Homestead_Grayson H. PREPARER
Preparer of the Sales Disclosure Form Title
Diana Rich Title Administrator
Company
Address(number and street,city,state,country,and ZIP Code)
20 NW First Street,Suite 100,Evansville, IN 47708
I, SELLERS)/GRANTOR(S)
Seller 1-Name as it appears on conveyance document Seller 2-Name as appears on conveyance document
Kenneth G. boomer
Address(number and street) �t /� ddr mber and street)
--1-1.69 E-709th Rd S ' ✓ X4 1 '{�VI
City,state,and ZIP Code City, te,and Vol i /
Lynnville, IN 47691 ° -a 6
Country
&untry
USA USA
E-mail address
best of my knowledge and belief,is true, ct and complete as
required by law,and Is prepared In accordance with iC 6-1.1-5.5.A person who knowingly and intentionally falsI tl lue of transferred
real property,or omits or falsltle any information required to be provided,commits a Level 5 felony.
SI ture of Sell r Signature of Seller
ri e Name of eller Date sign (m�dd/ 9yyyy) Printed Name of Seller 4/D ate st ned • ,� ,,
Kenneth G.Doerner /4�') ? 'i !t")
11( J
J. BUYER(S)/GRANTEE(S) -APPLICATION FOR PROPERTY TAX DEDUCTIONS-i ALL THAT
Buyer 1-Name as it appears on conveyance document Buyer 2-Name as It appears on yjapcg,document
Amy Nicole Grayson �O `,C
Address(number and street) Address(number and street) 4/4.
1i5)5 F 76e“, Qd 5
City,state,and ZIP Code .5
City,state,and ZIP Code
Lyn/Nil((, ii'J 2-/7b'1/
Country Country
USA USA
E-mail address
for certain deductions.Identify all of dose that apply:
YES NO CONDITION YES NO CONDITION ``
❑ ❑ 1.Will this property be the buyer's primary ❑ El3.Homestead , s t.
residence?
❑ ❑ 4.Solar Energy Heating or � !,
❑ /2. Does the buyer have a homestead to be vacated ❑ 05.Wind Power Device aryl
' for this residence? If yes, provide address:
❑ ❑✓ 6. Hydroelectric Power Device
Address(number and street)
❑ E3 7.Geothermal Energy Heating or Cooling Device
City,state,ZIP code,and county ac- 21 - 1 -300- 002- 2- S--- 001 .
Under penalties of perjury, I hereby certify that this Sales Disclosure,to the best of my knowledge and belief,Is true,correct and complete
of Buyer 2/Spouse SSN/Driver's License/ID/Other Number
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