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Page 2
D PIZEPA-RER
JeffyD.StkNeI1,AUomevaILai Anwey at Lm
i ` Preparer of the Soles Disclosure Form Title
S02 N. Pnxe Street Bamberger, Foreman, Oswald 8 Hahn, LLP
Address (Number and Street) company
Princeton, IN 47670
Number Email
-E., SELLERS )IGP,ANTORCS)���';,�.;
0- "1
Dorothy Chambers
Matti Jun Roy
Seller I -Name as appears on conveyance document
Selle,2 Na.am.ppa.rs.ocom,avao,ad..a:it
405 E. Wood
1963 IN 850 S
Address (Number and Street)
Addrm (Number and Street)
Frwdc=JN 47539
Fort Brand), IN 47648
Under penalties of perjury, I hereby certify that this Sales Disclosure, to the best of my knowledge and belief, is true, correct
anfx,omplete as required , law, and is prepared in accordance with IC 6-1.1-5.5, "Real Property Sales Disclosure Act".
2b
i (Y �flilln'd, 0111 J (Ix4tL PEA-zf
Sr signature ofSello
Santora olSeller V
Dorothy Chambers Marlyn Jean Roy
Printed Name ofSeller Sion Dow (MMIDD 0 Pi-incedlicure.1seller Sion Data WMIUD/rYrrl
T. BUYERS )/GgN� EfS):—:APPLICATION FOR PROPERTYJAX DEDUCTIONSZ%IDENITIF.Y ALL ITEMS THATAPPLY,`�
Gregory J. Alen 2
Buyer I - Name asrj�paors, on conveyance document
Buyer Nome as appears on conveyance document
iE- 0 fw5v,
Address (Number and Street)
Address (Number and Street)
c6or'vc-� ro 4-1 LZ,\
THE SALES DISCLOSURE FORM MAY HE USED TO APPLY FOR CERTAIN DEDUCTIONS FOR TH IS PROPERTY. ILQEN' THOS�ETHAI APPLY.
DIT[ON
ES No CONDITION
ITS NO CONDITION ONDITION
F-I 1. Will this property be the buyer's primary
Homestead
Fx- F. 3. Homestead
residence? Provide complete address of pri ary
--:L�: o
Energy g/Cooling System
r era,�)
Solar r
residence, including county:
_
E: Fxt S. Wind Power Device
C E)<; 6. Hydroelectric Power Device
Address (,Number and Screet)
Ci Rxi 7. Geothermal Energy Heating/Cooling Device
r' 8. Is this property a residential rental property?
Gry, State ZIPCode County
Ll rRI 2. Does the buyer have a homestead in Indiana to be
vacated for this residence? If yes, provide
F 9. Would you like to receive tax statements for this
complete address of residence being vacated,
property via e -mail? (Provide contact information
below. Please see instructions for more information.
including county:
Not available in all counties.)
Address (Number and Street)
010
City, State ZIP Code County
1
Primar,property owner contact name E-mail
V .
- c STATE FORM 5350(R/8-10) TREASLRER FOCwn.0
- APPROVED BY STATE BOARD OF ACCOUNTS,IDA PRESCRIBID BY THE DEPARTMENT OF ID CALCOVERNMENT FINANCE IC 6-1.1-2.24.1
Gibson County Auditor IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS
101 N.Main Street Individuals and married couples are limited to one homestead standard deduction.As the receipt of this deduction becomes
Princeton, IN 47670 more beneficial,there is more incentive than ever for honastead fraud.Homestead fraud causes higher tax bills for all;therefore.
• HEA 1344-2009 requires taxpayers who receive the homestead standard deduction to verify that they are eligible to receive the
.1 oT T benefit and to provide additional identifying information necessary to allow county government to letter monitor homestead
� L,� filings.This information will be kept confidential and tan only be accessed by authorized county officials.Tire Department homestead of
Local Government Finance will use this information to create tools that will help county officials eliminate homestead faud.
PART I: PROPERTY INFORMATION
APR 2 6 2011 .
Taxpayer Name Location Address
C.�.fn Chambers, Dorothy/Marilyn J Roy
405 E WOOD ST
GIBSON COUNTY AUDITOR FRANCISCO IN 47639
4638 - _ _
Gregory J Alen
MI DI I I=[III 11111 d III I III II1111I 11111111111H11111 11l li l H iiiii ii liii iii ii ii iL iiii -
405 E Wood
FRANCISCO IN 47649-9079
111rr1111r1111111111111111111111111111i11111111111111111111i1111r State Parcel Number Legal Description
26-13-20-101-000.146-005 /PT NW 20 2 9.15 AC CURLESS ADD 2
•
This form MUST be returned to County Auditor's office.
Please do NOT send this form back with your tax payment to the county treasurer.
,_ _ _________-
______ . _ PART 2 TAXPAYER R INFO% ATION
._ Ov. First Middle Last
L.,ckte00 rib?Mailing Address(number and street,city-state,and ZIP code) 1•4, Same as property address
Spouse First - Middle Last
Ai 0/1/4lE_
Mailing Address(Number and street,city,state,and ZIP code) 0 Same as property address
Social Security Number(last 5 digits) . Driver's License/State ID Number (last 5 digits) Other(please specify in Part 4 below)
1 I I 1 1 1 I I J_ -LJ S -- — _ _
'--f---H-'-it" - -7r'_._..--•`.-- -, - ' . PART 3: CERTIFICATION ',
Each undersigned certifies,under penalty of perjury,that the above and foregoing information is true and correct and that he or she is eligible to
receive the homestead standard deduction on this property.Each undersigned also understands that,by claiming additional homestead deductions
unlawfully,he or she may be liable for back taxes and substantial financial penalties.
r Signature Date
( )
PART 4: ADDITIONAL INFORMATION