HomeMy WebLinkAboutHomestead_Shain INDIANA SALES DISCLOSURE FORM SDF ID: 2019 Page 2
D. PREPARER
Amy Pollard 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 (
E. SELLER(S)/GRANTOR(S)
Jeremy Blankenberger
Seller 1-Name as appears on conveyance document Seller 2-Name as appears on conveyance document
203 S West
Address(Number and Street) Address(Number and Street)
Fort Branch, IN 47648
City,State.and ZIP Code City, State, and ZIP Code
X
E-mail Telephone Number E-mail
Under p lties of perjury, I hereby certify that this Sales Disclosure,to the best of my knowledge and belief, is true,correct
aftd co ete as re by law,and is prepared in accordance with IC 6-1.1-5.5, "Real Property Sales Disclosure Act".
XLaiiCSe!Ier Signature of Seller
Jeremy Blankenb er 5/20/2019 5/20/2019
iPrrrrferJName o Seller Sign Date(MM/DD/YYYY) Printed Name of Seller Sign Date(MM/DD/YYYY)
F. BUYER(S)/GRANTEE(S) -APPLICAT FOR PROPERTY TAX DEDUCTIONS -IDENTIFY ALL ITEMS THAT A LY
(
Kimberly Elizabeth Shain N
Buyer 1-Name as appears on conveyance document Buyer 2-Name as appe n n ment
159 Gazette Ave,#16
Address(Number and Street) Address(Number and Street) MAy 2 4 ' 0\9
Lexington, KY 40508
") E-mail Telephone Number ,,,���((}}td COtJNIY atj9 E-mail
ES L DISCLOSURE FORM M• :. -' • TO APPLY FOR CERTAIN DEDUCTIONS FOR THIS PROPERTY. I♦, N'ITFY ALL OF THOSE THAT APPLY.
YES NO CONDITION YES NO CONDITION
— _.❑_t._Will.this propertyll e;the buye iiimarys.`:vs,a.' 1 ,0 3-Ho_neste d;,
residence? Provide complete address of primary ❑ 0 4. Solar Energy Heating/Cooling System
residence, including county:
❑ 0 5. Wind Power Device
203 S West St.Address(Number and Street) ❑ 0 6. Hydroelectric Power Device
Fort Branch, IN 47648 Gibson: ❑ 0 7. Geothermal Energy Heating/Cooling Device
City,State ZIP Code County ❑ 0 8. Is this property a residential rental property?
r_ - -D the buyer:have a homesteadiin'Indiana to.be.. ❑ 0 9. Would you like to receive tax statements for this
"��`-�le e- roe via-email? (Provide contact information
vacated for this residence?If yes, provide complete property rtY
address of residence being vacated, including county: e ow. Please see ins ' formation.
Not available in all counties.)
Address(Number and Street)
Z20. g-- 8-403 •ten. 32Y- oat
City, State ZIP Code County Primary property owner contact name E-mail
License/ID/Other Number