Homestead_Bristow Jr H. PREPARER
Preparer of the Sales Disclosure Form Title
Amy B. Pollard , Settlement Agent
Company
Address(number and street,city,state,country,and ZIP Code)
7820 Eagle Crest Blvd,Suite 201,Evansville, IN 47715
I. SELLERS)/GRANTOR(S)
Seller 1 —Name as it appears on conveyance document Seller 2—Name as appears on conveyance document
Kevin W. Leathem Andrea N.Leathem
Address(number and street) Address(number and street)
PO Box 205 PO Box 205
City,State,and ZIP Code City,State,and ZIP Cade
Puryear,TN 38251 Puryear,TN 38251
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. A
Signal_ of Seller } "' Si ture of Seller
_an n ."ti- � -�f try d�- � I � R1''
Printed Name of Seller `bate Signed(mm/dd/yyyy) Printed Name of Seller Date Signed(mm/dd/yyyy)
Kevin W.Leathem 05/202023 Andrea N. Leathem _05/710/2023
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
Clifford R.Bristow,Jr Valerie J.Bristow
Address(number and street) Address(number and street)
1531 Waggoner Ave 1531 Waggoner Ave
City.Stale,and ZIP Code City,State,and ZIP Code
Evansville,IN 47714 Evansville,IN 47714
Country Country
US
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 CONDITION
(N D 1.Will this proper e buyer's primary NI 3. Homestead
residence? .` D ® 4.Solar Energy Heating or Cooling System
2.Does the buyer have .`..• . . .e vacated 0 ® 5.Wind Power Device
` j< for this residence? If yes, pro
®
ry
i 0 6. Hydroelectric Power Device
A.. -ss(number and street) OS ?D 9 0 ® 7. Geothermal Energy Heating or Cooling Device
,
City,State,and ZIP Ce �3 County
SQNr,, 2 QC- lq.- q- l n l-00o. Sbr— eoZ6
Under penalties of perjury,I he' y ''> .t thi Sales eisclosure,to the best of my knowledge and belief,is true,correct,and complete
as required by law,and is prepared ih4Ec. - c w 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.(Note:Both spouse's
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