Homestead_Campbell (4) HsPREPARER
Preparer of the Sales Disclosure Form Title
Roman Ricker Attorney
Company
Address(number and street,city,state,country,and ZIP Code)
21:9 N Hart Street, Princeton IN 47670
I .SELLER(S)/GRANTOR(S) _ - s
Seller 1—Name as it appears on conveyance document Seller 2—Name as appears on conveyance document
Kevin A. Jost
Address(number and street) Address(number and street)
734 S. Burkhardt Rd.
City,state,and ZIP Code City,state,and ZIP Code
Evansville, IN 47715
Country Country
USA
E-mail address
( )
Under penalties of,perjury,;I hereby certify this Sales Disclosure,to the best of myknowledge and b elief,is ue tr ,correct and complete as
qu reired by law,anis pa d prered in,accordance with IC 6 1 1, 5 5 A;person who knowingly and intentionally,falsifies the value of transferred,
real property,or of mits or•falsifies any information required:to be provided,commits arLevel:5 felony, , :" _"
Signatu eller A Signature of Seller
L l//lei
Pri ed Name of Seller Date signed(mm/dd/yyyy) Printed Name of Seller Date signed(mm/dd/yyyy)
Kevin A. Jost 1/15/2021
J`BUYERS)/GRANTEE(S) APPLICATION FOR PROPERTY TAX DEDUCTIONS IDENTIFY ALL THAT APPLY
Buyer 1-Name-as it appears on conveyance document Buyer 2—Name as it appears on convey.nce'document
Jessica M. Campbell
Address(number and street) Address(number and street) 14
7782 S 325 W
City,state,and ZIP Code City,state,and ZIP Code
Fort Branch, IN 47648 J4N : -411!)
Country Country 2.0 ,
USA Gis,
E-mail address
o&N",`RAJ ' . -
Pursuant to IC 6 1 1;1.2-44,the Sales Disclosure'Form may be used,'to apply;for certain deductions ,Id entify,;all ofahose{I1� pply; _
YES NO CONDITION YES NO CONDITION
RI 0 1.Will this property be the buyer's primary 11 0 3. Homestead
residence? 0 Ii6 4.Solar Energy Heating or Cooling System
0 2. Does the buyer have a homestead to be vacated 0 (,Zf 5.Wind Power Device
for this residence? If yes, provide address: 0 1ii 6. Hydroelectric Power Device
Address(number and street) 0 (21 7. Geothermal Energy Heating or Cooling Device
City,state,and ZIP Code County OrO /.9/ . tiOcP ei‘ 4.2