Homestead_Williams (23) INDIANA SALES DISCLOSURE FORM SDFID: Paget
D.PREPARER -_
Timothy Shea Closing Services
Preparer of the Sales Disclosure Form Tide
7820 Eagle Crest Blvd Ste 201 Regional Title Services
Address(Number and Street) Company
Evansville, IN 47715 (812)759-5555 closinesnreeionaltitlellcom
City,State,and ZIP Code Telephone Number E-mail
Kenneth C.Goldbach Robin A. Goldbach
Seller I-Name as appears on conveyance document Seller I-Name as appears on conveyance document
766 S Concord Drive 766 S Concord Drive
Address(Number and Street) Address(Number and Street)
Princeton, IN 47670 Princeton, IN 47670
and complleetteeewas require by ,and is prepared in accordance with 6- ,1-5).5,"Re operty Sales Disclosure Act".
Signature of Seller C. •��` )1 /nIn rs/n SignaturreeofSeelll[/err �� ^ /�
Kenneth C. Goldbach is !/ (y/L/t////ly Robin A. Goldbach Y//I
Printed Name of Seller Si Date{{{W OO/YYM Printed Name of Seller Si Datf(MM/DD/YYY1)
F;,BBY-ERfS}f6R.ANTEE(SIAAPPLICATIONFOR-PROPERTYTAXDEDUCTIONS-iIDENTIFY-ALL'ITEM t{9A Y
/Jon Nathan Williams
-Buyen.icmnensvpfiears on conveyance document Buyer 2-Name as appears on conveyance d .eat
1114 Canon Lane
Address(Number and Street) Address(Number and Street) NOV 2 0 2010
Harrisburg, IL 62946-3556 Ll U
PROPERTY.
�� IDENTIFY•__ALL OF THOSE THAT APPLY.
YES NO CONDITION Di J.Will this property be the buyer's primary (----- ❑ 3. Homesmes
tead
residence? Provide complete address of primary ❑ p 4.Solar Energy Heating/Cooling System
residence,including county: ❑ p 5.Wind Power Device
766 S Concord Drive Address(Number and Street) ❑ p 6. Hydroelectric Power Device
Princeton, IN 47670 Gibson ❑ 0 7.Geothermal Energy Heating/Cooling Device
City, ZIP lode County 0 8. Is this property a residential rental property?
[v� ❑ 2. Does the buyer have a homestead in Indiana to be ❑ 9.Would you like to receive tax statements for this
vacated for this residence? If yes,provide
complete address of residence being vacated, property via e-mail?(Provide contact information
ncluding county: below.Please see instructions for more information.
iNot available in all counties.)
II I LI C caul gal III
Address(Number Street) Jon Nathan Williamsa6 //� OQI• S5-4 -0az
1'{c.rr �56�.te)rc� ZL �Z44� 541;,.e "Pi 7
City,State ZIP Code County Primary property owner contact name E-mail
Number License/ID/Other Number