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Form
Ciry,Srou,
Seller 1� Nome as appears on ronveyvntt document
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Address (h'um6er and Stmt)
P:' InC.ef"D/I� //1/ `i �G ?O
rue
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Seller 2- Nome as appmrs om m�veynnte docummt
Addrezs (h'um ber and SVreQ
Ciry, Smtt, and LP Code
penalties o(perjury, t hereby certify [hat [his Sales Disclosure, [o the best of my knowledge and belief, is true, correct
mple[e as requjred by law, and is prepared in accordance with IC 6d.1-5.5, "Real Property Sales Disclosure Ac[".
TION�FOR�PR02ERT,Y TAX�-0
Buyer /- Name as appmrs on ronveyonte document
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Address (Num6er and Svee[J
Smre, andZ/PCode
Signa[ure o(Seller
eo e er
GTIONS=�[DENTIFY AhL-.ITEMS THAT,APPLY
JPttice /J1_So���y(I
.B/uyer 2� NomeQas appmn om m�veyanm documen[
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Address(NUmberand5vee[) �
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Ciry, Smu. and ZIPCade
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THE SALFS DISCLOSURE FORA1 A7.1Y BE USED TO APPLY FOR CERTAIY DEUURIONS FOR THIS PROPERTY. IDENTIFY ALL OF THOSE TFL1T APPLY.
Q ❑ 1. Will this property he the buyer's primary
residence? Provide complete address of primary
/�eside ryce, including county:
y(1 F • 6�n.y�[rvcw
�ddress (Numbe� and Svtttf
r,n�P�. /A/ L-/ 7� 74
Ciry, Sm[e ZlP Codr Coonry
❑ Q� 2. Does the buyer have a homestead in Indiana [o be
vacated for this residence? Ifyes, provide
comple[e address of residence being vacated,
including coun[y:
Address (Number and Srree[)
City, Smre Z/PCade lounry
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Homestead
S. Wind Power Device
System � U�
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6. Hydroelectric Po�ver Device
7. Geo[hermal Energy Hea[ing/Cooling Device
S. Is this property a residentlal rental property?
❑ [�j' 9. Would you like to receive tax sWtements for [his
property via e-mail? (Provide conmci in%rmotion
6e/ow. Please see instructions(or more information.
Not availa6/e in all counties.
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Under penal[ies of perjury, 1 hereby certify [ha[ this Sales Disclosure, [o [he bes[ of my knowledge and belief, is true, correc[
and comple[e 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 necess y if no Homestead Deduc[ion is
being filed.) ��j-�
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ast5digiGrojBu}rerZ/SpauseDriver's Smte Las[SDigiGSOjSocial5ecunty
License/lD/0[herNumber Number Litense/!D/OtherNumber