Homestead_ShoultzINDIANA SALES DISCLOSURE FORM SDF ID: Paee 2
i
'PREPAREk•= -' ` s
L—Steven L. Whitehead Attorney
ofthe Sala Disclosure Form Tide
0Preparer
-111 North Hart Street
Address (Number and Street) Company
Princeton, IN 47670
City, State, and 7JP Code Telephone Number E-mail
:E.'SEELER(S)� GPANTOR(S)_4 '-
Brian I Shoultz
5&ler 1 - Name as appears an conveyance document
4475 N State Road 65
Seller 2- Name as appears on conveyance document
Address (Number and Street)
Pntokn IN 47666
Address (Number and Street)
City. State, and 7JP Code
Ciry, State. and Zip Code
Telep hone Number E-mail
I Telephone Number E-mail
Under penalties of perjury, I hereby certify that this Sales Disclosure, to the best of my knowledge and belief, is true, correct
andco pleteasre Lured bylaw, and is prepared in accordance with IC 6-1.1-5.5, "Real Property Sales Disclosure Act".
SitinarureofSeller Sym.tureo[Saflar
Brian L Shoultz 7 "i -//
le Sion Dun? (MMIDDIffM Pnn fiff Sign Date (MMIDDIYYM
:F, BUYERS )ZGy4EE(S)'!-APP.LICATION-FOR PROPERTYTAX C-TIONS-'IDENTtlzY 'ALL ITEMSTHATAPPLY" � u.
Brian L. Shoultz -1)
Charlotte Shoultz
r - ppears on conveyance document
pi
-.Buyer 2. Name as ap on conveyance document
W
4475 -State Road 65
47771T�State Road 65
Address (Number and Street)
Address (Number and Street)
� 47666
okaL
Patoka. IN 47666
Drat_
Zi_ of NP Code
tv State,
City, Swig, and ZIP Code
E-mail
THE SALES DISCLOSURE FORM MAY BE USED TO APPLY FOR CERTAIN DEDUCTION'S FOR PER APPLY.
YES NO CONDITION YES NO CONDITION 77ETHAT
1. Will this property be the buyer's primary
✓ E] 3. Homestead
residence? Provide complete address of primary
❑ R] 4. Solar Energy Heating/Cooling System
residence, including county:
[:] R] 5. Wind Power Device
❑ [Z] 6. Hydroelectric Power Device
Address (Number and Street)
7. Geothermal Energy Heating/Cooling Device
City, State VP Code County
❑ n/ 2. Does the buyer have homestead in Indiana be
8. is this property a residential rental property?
a to
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.)
Address (Number and Strem)
a 5 /2,V 006 4, T -7 0
City State ZIP Code County
,
Prina.;y property owner contact name E-mail
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 �id.)
C,\-,
2!S A 'a A'ta\)
Signature afBayer2l5pouse
0SignatureofBoyarl
J 9 —
. an L. Shoult7 ChRrIottp. Shoult7
1'
Last 5 digits of Buyer I Driver's State Lost 5 Digits ofSocial Security Number Last 5 digits offtyer2lSpouse Driver's State Lost 5 Digits of Social Security
L
Licensell0l0ther Number ; Number License /ID /Other Number I
StME MCA!DRAM:I*-fl TRFANt@PoM1V—tA r
APPROVED BY Al AIL vt oOf MYNA CAT,.MN PRESCRIBED BY ME DEPART TOF LOCAL r{N-EI MrNr MV:ANCE 11,1-1.1-22-1 I
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 IAN hills for all:therefore.
di HEA I344--2009 requires taxpayers who receive the homestead standard deduction to verify that they are eligible to rtteise the
benefit and to provide additional identifyine information necessary to allow county eovemrnent to better monitor homestead
flings. This information will be kepi confidential and can only tic accessed by authorized county officials.The Ikparltnem of
Local Gown-town: Finance will use this information to creme tools that will help county officials eliminate homestead fraud.
PART 1: PROPERTY LNFORMATION
Taxpayer Name Property Address
-- Shout, Brian Lee/Charlotte L
4475 N SR 65
Patoka IN 47666
740
Brian Lee/Charlotte L Shoultz
4475 N SR 65 State Parcel Number Legal Description
Patoka IN 47666
26-05-15-100-000.697-017 697-00 PT SW SE 15-1-10 1.86 AC
D-12 0
D-12 C-1
1
PART 2:TAXPAYER INFORMATION
Owoe First Middle Last
_ 1-rah 1..x.,c Sr hf0 1JZ
�c Address(number mtd stmt,city,state,anti ZIP code) — ''- — -- -R'Same as property addrrs - -. - --
Spouse First Middle Last
Ch1rIo -H-C Louise Shou 1 +Z
Mailing Address(Number and street,city,state,and ZIP code) 'Same as properly address
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.
Owner I Signature Date
PART 4:ADDITIONAL INFORMATION
ill.