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INDIANA SALES DISCLOSURE FORM SDF ID: Page 2
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. P.ftEPARER �. arl..;� F._ e _. ,�>�.. . e.,�,t . z -.- r .;ni- � � k:t.w ..:_ . c �,c'ir- . -:.: r'3 s ;,,• .sr. '..
Kimberly A. Lewis Office Manager
Preparer of the Sales Disclosure Form Title r
226 W. Broadway Broadway Title, Inc.
Address (Number and Street) Company
Princeton, IN 47670
!,VSELLER S `.GRANTOR S
Charles B. Sullivan
Yuko Sullivan
Seller1 Name as appears on can veyance document
Seller 2 -Name as a pears onromeyance document
bld
814 Meyer Ave.
520 Cannon Way
Address (Number and Street)
Address (Number and Street)
Evansville, IN 47710
Evansville, IN 47711
City. Stott and Zip Cade
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Te/e hwrNumber Email
Under penalties of perjury, I hereby certify that this Sales Disclosure, to the best of my knowledge and belief, is true, correct
and coDiplet��ed py 1 ,and is prepared in accordance with IC 6111- S, "Real Property Sale; Disclosure Act ".
_Kiln/
A/g�.�aN�re �o /Seller ^� Signature. ' r
CAaf x6001 s trk f l r vAf7 09 -•�� -200
e5 P. .St,.l�,i�,� 09 e(y YuA�o
Printed Name o Seller Sian Date MM DD Printed Name a Seller Sion Date Mlump
`FB1J.XER S `GRANTEE S "-'.' APPEICATION:FOR�PROP.ER7iY�TAXt - _�-
Shaun W. Kelle
ndrea M. Kelle
Buye rl- N' ameasappearsanconveyanredocument /
Buyer 2- Name .s.,paars on conveyance document-
509 iq
509 W. Monroe St.
Address(Number and SVee)
Address(Num
Princeton IN 47670
Princeton, IN 47
City. Start and ZIP Cade
Email
THE SALES DISCLOSURE FORMMAY BE USED TO APPLY FOR CERTAIN DEDUCTIONS FO OPERTY. IDENTIFY ALL OF TIIOSETH Y.
YES NO CONDITION YES NO CONDITION
® ❑ 1. Will this property be the buyer's ary
® ❑ 3. Homestead '
residence? Provide complete address of prim
Solar Energy Heating /Coolin S m
residence, including county:
E) ® 5. Wind Power Device
7664 N. Thompson Rd.
❑ ❑X 6. Hydroelectric Power Device
Address(NumberandSVeer)
Hazleton, IN 47640
❑ ® 7. Geothermal EnergyHea ting /Cooling Device
❑ ® 8. Is this property a residential rental property?
City, State ZIP Cade County
?� ❑ 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
�.. dudin coun :
i
below. Please see instructionsfor more information.
0/ E
Not available in all counties.)
A 'Numberand Street)
cL
nr
5
14,-v
,ry,Statezipcode I County
Primary property muner contact name
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.
W / z
o/B rrrz /sv�a/.s�e
Slgn.m,ao/Buyert s'g'
,atvre
//c o 9 001 f 1p rli Fr ! l )ir�) ° le 1owle L cr,
Pn'nted Legal Nome aJBuyerl Sign Date(MM/DD/YYYI) Printed Legal Name oJBuyer2 /Spouse Sign Date(MM/DD/Dl'1)
Security Number Last S digits ofBvyer2 1Spouse Driver's State Last 5 Digits of5ocial Security
License /1D10ther Number Number License /1D 101her Number
STATE IORM 1!WIR'/Wit rPr GIIEAtORM TS-1A
ArrMOVED BY MATE BOARD OF rMTI.\Tt_mr WARMED BY ME DEPAR MEYt tf LOCAL GOVERNMENT MANGE IC 4-1.1-2:4,1
Gibson County Auditor 101 N.Main IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS
PRINCETON IN 47670 Individuals and married couples are limited to one homestead standard deduction.As the receipt of this deduction becomes
more beneficial.there is more incentive than eser for homestead fraud.Homestead fraud causes higher tax bills for all:therefore.
. HEA 1344-2009 requires taxpners who receive the homestead standard deduction to verify that they are eligible to receive the
benefit and to provide additional identifying information necessary to allow country government to better monitor homestead
filings.This information will be kept confidential and can only he accessed by authorized county officials The Department of
Local Government Finance will use this information to create tools that will help county officials eliminate homestead fraud.
PART 1: PROPERTY INFORMATION
Taxpayer Name Property Address
Sullivan, Charles B/Yuko
Ft I Box 246
I lazlcton IN 47640 i ' /
270 N
Shaun W Kelley
7664 N Thompson Rd State Parcel Number Legal Description
HAZLETON IN 47640-9355
26-05-57-110-000.785-017 009-00785-00 PT MD 110 1-10 3AC
I 1Ir1Iltllllllll rleilihillelnnlI11IrinitluelltnI11IIrnII C-1
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 INFORMATION
Owner I First Middle Last
C?A Us_n l � \\:k (N\O� Ye\\e��'{\
ion (number and street,city,state,and ZIP code) t oe as prapertd address
1401/3(4 m�–�\, >-CV\spl� co\) d \ n , \nJ k l �rn
/
Spouse First Middle Last
P-m\cep, 1 tojel\e V.91\eo
Mailing Address(Number and street,city,state,and ZIP code) - me as p rt address y-.,
II
--_---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.
Owne I ignite Date
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