032 ❑ 4.Improvement 7.Legal Description of Parcel A part of the Northeast Quarter of Section 26,Township 18 North,Range 3 East, Hamilton County, Indiana. ❑ 2.Split ❑ 3.Land ❑ 4.Improvement 7.Legal Description of Parcel 'B.CONDITIONS=IDENTIFY ALL THAT APPLY C.SALES DATA-D_ISCLOSE`VALUE OF ITEMS.LISTED IN TABLE B, ITEMS 1-15 II-condition 1 applies,filer is subject to disclosure and a disclosure filing fee. YES NO CONDITION 1.Conveyance date(MM/DD/yrrt): 11/25/2014 © ❑ 1.A transfer of real property interest for valuable 2.Total number of parcels: 1 consideration. 3.Describe any unusual or special circumstances related to this ❑ ❑ 2.Buyer is an adjacent property owner. sale,including the specification of any less-than-complete © ❑ 3.Vacant land. ownership interest and terms of seller financing. ❑ © 4.Exchange for other real property("Trade"). Permanent right-of-way acquired in conjunction with the Main Street ❑ © 5.Seller paid points.(Provide the value!able cltem 12.) Reconstruction Project. © ❑ 6.Change planned in the primary use of the Total Damages Paid: $200.00 property?(Describe in special circumstances in Table C Item 3.) ❑ C❑ 7.Existence of family or business relationship between buyer and seller.(Complete luble CItem 4.) ❑ ® 8.Land contract. Contract term[yn: and contract date(MM/oo/yrrn: ❑ © 9.Personal property included in transfer.(Provide the value YES NO CONDITION Table C Item 5.) ❑ © 10.Physical changes to property between March 1 ❑ © 4.Family or business relationship existing between and date of sale.(Describe in special circumstances in Table buyer and seller? ❑ © Amount of discount: $ 0.00 11.Partial interest.(Describe in special circumstances in Table C ltem 3.) Disclose actual value in money,property,a service,an agreement,or other consideration. ❑ © 12.Easements or right-of-way grants. it If conditions 13-15 apply,filers are subject to disclosure,but no disclosure filing fee. 5. Estimated value of personal property: $ 0.00 YES NO CONDITION 6.Sales price: $ 20,645.00 © ❑ 13.Document for compulsory transactions as a YES NO CONDITION result of foreclosure or express threat of n © 7.Is the seller financing sale? If yes,answer foreclosure,divorce,court order,judgment, questions(8-13). condemnation,or probate. ❑ ❑ © S.Is buyer/borrower personally liable for loan? © 14.Documents involving the partition of land between tenants in common,joint tenants,or n © 9.Is this a mortgage loan? tenants by the entirety. 10.Amount of loan: $ 0.00 © ❑ 1S.Transfer to a charity,not-for-profit organization, 11.Interest rate: 0.00 or government. 12.Amount in points: $ 0.00 13.Amortization period: 0.00 INDIANA SALES DISCLOSURE FORM SDF ID: SD() 1004101.1 Pane 2 • D.PREPARER Nancy E. Hermann Land Agent Preparer of the Sales Disclosure Form Title 5214 S.East Street,Suite D-2 RWS South, Inc. Address(Number and Street) Company Indianapolis, IN 46227 E-mail E.SELLER(S)/GRANTOR(S) • Anthony Insurance Partnership Seller 1-Name as appears on conveyance document Seller 2-Name as appears on conveyance document 1919E 191st Street Address(Number and Street) Address(Number and Street) Westfield IN 46074 City,State,and ZIP Code City,State,and ZiP Code 317.695.9026 Telephone Number E-mail Telephone Number E-mail Under penal •: of p•r• ry,[hereby certify that this Sales Disclosure,to the best of my knowledge and belief,is true,correct and comp s - I ■• ed : law,and is prepared in accordance with iC 6-1.1-5.5,"Real Property