Homestead_Wirth f ,
•
H. PREPARER
Preparer of the Sales Disclosdre Form Title
DAMES G. MCDONALD III ATTORNEY AT LAW
E-mail address f Telephone number
Company
Address(number and street,city,state,country,and ZIP Code)
170 South Main, Prinretcln, Indiana 47670
I. SELLER(S)/GRANTOR(S) Nam
2— Fa{�e son e T
y ID ocument
Seller 1 —Name as it appears on conveyance document Sellerj,, 1
Jesse F.Larkins
t 2U22
Address(number and street) Address(number and stree JUN
2721 Mounds Road. Trailer A6
City,state,and ZIP Code City,state,and ZIP Code ,t -'
�z a. 7.ird-
,AT1rIPr4nTl- TN CLAM 6• I Country COUNTY AUDITOR
Country GIBBON
USA Telephone number
E-mail address
best of my knowledge and belief,is true,correct and comple e
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 tr.
--I property,or omits or falsifies any information required to be provided,commits e of a Level 5 felony.
ynatureofSeller ler
X?7,,,..A..........,c....................../
• Printed Name of Seller I Date signed(mm/dd/yyyy)
rinted ame of Sell-7H Date signed(m /0 2-2.y)
Jesse F. Larkins I O 3,/ Za'LZ
IP
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 conveyance document --
William Wirth Annette Wirth
Address(number and street) Address(number and street)
O 2117 S Old SrateRr 65 2312 S Old State Rt 65
SCity,state,and ZIP Code City,state,and ZIP Code
Owcnsville, IN /17665 Owensville, IN 47665
Country
r‘.1Country
.--0
1. ( )
• 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 � 0 3.Homestead
—
f 1.Willthis property be the buyer's primary
-g O residence? O (@' 4.Solar Energy Heating or Cooling System
,,� 2. Does the buyer have a homestead to be vacated
0 Q' 5.Wind Power Device
1 1, r� for this r�ence? If yes,provide address: O cw 6.Hydroelectric Power Device
li e7 .dress(number and street)
t. 0 Q/ 7.Geothermal Energy Heating or Cooling Device
7. I' - i 3 canna-ea
J it te,ZIP code,and county 44 76 7 z (--11 _\Q -00 -Oo I - 0 Z6- 0 u
Tj2 t�Le -rd r .�jv l `
f"ti j nder penalties of perjury,I hereby certify that this Sales Discloser ,to the best of my knowledge and belief,is true,correct and complete
4 s required by law,and is prepared in accordance with IC 6-1.15.5. person who knowingly and intentionally falsifies the value of
ansferred real property,or omits or falsifies any information requi ed to be provided,commits a Level 5 felony.(Note:Both spouse's
t u
-m nfor ation,SSN/Driver's Lice se D/Other Number is necessary if 2 Homestead Deduction is being filed.)
Sign re ff Buyer
}� Sig Lure of Buyer 2/ pause. `
x //J r W Sign Date(MM/D /YY)
•
Sign Date(MM/DD/YY) Printed Legal Name..�QQf Buyyegr 2/SpouseOs 3 P2YY.l
Prime ll Name of Buyer Wirth 1 g Annette Wirth //
William 0 S�3//2�Z
Last 5 Digits of Buyer 1 SSN/Driver's License/ID/Other Number Last 5 Digits of Buyer 2/Spouse SSN/Driver's License/ID/Other Number
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