HomeMy WebLinkAboutHomestead_HollandH. PREPARER
Preparer of the Sales Disclosure Form
Title
Pamela Partenheimer Mick
Attorney
Company
E-mail address
Telephone number
Partenheimer, Kinkle & Partenheimer Mick
Pamela@pkpmlaw.com
(812 ) 386-0050
Address (number and street, city, state, country, and ZIP Code)
219 N Hart St, PO Box 13, Princeton, IN 47670
I. SELLER(S)IGRANTOR(S)
Seller 1 - Name as it appears on conveyance document
Seller 2 -Name as appears n o e nce
William A. Hembrecht
t-i n
Address (number and street)
Address (number and street)
PO Box 11
City, state, and ZIP Code
City, state, and ZIP Code
JUL 8 6 2026
Patoka, IN 47666
Country
Country
us
E-mail address
Telephone number
E-mail address
GIBSON COlitv-y
hJnumber
hembrechtwilliam@gmail.com
( ) 812-385-6541
q�Dho
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.
Signature qfleller
Signature of Seller
Printed ame of Seller
Date signed (mm/dd/yyyy)
Printed Name of Seller
Date signed (mm/dd/yyyy)
William A. Hembrecht
107/15/2026
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
Richard Holland
Amber Smith
Address (number and street)
Address (number and street)
214 W Second St
214 W Second St
City, state, and ZIP Code
City, state, and ZIP Code
Hazleton, IN 47640
Hazleton, IN 47640
Country
Country
us
us
E-mail address
rAh011undC1�51@tx,, 1004
Telephone number
cg►vs3o-g225
E-mail address
QViS ti+h2RlP3@ 9mq►1 corn
Telephone number
cawj4tVy-11; 03
Pursuant to IC 6-1.1.1244, the Sales Disclosure Form may be used to apply for certain deductions. Identify all of those that apply:
YES NO CONDITION
YES NO CONDITION
O O 3. Homestead
O O 1. Will this property be the buyer's primary
residence?
❑ Q 4. Solar Energy Heating or Cooling System
O O 5. Wind Power Device
O O 2. Does the buyer have a homestead to be vacated
for this residence? If yes, provide address:
❑ p 6. Hydroelectric Power Device
❑ Q 7. Geothermal Energy Heating or Cooling DeviceCity,
Address (number and street)
t � - Q - Ij� - 0'3� - c)� (`�\
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 License/1D/Other Number is necessary if a Homestead Deduction is being filed.)
Si ature of Buy
11
Sig lure of Buyer Spouse
Printed Legal Name of Buyer 1 Sign Date (MM/DD/YY)
Pri ed Legal Nam uyer 2/Spouse Sign Date (MM/DD/YY)
Richard Holland 07/ 15 /2026
Am er Smith 07/ 15 /2026
Last 5 Digits of Buyer 1 SSN/Driver's License/ID/Other Number
Last 5 Digits of Buyer 2/Spouse SSN/Driver's License/ID/Other Number
9 '751
Za
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