Homestead_Klem INDIANA SALES DISCLOSURE FORM 51./ Ill: ragc L.
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D PREP�RER.�? r _ .w '. a.,�t. a� ;,�r a. - ._ . si. . ; ^ :k�, . . ,n 1„,7t .. . �� j � t . � .,. : nt rr:4_...., a�•�.P ati::At-
Crista Wallace Typist
Preparer of the Sales Disclosure Form Title
605 S. E. Martin Luther King Jr. Blvd. Southwestern Indiana Land Title
Address(Number and Street) Company
Evansville,IN 47713
E-mail
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Seller 1.Name as appears on conveyance document Seller 2-Name as appears on conveyance document
Address(Number and Str et) Address(Number and Street)
City,State,and ZIP Code City,State,and ZIP Code
Telephone Number r E-mail Telephone Number E-mail
Under penalties of perjury,I hereby certify that this Sales Disclosure,to the best of my knowledge and belief,is true,correct
and co lleete as r/�equired b a and is prepared/ in accordance with IC 6-1.1-5.5,"Real Property Sales Disclosure Act".
SignatuiEo Seller Signature of Seller
Tammy Klem
Printed Name of Seller Sign Date(MM/DD/YYYY) Printed Name of Seller Sign Date(MM/DD/YYYY)
F, l3[1YE11(S)%GRANTEE(S)—APPLIC al FQR.PktMiY'r D"I b CTI WIran~al ITEl1 S THI TRIf)?IFEA gn .-';''a
Chris R. Klem
Buyer 1-Name as appears on conveyance document Buyer 2-Name as appears on conveyance document
401 S.Willard St.
Address(Number and Street) Address(Number and Street)
Ft. Branch IN 47648
City,
• E-mail Telephone Number E-mail
THE SALES DISCLOSURE FORM MAY BE USED TO APPLY FOR CERTAIN DEDUCTIONS FOR THIS PROPERTY. IDENTIFY ALL OF THOSE THAT APPI. p 6U LULU
YES NO CONDITION YES NO CONDITION 7r��
✓❑ ❑ 1.Will this property be the buyer's primary ❑✓ ❑ 3.Homestead GIBSON COUNTY AUDITOR CB
residence? Provide complete address of primary ❑ ✓❑ 4.Solar Energy Heating/Cooling System
residence,including county: ❑ ❑ 5.Wind Power Device
401 S.Willard St.
Address(Number and Street) ❑ ✓❑ 6.Hydroelectric Power Device
_ Ft. Branch IN 47648 Gibson ❑ ❑✓ 7.Geothermal Energy Heating/Cooling Device
Ciry,State ZIP Code County
❑ 22.Does the buyer have a homestead in Indiana to be ❑ ✓❑ 8.Is this property a residential rental property?
vacated for this residence? If yes,provide ❑ ✓❑ 9.Would 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 instrugtions for more information.
Not available in all counties)
Address(Number and Street)
26-19-19-101-001. 376-026
City,State ZIP Code County E-mail
Primary property owner contact name
Number License/ID/Other Number