Homestead_Kenworthy H. PREPARER
Preparer of the Sales Disclosure Form Title
Matthew Jarvis Escrow Officer
Company
Address(number and street, city, state, country, and ZIP code)
605 SE Martin Luther King Jr Boulevard, Evansville IN United States of America 47713
I. SELLER(S)/GRANTOR(S)
Seller 1 -Name as it appears on conveyance document Seller 2-Name as it appears on convince document
David L.Larson,by Shawn Larson,his attorney-in-fact ��
Address(number and street) Address (number and street)
1098 N 450E /�/Ov 'q,� ,
City, State and ZIP Code City, State and ZIP Code 1
Country
IN 47670 ' g�.
Country Country G
United States of America ,e`SOAr c-,
E-mail address
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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 pre aced in accordance with IC 6-1.1-6.5.A person who knowingly and intentionally falsifies the value of transferred
real property,or omits or Isifies y Information required to be provided,commits a Level 6 felony.
Signature of Seller a` Pa /X.A Signature of Seller
Printed Name of Seller signed(mm/dd/yyyy) Printed Name of Seller I Date signed(mm/dd/yyyy)
I Date g
David L.Larson, by Shawn L on, his �y �O/3( /Zp22
attorney-in-fact
J. BUYER(S)/GRANTEE(S)-APPLICATION FOR PROPERTY TAX DEDUCTIONS-IDENTIFY ALL THAT APPLY
-
Buyer 1 -Name as it appears on conveyance document Bu
Chaz Kenworthy Jamieer 2
Y Ke Name as it appears on convey d e nworthy
Address(number and street) Address(number and street)
107 E.Vine St. 107 E.Vine St.
City,State and ZIP Code City, State and ZIP Code
Fort Branch,IN 47648 Fort Branch, IN 47648
Country Country � `
cv United States of America
p ❑ 1. Will this property be the buyer's primary residence? 0 m 4. Solar Energy Heating or Cooling System
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2. Does the buyer have a homestead to.be vacated for ❑ Q 5. Wind Power Device
(� this residence? If yes, provide address:Address(number and street) 0 m 6. Hydroelectric Power Device
CIm 7. Geothermal Energy Heating or Cooling Device
-i- o 1- E \M e s� -
c2.0 City,State,ZIP code,and county ^�_1 _� �D�_ �� C�
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'-° Under penalties of perjury,I hereby certify that this Sales Disclosure,to the best of my knowledge and belief,is true,correct and complete
Nas required by law,and is prepared In accordance with IC 6-1.1-6.5.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 6 felony.(Note:Both spouse's
information, SSN/Driver's License/ID/Other Number Is necessary if a Homestead Deduction Is being filed.)
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