HomeMy WebLinkAboutHomestead_Hayes (2)H. PREPARER
Preparer of the Sales Disclosure Form
Title
Matthew Jarvis
Escrow Officer
Company
E-mail address
Telephone number
Southwestern Indiana Land Title
matt@swinland.com
(812) 425-0055
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 conveyance document
Hoosier Homes and Hospitality LLC, an Indiana limited liability
company
Address (number and street)
Address (number and street)
3308 W 300 S
City, State and ZIP Code
City, State and ZIP Code
Princeton, IN 47630
Country
Country
United States of America
Email Address
Telephone Number
Email Address
Telephone Number
johnkissel@atpropertiesind.com
(812) 215-9008
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 pro 'ded, commits a Level 5 felony.
ignature of Seller
Signature of Seller
d
Printed Name of Sell r
Date Signed (mm/dd/
Printed Name of Seller Date Signed (mm/dd/yyyy)
John Kissel, Member
yyyy)
19/29/2026
J. BUYER(S)/GRANTEE(S) -APPLICATION FOR PROPERTY TAX DEDUCTIONS -IDENTIFY ALL T A PLY
Buyer 1 - Name as it appears on conveyance document
Buyer 2 - Name AA-aleon conveyance document
Jacklyn S. Hayes
Address (number and street)
Address (number and stre�tl 0
10147 N Pine Bluff Dr
City, State and ZIP Code
City, State and ZIP Code //���O1_0
CN P
Bicknell, IN 47512
Country
Country 0�1 G
United States of America
Gos'
Email Address
Telephone Number
Email Address
Telephone Number
(618) 384-9276
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
0 ❑ 1. Will this property be the buyers primary residence?
0 ❑ 3. Homestead
❑ 0 4. Solar Energy Heating or Cooling System
❑ 9i 2. Does the buyer have a homestead to be vacated for
this residence? If yes, provide address:
❑ 0 5. Wind Power Device
❑ 0 6. Hydroelectric Power Device
Address (number and street)
❑ 0 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 spouses information, SSN/Drivers
License/ID/Other Number is necessary if a Homestead Deduction is being filed.)
S' na re of Buyer 1
Signature of Buyer 2/Spouse
��6s:
Pri t d Legal Name of Buyer 1 Sign Date (MM/DD/YY)
Printed Legal Name of Buyer 2/Spouse Sign Date (MM/DD/YY)
Ja lyn S. Hayes 9/29/2026
ast 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
sN: IYN4%.' VD .3S