Homestead_Burkhardt . H. PREPARER
Preparer of the Sales Disclosure Form Title
Sar(An Do,rn v n BiA e..e"
Company
Address(number and street,city,state,country,and ZIP Code)
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I. SELLER(S)/GRANTOR(S)
Seller 1-Name as it appears on conveyance document Seller 2-Name as appears on conveyanceficument
Roc ex' L ee.
Address(number and street) Address(number and street) -. _
2_0._ s C.Dun g_Lk. 160 G
City,State,and ZIP Code City,State,and ZIP Code
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a
Country Country , 4?,y,
,
US Q4..
Email Address
, -04, -
Under penalties of perjury,I hereby certify this Sales Disclosure,to the best of my knowledge and belief,is true,cds9., v..nd complete as
required by law,and is prepared in accordance with IC 6.1.1-5.5.A person who knowingly and Intentionally falsifies iffei)13".- of transferred
real property,or omits or falsifies any information required to be provided,commits a Level 5 felony.
Signature of Seller Signature of Seller
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Printed N. e of Seller Date Signed(mmldd/yyyy) Printed Name of Seller Date Signed (mm/dd/yyyy)
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J. BUYER(
YES NO CONDITION YES NO CONDITION
,--, 1.Will this property be the buyer's primary Ef 0 3. Homestead
" residence? o a 4.Solar Energy Heating or Cooling System
0 te.i
,--A 2. Does the buyer have a homestead to be vacated 0 (2r 5.Wind Power Device
for this residence? If yes, provide address: 0 L1 6. Hydroelectric Power Device
Address(number and street) 0 O' 7. Geothermal Energy Heating or Cooling Device
City,State,and ZIP Code County
db- 14 - 1310 -000; 110 - 004
Under penalties of perjury,I hereby certify that this Sales Disclosure,to the best of my knowledge and belief,is true,correct, and complete
as 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
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