HomeMy WebLinkAboutHomestead_Bockhold (3)H. PREPARER
Preparer of the Sales Disclosure Form
Title
Kris L Coon
Escrow Officer
Company
E-mail Address
Telephone Number
Regional Land Title Company
Kris@regional-it.com
(812) 470-1300
Address (number and street, city, state, country, and ZIP Code)
4600 Washington Avenue, Suite 102, Evansville, IN 47714
I. SELLER(S)IGRANTOR(S)
Seller 1 - Name as it appears on conveyance document
Seller 2 - Name as appears on n yAnce document
Daniel M. Kirslis
Address (number arn~d street) �},�
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Address (number and street)
City, State, d ZIP Code
ql(ao
City, State, and ZIP CodePrJh0.4*1V1
Country
Country u�U
United States of America
E-mail Address Telephone Number
E-mail Address O
/VOOUQ
Telephone Number
dankirslis@hotmail.com (618) 534-7512
Under penalties of perjury, I hereby certify this Sales Disclosure, to the best of my knowledge and belief, r reFt and complete as
required by law, and Is prepared in accordance with IC 6-1.1-5.5. A person who knowingly and intentionally fa a value of transferred
real property, or omits or falsifies any information required to be provided, commits a Level 5 felony.
Signal f Se11a ) , J J
Signature of Seller
Printed Name of Seller
Date Signed ( mlddlyyyy)
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Printed Name of Seller
Date Signed (mm/dd/yyyy)
Daniel M Kirslis
_
I BUYER(S)IGRANTEE(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
McKinzy Bockhold
Address (number and Street)
Address (number and street)
r
U
City, State, aniP(o e
d
n r `
City, State, and ZIP Code
t U!
Country
Country
United States of America
E-mail Address
Telephone Number
E-mail Address
Telephone Number
bockholdmckinzy@gmail.com
812 664-2334
Pursuant to IC 6-1.1-12-14, the Sales Disclosure Form may be used to apply for certain deductions. Identq all of those that apply:
YES NO CONDITION
YES NO CONDITION
M ® 3. Homestead
1. Will this property be the buyer's primary
Id El
residence?
❑ ® 4. Solar Energy Heating or Cooling System
❑ ❑X 5. Wind Power Device
❑ 2. Does the buyer have a homestead to be vacated
for this residence? If yes, provide address:
❑ FX_J 6. Hydroelectric Power Device
❑ 7. Geothermal Energy Heating or Cooling Device
\n' - `
� - ICJ 4z -
Address (number and street)
City, State, ZIP code, and 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 LicenselID/Other Numberis necessary only tf a Homestead Deduction is being flied.)
Si ?tore of Buyer 1 }
Signature of Buyer 2/Spouse
rin ed Legal P&One of Buyer 1 Sign Date (MM/DDIM
Printed Legal Name of Buyer 2/Spouse Sign Date (MM/DD/YY)
McKinzy Bockhold
Last 5 Digits of Buyer 1 SSNJOrivver LicenselliplOther; �baf
1� L
Last 5 Digits of Buyer 2/Spouse SSN/Driver's License/ID/Other Number
SSN: 1-2533 h11 ttT J
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