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Homestead_Urbanek
INDIANA SALES DISCLOSURE FORM SDF ID: Page 2 KAREN HARBISON VP Preparer of the Sales Disclosure Form Title 803 E STATE HWY 68 HAUBSTADT STATE BANK Address(Number and Street) Company HAUBSTADT IN 47639 812-768-5800 kharbison(E esbanc.com City,State,and ZIP Code Telephone Number E-mail `.E•..SECEER(S)/GRANTOR(S)` • i C ., -;_;'.---` - -. - - - ' _Z-=, GAI EN R JONES DEBRA L JONES Seller I-Name as appears on conveyance document Seller 2_Name as appears on conveyance document 901 MOHAWK DR 903 MOHAWK DR Address(Number and Street) Address(Number and Street) Under penalties of perjury, 1 hereby certify that this Sales Disclosure,[ the be t of my knowledge and belief,is true,correct and Signature let as r�' ed by law,and is prepared in accordance ws9h� eFa l.a-( 5,"Real Property Sales Disclosure Act". s re oof Seller t / y—J eoW✓((1I of Seller CAI EN R.IONES 06/70/2016 DEBRA L JONE 06/7017016 Printed Name o(Sellee Sian Date(MM/DD/'mY) Printed Name of Seller Sian Date(MM/DO/rvnY1 - - - - _ - - - - _ T r _ _ r`.?/' F.BUYER(S)'%GRANTEE(S) AP.PLICATION;F,OR�I?RUPER•TiY!TAXqDEDUGTIONS�;IDENTIFYiALLTrITEMSrTHATiAP,P,bY� ~-' °' JAN M URBANEK ROBERT L URBANEK Buyer I•Name as appears on conveyance document Buyer 2-Nome as appears on conveyance document 327E 79 b 327E 795 S Address(Number and Street) Address(Number and Street) FORT BRANCH IN 47648 FORT BRANCH IN 47648 S�J e /' YES NO CONDITION I YES NO CONDITION /�C0.4.e egh, L ❑ 1.Will this property be the buyer's primary 0 ❑ 3.Homestead C,O V residence? Provide complete address of primary ❑ © 4.Solar Energy Heating/ e'l: 'Vitt,' residence, including county: 5.Wind Power Device iGO 903 MOHAWK DR ❑ /T Address(Number and Sweet) ❑ 0 6.Hydroelectric Power Device O,S. FORT BRANCH IN 47648 GIBSON ❑ 0 7.Geothermal Energy Heating/Cooling Device Ciry,State ZIP Code County Q ❑ 2.Does the buyer have a homestead in Indiana to be 111 8.Is this property a residential rental property? vacated for this residence? If yes,provide ❑ E 9.\Vould 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. 327 E 795 S Not available in all counties.) Address(Number and Street) FORT BRANCH IN 47648 GIBSON dQ-/9/f/6/- o9/ � war- 0.46 City,State ZIP Code County Primary property owner contact name E-mail