HomeMy WebLinkAboutHomestead_PollockDocusign Envelope ID: 9AAA4174-5743-8742-815C-CF9BAF532162
H. PREPARER
Preparer of the Sales Disclosure Form Tide
Jeannie M. Kiesei Director of Operations
Company Emall Address Telephone Number
Lockyear Title, LLC eannie a@lockyeartitle.com 1 (812 ) 421-8405
Address (number and street, city, state, country, and ZIP Code)
20 NW Third Street, Suite 840, Evansville, IN 47708
1. SELLER(S)IGRANTOR(s)
Seller 1 - Name as It appears on conveyance document Seiler 2 - Name as appears on conveyance document
Robin L. Fortner Joan E. Fortner
Address (number and street) Address (number and street)
18907 Roscommon Road 18907 Roscommon Road
City, State, and ZIP Code City, State, and ZIP Code
Evansville, IN 47725 Evansville, IN 47725
Country Country
USA USA
Email Address Telephone Number Email 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 8.1.1-5.5. A person who knowingly and Intentionally falsifies the value of transferred
real DroDerty. or omits or falsifies any Information required to be provoded, commits a Level 6 felony.
Robin L. Fortner 1 11-11175 I:d0.21 �o I Robin LFormer&TraceyArnnlrungasCovG=sdlana I %-I/ I 2SI dVr( W
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 ancame ante document
Sway James Pollock
Address (number and street)
Address (number and street)
18907 Roscommon Road
City, State, and ZIP Code
City, State, and ZIP Code
Evansville, IN 47725
Country
Country
USA
Email Address
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Telephone
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Email Address
Telephone Number
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Pursuant to IC 6.1.1.12.44, the Sales Disclosure Forth may be used to apply for certain deduct 1 kfd7ilds@ Itttdt rye
YF-S NO CONDITION
YES NO CONDITION
1. will this property be the buyer's primary
❑ ❑
❑ ❑ 3. Homestead
residence?
❑ ❑ 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:
❑ ❑ 6. Hydroelectric Power Device
❑ I] 7. Geothermal Energy Heating or Cooling Device
Address (number and street)
q_ 1 ' C)I - 1 cl� - Occ,
City, State, and ZIP Code County
Under penalties of perjury, I hereby certify that this Sates Disclosure, to the best of my knowledge and belief, Is hue, correct, and complete
as required by law, and Is prepared In accordance with IC 6.1.14.6. 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: Botb spouse's
hrform Won, SSN/Drfvees Ucense4AVOfher Number is necessary on Na. Homestead Deduction is being filed.)
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Signature of Buyer 2/Spouse
Printed Legal Name of Buyer I Sign Date ( /YY)
Printed Legal Name of Buyer 2/Spouse -Sign Date (MM/DDIW)
Sway James Pollock
Last 5.D►alts of Buver 1 SSN/Driver'A Lipense/1P/Othe�NuMber
Last 5 Digits of Buyer 21Spouse SSNIDriver's Lleense/ID/Other Number
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