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HomeMy WebLinkAboutHomestead_SeseH. PREPARER Preparer of the Sales Disclosure Form Tltle Kris Coon Escrow Officer Company E-malt Address Telephone Number Regional Land Title kris@regionaf-It.com (812) 470-1300 Address (numberand street; c€iyr state, country, and ZIP Code) 4600 Washington Avenue, 102, Evansville, IN 47714 1. SELLER(S)IGRANTOR(S) Seller 1 - Name as it appears on conveyance document Seller 2 -- Name as appears on conveyance document Julia C. Betleyoun Fred D. Betleyoun Jr Address (number and street) Address (number and street) S6 �z , k Ino 1s 960 City, State, and ZIP Code I Link Gam 1)6 City, State, and ZIP Code Country Country E-mail Address Telephone Number E-mail Address Telephone Number a UrmGrtA - wr q V' l) "dq' (d40 Under penalties of perjury, I hereby certify 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. Sign a Sell Sign" ofs ler Pri Name of Seller Date Signed (mm/ddlyyyy) Printed Name of Seller Date Signed (mmtddlyyyy) Owl Juila C Betleyoun 2Q4 Fred D. Betleyoun, Jr 2Qk .1. BUYER(S)IGRANTEE(S) - APPLICATION FOR PROPERTY TAX DEDUCTIONS - IDEN ALL THAT APPLY Buyer 1 - Name as it appears on conveyance document Buyer 2 - Name as it appears onfqvelarort Andrei Sese ss ( ber R i t t) Address (number and street) State, a IP Code City, State, and ZIP Code 0 0 O ountry Country E-mail Address Teleph Num er E-mail Address Spy t,OUNi le hone Number t 22 u s nt Mg1.1- -44, t Sales Disclosure Fo may be used to applyfor certain deductions. Identify all of those tt4af apply: YES NO CONDITION YES O CONDITION [] 3. Homestead ❑1. Will this property be the buyer's primary residence? ❑ g2/ 4. Solar Energy Heating or Cooling System ❑ 5, Wind Power Device 2. Does the buyer have a homestead to be vacated ❑ ❑ for this residence? If yes, provide address: © ydroelectric Power Device ❑ [7 C-eothermal Energy Heating or Cooling Device Address (number and street) -07 - `1d - C)QQ , I Lot 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 fi-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 Lave] 5 felony. (Note: Both spouse's information, SSN/Driver's LicenseAD/Other Number Is necessary only if a Homestead Deduction is being filed.) Sig of Buyer 1 I Signature of Buyer 2lSpouse 5i e Printed Legal Name of Buyer 1 MIDD/yy) Printed Legal Name of Buyer 2/Spouse Sign Date (MMlDD/YY) Andrei Sese k,O , 20_ , 20_ Last 5 i its of Buyer 1 S N/Driver's License/ID/Other Number 916.5 Last 5 Digits of Buyer 2JSpouse SSNIDriver's License/ID/Other Number Page 3 H. PREPARER Preparer of the Sales Disclosure Form I Title Kris Coon i Escrow Officer Company ! E-mail Address Regional Land Title kris@regional-It.com Telephone Number (812) 470-1300 Address (number and street, city, state, country, and ZIP Code) 4600 Washington Avenue, 102, Evansville, IN 47714 I. SELLER(5)/GRANTOR(S) Seiler 1 - Name as it appears on conveyance document Julia C. Betleyoun Seller 2 - Name as appears on conveyance document Fred D. Betleyoun Jr Address (number and street) A s (number and street) City, State, and ZIP Code Stat , and ZIP Code Country Cobtfry E-mail Address Telephone Number E-mail Address Telephone Number Under penalties of perjury, I hereby certify 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 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. Signature of Seller Signature of Seller Printed Name of Seller Julia C Betleyoun Date Signed (mm/ddlyyyy) , 20 Printed Name of Seller Fred D. Betleyoun, Jr Date Signed (mmldd/yyyy) 20 J. BUYER(S)t'GRANTEE(S) - APPLICATION FOR PROPERTY TAX DEDUCTIONS - IDENTIFY ALL THAT APPLY Buyer 1- Name as It appears on conveyance document Buy r 2 - Name as if Vi3ears on conveyance document A es num and at Address (numbk street) S ate, a P Code 4 City, State, and ZIP Code untry Country E-mail Address T lephone Number E-mail Address ph ne , g er --- Pursuant to IC 6-1.1-12.44, the Sales Disci sure orm may be used to apply for certain deductions. Identify all o those that apply: YES NO CONDITION YES NO CONDITION IV❑ 3. Homestead ❑ E]-""4. Solar Energy Heating or Cooling System Q• Wind Power Device ❑ ; Hydroelectric Power Device ❑ P7. Geothermal Energy Heating or Cooling Device El1. Will this property be the buyer's primary residence? El�%l Does the buyer have a homestead to be vacated llaadd for this residence? If yes, provide address: 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 8-1.1-5.5. 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, SSNIDriver's License/ID/Other Number is necessary only if a Homestead Deduction Is being riled.) Signature of 1 � � � �� �� Signature of Buyer Spouse - gDate Printed Le wale o uyer Sign Date ( 20- Pri ted Le IN e B er 2/Spouse Sign M/DD/YY) L 20 Last 5' ig!ts of Bu er SS river ) icense/ID/other Number Last 5 Digits 8 yer 2/Spouse SSITDriver s License/ID/Other Number Page 3