Homestead_KiserI IYUtANA aAL113 u13LLV3unn rumn our ru: Pe e Z
D. PREPARER — "
'am Kruger Loan Processor
PrepareroftheSales Disclosure Form Title
Elberfeld State Bank
Company
Haubstadt IN 47639
City, State• and ZIP Code Telephone Number E -mail
E.SELLER(SI /GRANTOR(SI -. - _. - , .
Jesse A Simmons
Seller 1 - Name as appears an ronveya..c document
11,4 s On'
n P(I _I!vd
Address (Numberad e
Andrea B Simmons
Seller 2 - Nome as appears on mnveyoncedocument
Same I(Li 5 CCtntDb {II ��VC1
Address (Number and Street)
City, Sta te, and ZIP Code
Under penalties of perjury, I hereby certify that this Sales Disclosure, to the best of my knowledge and belief, is true, correct
a p quired by law, and is prepared in accordance wit "C 6- 1.1 -5.5, "Re 1 Property Salespisclosure Act ".
- -� �11)ytloCZ /�Z1�Zt�L/Y
gnature of Seller Sig %�Nre ofSeller,
J Srmm�tis I' ID J-IYiCI,' r, � 5rmmo.t 5 08'o5 I°
Buyer 1- Name as applart on conveyance document
/
IDENTIFY. ALL ITEMS,THATAPP.L
Buyer 2 - Name as appears on conveyance document
Address (Number and Sweet)
City, State, and ZIP Code
THE SALES DISCLOSURE FORM MAY HE USED TO APPLY FOR CERTAIN DEDUCTIONS FOR THIS PROPERTY. IDENTIFY ALL OF THOSE THAT APPLY.
Q ❑ 1. Will this property be the buyer's primary
residence? Provide complete address of primary
residence, including county:
114 S Camnhell Blvd
Address (Number and Stmt)
Haubstadt IN 47639
City, State ZIP Cade County
Q ❑ 2. Does the buyer have a homestead in Indiana to be
vacated for this residence? If yes, provide
complete address of residence being vacated,
including county:
335 Sharon RD
Address (Number and Sweet)
West Lafayette. IN 47906
Ciry, Smre ZIP Code County
Q
❑
3. Homestead
❑
Q
4. Solar Energy Heating /Cooling System
❑
Q
S. Wind Power Device
❑
Q
6. Hydroelectric Power Device
❑
Q
7. Geothermal Energy Heating /Cooling Device
❑ Q 8. Is this property a residential rental property?
❑ Q 9. Would you like to receive tax statements for this
property via e-mail? (Provide contact information
below. Please see instructions for more information.
Not available in 11 counties.)
�� - /� —,3G - - Qom. ,To'8- 009
Primary Property owner contact name E -mail
Under penalties of perjury, 1 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.) _ ,
10
Sign Date
Last 5 digits of Buyer l Driver's State Last S Digits
Signature of Buyer2/Spouse
Printed Legal Name ofBuyer2 /Spouse Sign Dow(mm1milYYYV)
Last 5 digits of Buyer 2 1Spouse Driver's State Last 5 Digits ofsocialSecurity
Number License /lD /Other Number
0\