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D.PREPARER
Brvceann N. Cutsinqer
Preparera/lhe Sa/a D'udaturr Form Ti[!e
226 W. Broadwav Broadwav Title Inc.
Addres (Number ond Svee[) Company
Princeton IN 47670 812-386-7687 samantha.bti(dmw.rivctic.com
Ciry,Srnre,andZlPCode TelephoneNumber � E-mail
E.
Seller 1- Name os appean om m�veyanre dacument
i0521 W SR 165
Addras (Number ond SVttQ
Danita L Criffin
Sellerl�Namrasappearsomm�vryvnteda'umm[ ;
�10521 W SR 165
,lddress (NUmber and Sveet)
Owencville IN 47655 Qwencvillr IN 47665
I E'-mail
Under penalties of perjury, l hereby certify that this Sales Disclosure, [o the best of my knowledge and belief, is true, correct
and complete as required by law, and is prepared in accordance wi[h IC 6-1.1-5.�5/ "Real Property Sales Disclosure Act".
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Signamreo/Sel SignoNreofSeller —T I � � �
on ronvryana da'umenl
TAX DEDUCTIONS- IDENTIFY
Buyer I� Name os appears on ronveyance dorumenl
5146 $.980 W.
Addrm (Nvmberand Svte[J Addrets
Owensville IN 47665
Ciry.Sm[e. and21P Code Ciry, Srn
THE SALFS DISdOSURE PORM MAY BE USED TO APPLY FOR CFJtTAIN DEDURIOYS FOR THIS PROPERTY. IOENTIFY ALL OF THOSE THAT APPLY.
Q ❑ 1. Will this proper[y be the buyer's primary �
residence? Provide complete address of primary
residence, including county:
R940 S 7125 W
Addres(Num ond5[reelJ '
Owensville IN 47665
Liry,SmuZ Code Counry
❑ 2. Does [he buyer have a homes[ead in Indiana to be
vatated for [his residence? If yes, provide
mmple[e address of residence being vacated,
including county:
5146 S 980 W
Addres (NUmber md Sveee)
Ciry, Smte ZIPCOde
Q ❑ 3. Homes[ead
❑ � 5. Wind Power Device �
❑ � 6. Hydroelectric Power Device
❑ Q 7. Geo[hermal Energy Heabng/Cooling Device
❑ Q 8. Is [his property a residentiai rental property?
❑ � 9. Would you like to receive tax s[at�ementr for this
property via e-mail? (Provide conioct informaCion
�Not availa6le in all rountles.J " �
�/ -17-�9_reo-ooy3!96-0�-/
Under penalties of perjury, t hereby cer[ify [hat this Sales Disclosure, to [ e es[ o my ow e ge and belief, is [rue, correc[
and complete as required by law, and is prepared in accordance with IC 641-5.5, "Real Proper[y Sales Disclosure AcY'. (Note:
Spouse information, Social Security and Driver's License/Other numbers are not necessary if no Homes[ead � educ[ion is
being �fiyled.) .//
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Signamreo/Buyerl —/� Signamreo(Bvyerl/Spouse
Qrara F Kohler l� — �
Lirense/ID/Other Num6er
Pnn[edLegolNameo(Buyerl/Spouee Sign�ate(MM/OO/YYttj
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Last S digiGS o(Buyer7/Spouse Dnver's Smte Last SGigics oj5ocial5ecunry
Number License/ID/O[herNumber �