Sales Disclosure Act". d# Signature of Sel-r Signature of Seller ire, e5 r h7'1Of1 /I. fa Printed Nam..fSeller Sign Date(MM/DD/YYYY) Printed Name of Seller Sign Date(MM/DD/YYYY) F.BUYER(S)/GRANTEE(S)—APPLICATION FOR PROPERTY TAX-DEDUCTIONS—IDENTIFY ALL ITEMS THAT APPLY • City of Carmel, Indiana Buyer 1-Name as appears on conveyance document Buyer 2-Name as appears on conveyance document One Civic Square Address(Number and Street) Address(Number and Street) Westfield, IN 460674 City,State,and ZIP Code City,State,and ZiP Code 317.571.2400 Telephone Number E-mail Telephone Number E-mail THE SALES DISCLOSURE FORM MAY BE USED TO APPLY FOR CERTAIN DEDUCTIONS FOR THIS PROPERTY. IDENTIFY ALL OF THOSE THAT APPLY. YES NO CONDITION YES NO CONDITION ❑ © 1.Will this property be the buyer's primary ❑ 0 3.Homestead residence? Provide complete address of primary ❑ © 4.Solar Energy Heating/Cooling System residence,including county: One Civic Square El IN S.Wind Power Device Address(Number and Street) ❑ © 6.Hydroelectric Power Device Westfield, IN 46074 Hamilton ❑ 17I 7.Geothermal Energy Heating/Cooling Device City,State ZIP Code County ❑ Z 2.Does the buyer have a homestead in Indiana to be El 8•Is this property a residential rental property? vacated for this residence? If yes,provide ❑ Z 9.Would you like to receive tax statements for this complete address of residence being vacated, property via e-mail?(Provide contact information including county: below.Please see instructions for more information. Not available in all counties.) Address(Number and Street) City,State ZIP Code County Primary property owner contact name E-mail 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 is prepared in accordance with IC 6-1.1-5.5,"Real Property Sales Disclosure Act".(Note: Spouse information,Social Security and Driver's License/Other numbers are not necessary if no Homestead Deduction is being filed.) -- .....00----- Signature of Buy• Signature of Buyer2/Spouse Printed Legal Name of Buyer 1 Sign Date(M /DD/YYYY) Printed Legal Name of Buyer Z/Spouse Sign Date(MM/DD/nYY) C-cr'y ijk OA Lost5 digits of Buyer 1 Driver's State Last 5 Digits of Social Security Number Last 5 digits of Buyer 2/Spouse Driver's State Last 5 Digits of Social Security License/ID/Other Number Number License/ID/Other Number INDIANA SALES DISCLOSURE FORM SDF ID SDO ID 1804617 Page 3 PART 2 COUNTY ASSESSOR The county assessor must verify and complete items 1 through 14 and stamp the sales disclosure form before sending to the auditor: 1.Property 2.AV Land 3.AV Improvement 4.Value of Personal S.AV Total 6.Property 7.Neighborhood 8,Tax District 9.Acreage Property Class Code Code A.) B.) Assessor Stamp 10.Identify physical changes to property between March 1 and YES I NO I CONDITION date of sale. ❑ ❑ 11.Is form completed? ❑ ❑ 12.State sales fee required? 13.Date of sale(MM/uu/rvnl: 14.Date form received(Mal/DD/VSVV): Items 15 through 18 are to be completed by the assessor when validating this sale: 15.If applicable,identify any additional special circumstances relating to validation of sale. YES I NO I CONDITION ❑ ❑ 16.Sale valid for trending? ❑ ❑ 17.Validation of sale complete? 18.Validated by: PART 3-COUNTY AUDITOR Auditor Stamp 1.Disclosure fee amount collected:$ YES NO CONDITION 2.Other Local Fee: $ ❑ ❑ 6.Is form completed? 3.Total Fee Collected:$ ❑ ❑ 7.Is state fee collected? 4.Auditor receipt book number: ❑ El 8.Attachments complete? 