Homestead_Black H. PREPARER
Preparer of the Sales Disclosure Form Title
JAMES G. MCDONALD. III ATTORNEY AT LAW
Company
Address(number and street,city,state,country,and ZIP Code)
120 S Main Street_ Princeton. TN 47670
I.SELLER(S)/GRANTOR(S)
Seller 1 -Name as it appears on conveyance document Seller 2-Name as appears on conveyance document
Jeffrey R. Black R. Star Black
Address(number and street) Address(number and street)
PO Box 251 PO Box 251
City,state,and ZIP Code City,state,and ZIP Code
Patoka , TN 47666 Patoka, IN 47666
Country Country
United States United States
E-mail address
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.
Signature of Seller Signnatwp of Seller
it of Seller Date signed(mm/ddlyyyy) Printed Name of Seller Date signed(mm/dd/yyyy)
Je frey R. Black /Z)- -Z/-?Z R. Star Black f� Z/ -�c,z2
J. BUYER(S)IGRANTEE(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 orlpe n doc 't
Lewis R. Black
Address(number and street) Address(number and street)
209E. Cross Street OCT 2 42022
City,state,andd ZIP Code City,state,and ZIP Code
Patoka, IN 47666
Country Country c�
United States //lsclin,./t�tt,�F\ qn:
E-mail address
( )
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 NO CONDITION
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1.Will this property be the buyer's primary 3.Homestead
residence? O f 3/ 4.Solar Energy Heating or Cooling System
O r,/ 2. Does the buyer have a homestead to be vacated 0 0— 5.Wind Power Device
for this residence? If yes,provide address: 0 Q/ 6.Hydroelectric Power Device
Address(number and street) O Q/ 7.Geothermal Energy Heating or Cooling Device
City,state,ZIP code,and county CMG/ GM:
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