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INDIA NP SALES DISCLOSURE FORM SDF ID: ' l 3 Pa e 2
D PREPARER _
Karen Harbison VP VP
P,ep'oer u/ [he Sales DErlasure Form Title
803 E State Rd 68 The Elberfeld State Bank
Address (Numberand Street) Company
Haubstadt. IN 47639
E -mail
E. SELLERS GRANTOR S
Country Ayce Inc
Seller) Name as appears on conveyance document
Seller2 Nome as appears on conveyance document
9980 E Warrenton Rd
Address (Number and Streer)
Hal hctadt IN 47639
Address (Number and Sweet)
E -mail
Telephone Number E -mail
Und r penalties of p ry try, I hereby certify that this Sales Disclosure, to the best of my knowledge and belief, is true, correct
and c tnpl a { blr v, and is prepared in accordance with IC 6- 1.1.5.5, "Real Property Sales Disclosure Act ".
Signature of5eller Signature of Seller
David F Gras hel PrasidPnt x17-18-2011
Printed Name of5eller Sian Date(MM /DD/YYYY) Printed Nameo Seller Sian Date MMADD/YYYn
F. BJTEW GRANTEES - APP.CICATIONIF. - UCTIONSIilDEN :TIF;YAL'LJITEMS--THATAP.PLY.,' _ ,- -,r '
Lowell R Hayhurst 8 Emily Y Hayhurst Revocable` Living Trust
I
waver 1. Name or appears oa conveyance document
6uyer2 Name as appears on conveyance document
4 West Red Bank Rd
Address (Numbe rand Street)
Address (Number and Street)
Branch. IN 47648
®Ft
Ciry. Sane. and ZIP Code
City, State, and ZIP Code
Email
Tele hone Number Email
TO E SALES DISCLOSURE FORM NAY BE USED TO APPLY FOR CERTAIN DEDUCTION'S FOR THIS PROPERTY. IDENTIFY ALL OF THOSE THAT APPLY.
YES NO CONDITION I YES NO CONDITION
/ ❑ 1. Will this property be the buyer's primary
❑
❑✓ ❑ 3. Homestead
residence? Provide complete address of primary
❑ ❑✓ 4. Solar Energy Heating /Cooling System
residence, including county:
E] R] S. Wind Power Device
bon S Qth Ave
❑ [Z] 6. Hydroelectric Power Device
Address (Number and Street)
Haubstadt. IN 47639 Gibson
❑ ❑✓ 7. Geothermal Energy Heating /Cooling Device
❑ FV] 8. Is this property a residential rental property?
Ciry, State ZIP Code County
❑J ❑ 2. Does the buyer have a homestead in Indiana to be
vacated for this residence? If yes, provide
❑ ❑✓ 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.)
4 West Red Bank Rd
^^11
Q Q -000 9 2 9
Primary property owner contact name Email
Andres, (Number and Street)
Ft Branch. IN 47648 Gibson
Ci y,, State ZIP Code County
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.)
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Si Bu�f
Signature f Signature afBeyerl g o / y r ov
®n all R -- rct Tr ct a 07 -18 -9011 Emily Y Hayhurst. Tr tctep 07 -18 -2011
PPcnted Legal Name ofBuver l Sign Date(MM/DD/YYYY) Printed legal Name of Buyer 2 1Spouse sign Date(MMPOD/YYYY)
Driver's State Last S Digits of Social Security Number Last 5 digia of Buyer 2 /Spouse Driver's State Last 5 Digits ofSonal Security
License /ID /Other Number Number License /ID /other Number