Homestead_Ellerbrook H. PREPARER
Preparer of the Sales Disclosure Form Take G �, tea'`r
.wn Shaw
Company
Address(number and street,city,state,country,and ZIP Code)
5231 Oak Grove Road,Suite A,Evansville, IN 47715
I. SELLERS)/GRANTOR(S)
Seller 1-Name as it appears on conveyance document Ralph H.Hoffman Seller 2-Name as appears on cone 1flt
1��JJ/
Address(number and street) L
622 W Jennings St Address(number and street)
City,state,and ZIP Code APR 2 9 2022
Newburgh, IN 47630 City,state,and ZIP Code
Country Country e���
t �/ , ,...,.
United States of America United States of America / /J
Ot1NTY AUDITOR
G1ttSON
Under penalties of perjury, I hereby certify this Sales Disclosure, to the best of my knowledge and belief, is true, correct and complete as
required by law,and is prepared In accordance with IC 6-1.1-5.5.A person who knowingly and Intentionally falsifies the value of transferred
real property,or omits or falsifies any information required to be provided,commits a Level 5 felony.
1,S,nature of Selir
// �/. // _ Signature of Seller 11
Pri Name of Senor //,^- Date ined(rm✓dd/yyyy) Printed Name of Seller Date
Ralph H.Hoffman 5,! -2a- .Z. i signed(mm/dd/yyyy)
J. BUYER(S)/GRANTEE(S)—APPLICATION FOR PROPERTY TAX DEDUCTIONS—IDENTIFY ALL THAT APPLY j
Buyer 1-Nam*as it appears on conveyance document I Buyer 2-Name as appears on conveyance document
Lexuss Kay Ellerbrook
Address(number and street) Address(number and street)
514 W.College St
City,state,and ZIP Code
City,state,and ZIP Code
Oakland City,IN 47660
Country 1 Country
United States of America
Pursuant to IC 6-1.1-12-44,the Sales Disclosure Form may be used to apply for certain deductions.Identify all of those that apply:
YES NO CONDITION YES NO CONDITION
.�� ❑ 3. Homestead
❑ 1.Will this property be the buyer's primary residence? El rat 4. Solar Energy Heating or Cooling System
❑ Ear-2. Does the buyer have a homestead to be vacated for El
lLJ 5.Wind Power Device
this residence? If yes, provide address: 6. Hydroelectric Power Device
Address(number and street) ❑ 0 7. Geothermal Energy Heating or Cooling Device
City,state,and ZIP Code County C] I •-l1.-'$-3Qi_-000` ,- 1 --Ju
COPY