Homestead_Goldsberry INDIANA SALES DISCLOSURE FORM SDF ID: Page 2
1 D.PREPARER_ - -
Jamie Perry Closer
Preparer of the Sales Disclosure Form Title
7820 Eagle Crest Blvd, Ste 201 Regional Title Services,LLC
Address(Number and Street) Company
Evansville, IN 47715 812-759-5555 Jamie,oerrv(@regionaltitlellc.com
CieB State,and ZIP Code Telephone Number E-mail
.E.SELLERS)/GRANTOR(S) - -
Daniel I Rack Dennis W Black
Seller 1-Name as appears on conveyance document Seller 2-Name as appears on conveyance document
5io az,Air-/a.,-e PO Box 328
dress(Number and Street) Address(Number and Street)
/=
Under nalties of perjury, I hereby certify that this Sales Disclosure,to the best of my knowledge and belief,is true,correct
and omplete as required b law,a d is prepared in accordance wt.C 6-1.1-5.5,"Real Property Sales Disclosure Act".
ignamre of Seller Signature of Seller
Daniel L Black j oh•J CC I.n
1 Dennis W Black Li 7 Li /!
Printed Name of Seller Sian Date(MM/DD/n l) Printed Name of Seller Sion Date Pa/DD/my(
,_F. BUYER(S)/GRANTEE(S)-APPLICATION FOR PROPERTY TAX DEDUCTIONS-IDENTIFY ALL ITEMS THAT APPLY
Jacob L. Goldsberry
Buyer I-Name as appears on conveyance document Buyer 2-Name as appears on conveyance document
9031 E 400 S
Address(Number and Street) Address(Number and Street)
Oakland City. IN 47660
Telephone Number E-mail
THE SALES DISCLOSURE FORM MAY BE USED TO APPLY FOR CERTAIN DEDUCTIONS FOR Tills PROPERTY. IDENTIFY ALL OF THOSE THAT APPLY,
YES NO CONDITION YES NO CONDITION
5 n 1.Will this property be the buyer's primary 0 n 3. Homestead
residence? Provide complete address of primary ❑ 5 4.Solar Energy Heating/Cooling System
rssidenc including county:
.q`I„ 1 IA r 31- ❑ 5 5.Wind Power vt
LA dress W Wither ant Street n 5 6.HydroelectricJ\vtj vi �D
U 0-��G L 1H f i f I '�fl U(20 i,5C7\ n El 7.Geothermal Energy Heating/Cooling Device
rl•.State P Code
pf
2. Does the buyer have a homestead in Indiana to be
❑ 0 8. Is this property aiEe2trinclatal property?
vacated for this residence? If yes,provide ❑ 5 9.Would you like to receive tax statements for this
complete address of residence being vacated, property via a-m-j; r. 4- -.1 act information
including county: below. Ple �r•�ps(� �rky0 rwffor ormation.
Notavailab`�e� in al counties.)
Address(Number and Street)
a4 - ►y-Ig -j q1 - 000. 017-087
Og State ZIP Code County
Primary property owner contact name E-mail
•