Homestead_Coughlin H. PREPARER Pit,
Preparer of the Sales Disclosure Form • Title
Payge Marx Escrow Officer
Company
7412 Eagle Crest Blvd Evansville, IN 47715 O �. �.
I. SELLER(S)/GRANTOR(S) SON p C
Seller 1 -Name as it appears on conveyance document Seller 2-Name as appears on conveyance db�fr—
Sandra D. Naas Pamela K. Payne Akio. bJ
Address(number and street) p / Address(number and street) OR
A 's( 3 Vv ye s-_ S+Q�C'. gad. Z� ��� B rGt c i F zJ r�t ''' 'el
Cily,state,11, 1 nd�I�C�ode/ - n' / i7 ,39
� City,state,and ZIP Code
�IL.j( \f._>> (,1,,A C!� yt\"/��a v�n S vl 11-e 1 N `1-t� I S
Country Country
US US
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. 10
Agnes a of Seller /�j �yr_� ^ gnatur f Seller()
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Printed Name of Seller / Date signed(mm/dd/yyyy) ii)nted ame o eller I ate si ned(mm/dd/yyyy)
Sandra D. Naas t 11111.3 Pamela K. Payne I 1111113
J. BUYER(S)/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
Patrick J.Coughlin, Ill
Address(number and street) Address(number and street)
6111 BIRKDALE DRIVE
•
City,state,and ZIP Code City,state,and ZIP Code
Evansville, IN 47715
Country Country
US US
apply for certain deductions.Identify all of those that apply:
YES NO CONDITION Y NO CONDITION
CIO 1.Will this property be the buyer's primary 0 3. Homestead
residence? ����// Cl 4.Solar Energy Heating or Cooling System
'----:17 O X 2. Does the buyer have a homestead to be vacated O CI 5.Wind Power Device
for this residence? If yes, provide address: O Q 6. Hydroelectric Power Device
Address(number and street) O C) 7.Geothermal Energy Heating or Cooling Device
City,state,ZIP code,and county a 1-(Q- D) - a0(� - oOd. 7 g 3 �( gP
Under penalties of perjury,I hereby certify that this Sales Disclosure,to the best of my knowledge�_ff and belief,is true,correct and complete
Last 5 of SSN:
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