5.Date of transfer(MM/DD/vvvl): • PART 4-.RECEIPT FOR STATEMENT OF DEDUCTION OF ASSESSED VALUATION SDF ID SDF Date(MM/DD/rvvY Buyer I-Name as appears on conveyance document Parcel Number Address of Property(Number and Street) Check all that apply: City,State,and ZIP Cade of Property • Homestead Solar Energy Wind Power • Hydroelectric ❑Geothermal 0 Rental Property AoditerSignature Date(MP4/DD/Vm) n Electronic Statement(e-mail) A person who knowingly and intentionally falsifies value of transferred real property,or omits or falsifies any information required to be provided in the sales disclosure form commits a Class C felony. INDIANA SALES DISCLOSURE FORM SDF ID SDO ID 1804617 Page 1 Parcel Addendum Sheet 1.Property Number Check box if applicable to 5.Complete Address of Property 6.Complete Tax Billing Address(if different from parcel properly address) 1 ) © 2.Split 0 Old Meridian Street One Civic Square 29.09-26-203-022.000.018 3.Land Carmel,IN 46032 Carmel,IN 46032 0 4.Improvement 7.Subdivision Name Jr Lot Number 8.Deductions ❑Homestead ❑Solar Energy ❑Wind Power ❑Hydroelectric ❑ Geothermal 9.Rental Property ❑ 10.Parcel Acreage 0.08 10.Legal Description A part of the Northeast Quarter of Section 26,Township 18 North,Range 3 East,Hamilton County,Indiana. Signature Date INDIANA SALES DISCLOSURE FORM SDF ID SDO ID 1804617 Page 2 Seller Addendum Sheet James T.Anthony Anthony Insurance Partnership Seller-Name as appears on conveyance document 1919 E.191st Street Address(Number and Street) Westfield,IN 46074- City,State,and ZIP Code 317-695-9026 Telephone Number E-mail IN Last 5 digits of Seller Driver's State Last S Digits of Social Security Number License/ID/Other Number Signature Date INDIANA SALES DISCLOSURE FORM SDF ID SDO ID 1804617 Page 3 Buyer Addendum Sheet City of Carmel,Indiana Buyer-Name as appears on conveyance document One Civic Square Address(Number and Street) Carmel,IN 46032- City,State,and ZIP Code 317-571-2400 Teteshane Number E-mail IN Lust 5 digits of Buyer Driver's Stute Lust 5 Digits'of Sochi!Security Number License/ID/Other Number Signature Date I "Il .11 11 0 Ira II iron PPM alma CI ��►=�� 1 EL JAMES BRAINARD, MAYOR COST TO CURE REMOVAL NOTICE Anthony Insurance Partnership Attn: Tony Schelonka 1919 E. 19151 Street Westfield, IN 46074 Des. No.: 1400673 Project No.: 1400673 Parcel No.: 15 The City of Carmel, Indiana, has paid for a cost to cure on the property generally located at: Address/Location: 13200 Old Meridian Street, Carmel, IN 46032 In order to comply with State& Federal regulations, it is our responsibility to notify you that the item which you agreed to move must be removed from the right of way by the date stated below. Items in the Right of Way: Remove two post signs Please consider this letter as your notification to vacate the acquired right of way and remove all personal property no later than: M404- 11 Be aware that any items left in the right of way after the specified date, will remain at your risk. Contractors will be authorized to remove these items. In order to ensure that the construction phase of this project goes smoothly for you, as well as the contractor, please feel free to contact Jeremy Kaslunan at the City of Carmel, (317) 281-1379, if questions arise or if verification is needed. Sincerely, Jer Kas man, City Engineer City of Carmel DEPARTMENT OF ENGINEERING ONE Civic SQUARE, CARAIEL, IN 46032 OFFICE 317.571.2441 FAx 317.571.2439 EMAIL engineeringecannel.in.gov