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-,•INDIANA SALES DISCLOSURE FORM SDF ID:u"G O1�XJ �I -�00090 � 1' Pa e 2�
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� a M. Drule Attomev No. 4759-26
eparer o/Ne Sala Dlsdosvre form 7SUe
505 N. Church Street P.O. Box 146 Law Office of Rav M. Drulev
Mdress(Num6erand5veetJ Compvny
Fort Branch. IN 47648
E-mall
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Estate af Jackie S Hollic
Shcerl-Nameasappeanonconveyvncedocummt Sd/er2-Nameasa rsoncanv
ppea eynnredocumen[
_]76 E 795 S
Address (Numberand Sveet) Address (NUmbermd Strre[)
�ort 8rench. IN 4764A
E-mall Tefe honeNumbrr E-mail
Under penal[ies of perjury, I hereby certify [hat this Sales Disclosure, to the best of my knowledge and belief, is true, correc[
and co� ple/� e as /re�quire��d� ,b�y �w�, and is prepared in accordance with IC 6-1.1-5.5, "Real Proper[y Sales Disclosure Act".
116�YIM-`T. C�wzu�fY
Sig reo(Selfu 9gnamreo(Shcer
Estate of Jackie S. Hollis John R Hollis PR 11I73I2004
PAnredNamea Seller Si nDate HM O Prin[edNameo SAIer 5! nDo[e NM 0
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rE':BU,YE . R�4NTEE S��AP:P.LIGATION;FOR�P,ROP,ERT;YI�TAX�DEDUC-TIONS=.IDENTIF,YSAEL�ITiEMSYTHATRP,P,LY�?,��,��,-�,'��'�S
BI r
Buyerl�Nameasop omm�veyvncedocumen[ Buyel2-Namevsoppearsonronveyoncedocument
04 nd u
�Arec.(NumW and StmQ Addras (Numbe� and Street)
.+ansville. IN 47715
E�mal1 Te E-mail
THESALESDISCLOSUREFORMMAYBEUSEDTOAPPLYFORLERTAIYDEDUC710NSF NISPROPER71'.IDENTIFYALLOFT ETNATAPPLY.
YES NO COYD1770N YFS NO CONDRION
�✓ � i. Will this property be the buyer's primary �✓ � 3. Homestead
residence? Provide complete address of prima rgy Heating/Cooling System
residence, including county:
707 E. VinP Street ❑ Q 5. Wind Power Device
Addres(Numberandstreeq ❑ ✓Q 6. Hydroelectric Power Device
Fort Branch. IN 47648 Gibson � Q 7, Geothermal Energy Hea[ing/Cooling Device
[iry, Smre LPCade [ounry
� �✓ 2. Does the buyer have a homestead in lndiana [o be � ❑� 8• �s [his property a residential rental property?
vacated for this residente? IFyes, provide ❑ ❑ 9• Would you like to receive tax statements for this
comple[e address of residence being vacated, property via e-mail? (Provide contacf injormatlon
including county: 6elow. Please see instructions(or more in%rmation.
�� % � �Q ble�� c��s, �
Addrgs(NvmberandSbee[) �V ' p,J�(y
Coo�l F��ac�caa.D
Gty, 5rure 2/PCade Caunry
Prlmaryproperryawnercanmetname £-mail
Under penal[ies of perjury, l hereby certify that [his Sales Disclosure, to the best of my knowledge and belief, is true, correct
and complete as required by law, and is prepared in accordance wi[h IC 6-1.1-5.5, "Real Property Sales Disclosure Ad". (Note:
Spouse information, Social Security and Driver's License/Other numbers are not necessary if no Homes[ead Deduction is
being�.��
namreoJBuyerl 5(qnamreo(Buyer2/Spouse
�Kj3Jarkar�i 11/t:i/7(1�4
PnntedLegalNameo(BUyerl
Driver's Sfate Lar[SDigiGSO�Social5ecuriryNumber Las[Sdigiuo%Buyer2/SpouseDriver's Smte LastSDigitrof5ocialSecunty
License/lD/OrherNum6er Num6er License//D/ONerNum6er
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