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FORM
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TelephoneNumber E-mail
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Seller 2- Nome os appears an ronveynn¢ docvm�n[
Address (Number and Sheet)
Ciry, Smfe, and Z/PCOde
Under penal[ies of perjury, 1 hereby certify tha[ this Sales Disclosure, to the best of my knowledge and belief, is true, correct
and comple[e as required by law, and is prepared in accordance �vith IC 6-1.1-5.5, "Real Property Sales Disclosure Act".
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ZIPCode
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document
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THE SALFS DISQOSURE FORhI Mdl' BE USED TO APPLI' FOR CERTdi\ DEDUCTIOYS FOR T/HIS
1'FS /.CO CO\DITIOF //1 �
[� ❑ 1. 4Vill this properry be the buyer's primary �
residence? Provide mmplete address of primary
residence, indudin� county:
ISa�1 ?necc,�e �
�dr¢s(Numqe and5veet) -j
r"inG¢tbYi IrJ u'7(�70 � ►�
Ciy,SmceZIP e Counry
❑ 2. Does the buyer have a homestead in Indiana [o be
vaca[edforthisresidence? Ifyes,provide
complete address of residence being vacated,
induding county:
aeeras /NUm6er onesveecJ
City, Stoce ZIPCode Counry
APPLY.
❑ 3. Homestead
'�}�_e�4 Solar Fr�ns.��eating/Cooling System
❑ [� 5. N+ind Po�ver Device
❑ [� 6. Hydroelec�ric Power Device
❑ []� 7. Geothermal Energy Heating/Cooling Device
❑ [� s this proper[y a residen[ial rental propeiYy?
❑ f,�9. Would you like m receive tax s[atements for this
property via e-mail? (Provide conmct in�ormation
6elow. Please see instructions�or more injormation.
Not availa6/e in all counties.)
c? (o -/ o? -�S -
owner tonma nome
Z
E-mail
Under penal[ies of perjury, I hereby certify tha[ [his Sales Disclosure, to the best of my knowledge and belief, is [rue, correct
and complete as required by la�v, and is prepared in accordance with IC 6-1.1-S.S, "Real Property Sales Disclosure Ac[". (NOte:
Spouse information, Social Security and Driver's License/O[her numbers are not necessary if no Homestead Deduction is
being fjlqd.) � � �'
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PnntedLepal ameo%Buy�l � SignQvte(MM/OD�
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l iCense/1D/Other Number
Name a(Bvyri 2/Spouse
Last 5 digifs of Buyer Z/Spouse Onve� s
Num6er Litense/ID/O[herNumber
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Last 5 Digiu o�So[iol5ecunty
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