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Homestead_Burgess ,..
Preparer of the Sales Disclosure Form Title
Jamie E. Smith Escrow Officer
Company
Address(number and street,city,state,country,and ZIP Code)
101 Plaza East Boulevard, Suite 102, Evansville, IN 47715
1... SELLER(S)/GOANTOk(8) .:,:C. ,, ',:••!.'.,..•'.. .i.;:-. ..:,:,':,::::-":3. •.-•.•,-,:.:':::•:::: ,.•.:•••'... •:,-.;! : ::::.::,,r.:•;-.:; :•....*:,::.,::.-!;i!:•:, iT: - -.:i.,,-•-..::;;''-_--..-:-,T.-:. ..: .;?•:-:i. -,:i :'.::.;.:1,:i:.-•::.,
Seller 1-Name as it appears on conveyance document Seller 2-Name as appears on conveyance document
AUSTIN O'RISKY REBEKAH O'RISKY
Address(number and street) Address(number and street)
512 N Polk Street 512 N Polk Street
City,State,and ZIP Code City,State,and ZIP Code
Fort Branch, IN 47648-1020 Fort Branch, IN 47648-1020
Country Country
Under penalties of perjury, Sales best of my knowledge'andlielief,1S.trUe,'COrrecfand complete as !;
.required by law,and is prepared in.apcordifice:with iC..641:1;•5:5.-A.PersCn Who knowingly and intentionally falsifies value of ..
real property,oromits:orfaleifieeanY inforrnatiOn'required.to.be provided,commits a-Level-4 feloriy..' :. .:1:::':'::,::'.r.;:.''r'.: :,:::.•:-,:l.:::.-;:!:,' , ,: :::'
Signature of Seller Signature of Seller
NA r k„\, 01 ./,4 ../ x 00 N\
e
rated Name of Sal Date Signed(mmickl/thy). PrinTedVameof ell Date Signed(mm/dd/yyyy)
AUSTIN O'RISKY May 30, 2023 REBEKAH O'RISKY May 30,2023
ji•BPYtg(0)/PMI9TEE(O'7APPLICNPONOkPOPP3::.1n(T4'PO:pqTIQNS,40.EN*O-Au:;l"tfiq",00•PVQ;T: •:e
Buyer 1-Name as it appears on conveyance document Buyer 2-Name as it appears on conveyance document
DELANIE BURGESS KYLE HODGES
Address(number and street) Addressialumber and street) '
.512 N Polk Street 512 N Pblk Street
City,State,and ZIP Code City,State,a?ciZIP Code -1
Fort Branch, IN 47648-1020 Fort Branch, IN 47648-102'0
Country Country
E-mail Address
':-:-:
YES NO CONDITION Y;(7 No CONDITION
D7 3.Homestead 4.
I—I 1.Will this propert eit..; r's primary
i L-1 residence? 4„,,),
4ye
El eil 4.Solar Energy Heating or Cooling System
rd2.Does the buyer/owe a horn t a,d/i0 e vacated 0 Er 5.Wind Power Device
El 1.
for this idence? ITS/Orovide .; . -....: 0 Er 6. Hydroelectric Power Device
Address(number arqV 4 0 [2 7.Geothermal Energy Heating or Cooling Device
0
r, L.....,
City,State,ZIP code,and Co?m ,--
%-1 8 1 —L4°1 - 000 . 612-0 2--a
4f
Under penalties of Perjurjr,:l.fiereby, ,ii"-4,. v•trthi .:sales•Disclosure;.to.tne best of my knowledge and belief,is true,correct and complete .'
as required by law,and is prepared In a 6.4.ance with IC 6-1.1:-55:A Person who knowingly and Intentionally falsifies the value of
'
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