Homestead_Clark (2) INDIANA SALES DISCLOSURE FORM SDF ID: 2016 Page 2
D. PREPARER
Teresa S. Holifield Escrow Officer
Preparer of the Sales Disclosure Form Title
605 SE Martin Luther King Jr Boulevard Southwestern Indiana Land Title
Address(Number and Street) Company
Evansville, Indiana 47713 (812)425-0055 tresa @swinland.com
City,State,and ZIP Code Telephone Number E-mail
E. SELLER(S)/GRANTOR(S)
James T. Czoer
Seller I-Name as appears on conveyance document Seller 2-Name as appears on conveyance document
650 E 1025 S
Address(Number and Street) Address(Number and Street)
Under penaltie of perjury, I hereby certify that this Sales Disclosure, to the best of my knowledge and belief, is true, correct
and comple s require y law, and is prepared in accordance with IC 6-1.1-5.5, "Real Property S Djp sure- ct'.
4 Sig Lure o�S Seller /� Signature of Seller
Ja es T. Czoer /� 7/12/2016 MIL 14 9n? 12/2016
Printed Name of Seller Sign Date(MM/DD/YYYY) Printed Name of Seller Sigd'O (MM/DD/YYYY)
F. BUYER(S)/GRANTEE(S) -APPLICATION FOR PROPERTY TAX DEDUCTIONS-IDENTIFY ALL ITEMS;14/T APP
Mike Clark Jana Clark GIBSON CCHINTv At'DITOft
`Beyer 1-Nameas app gars on conveyance document Buyer 2-Name as appears on conveyance document
(/ ? L . �ISOS YSblE - /l SD 5.
?Tress(Number d Street) Address(Number and Street)
_ { � f .
THE SALES DISCLOSURE FORM MAY BE USED TO APPLY FOR CERTAIN DEDUCTIONS FOR THIS PROPERTY. IDENTIFY ALL OF THOSE THAT APPLY.
YESr NO CONDITION YES NO CONDITION
,S/�f`J 1. Will this property be the buyer's primary ' ❑ 3. Homestead
residence? Provide complete address of primary ❑ ik. 4. Solar Energy Heating/Cooling System
residence, including county:
❑ l 5. Wind Power Device
1679 E Lincoln
Address(Number and Street) ❑ 6. Hydroelectric Power Device
IHaubstadt, IN 47639 I Gibson ❑ 7. Geothermal Energy Heating/Cooling Device
City.State ZIP Code County ❑ 8. Is this property a residential rental property?
❑ El 2. Does the buyer have a homestead in Indiana to be ❑ X 9. Would you like to receive tax statements for this
vacated for this residence? If yes, provide complete property via-email? (Provide contact information
address of residence being vacated, including county: below. Please see instructions for more information.
Not available in all counties.)
Address(Number and Street)
(Q(0-4Q 3-16-02W00a. "181-Ca 4
City, State ZIP Code County Primary property owner contact name E-mail