Homestead_Ebelhar H. PREPARER
Preparer of the Sales Disclosure Form Title
Matthew Jarvis Escrow Officer
Company
Address (number and street, city, state, country, and ZIP code)
605 SE Martin Luther King Jr Boulevard, Evansville IN United States of America 47713
I. SELLER(S)/GRANTOR(S)
Seller 1 — Name as it appears on conveyance document Seller 2 — Name as it appears on conve nce document
Derrick Coy
Address (number and street) Address (number and street)
tel1/4
12196S50W
City, State and ZIP Code City, State and ZIP Code to -,..--,. ..e) i
Haubstadt, IN 47639
Country �� ��
Country es ��
United States of America b4, �s
Email Address
1'." -
Under penalties of perjury, I hereby certify this Sales Disclosure, to the best of my knowledge and belief, is true, co rr �d 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 tEsferred real property, or
omits or falsifies any information required to be provided, commits a Level 5 felony.
ignature of Sell jorr
Signature of Seller
zi
Printed Name of Se ler Date Signed (mmrddi Printed Name of Seller Date Signed (mmidd/yyyy)
Derrick Coy YYYY)
9/12/2025
1
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
Hannah Ebelhar Christian Hill
Address (number and street) Address (number and street)
6467 N Nixon Rd. 6467 N. Nixon Rd.
City. State and ZIP Code City, State and ZIP Code
Hazleton, IN 47640 Hazleton, IN 47640 c__ i:
Country Country
United States of America United States of America
Email Address
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 if
ii IN
2 [I 1. Will this be the buyer's primary residence? 2 ❑ 3. Homestead
property
❑ (�l. 2. Does the buyer have a homestead to be vacated for ❑ ❑ 4. Solar Energy Heating or Cooling Sys� -� - .��.
this residence? If yes, provide address: ❑ 2 5. Wind Power Device ,.
0 2 6. Hydroelectric Power Device
Address (number and street)
0 2 7. Geothermal Energy Heating or Cooling Device
City, State, and ZIP Code County
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 transferred real
property, or omits or falsifies any information required to be provided, commits a Level 5 felony. (Note: Both spouse's information, SSN/Driver's
License/ID/Other Number is necessary if a Homestead Deduction is being filed.)