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FORM
Kimberly A Lewis �ff;ra ManaaPr
Neparsr oJlhe Safes D"ucloivrs Form Title
� 226 W. Broadway Broadway Titie, Inc.
Address(Numberand5o
Princeton
Ciry, Smtq andZlP Code
Underpena
IN 47670
perjury, 1
quired by
618 Cl�ze3a�id Ave.
Addras (Number and Strnt)
Princeton, IN 47670
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Company
B h A_ Ainc -oiqh
Selfu 2� Name as oppears on ronveyanre docvment
815 S. Concord Dr.
Addrat (Number ond Sveet)
Princeton, IN 47670
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�rtify [ha[ [his Sales Disdosure, to the best of my knowledge and belief, is true, correc[
is prepared in accordance wi[h IC 6d.�5.5, "Real P�ioperty Sales Disclosure Act".
THE SALFS DISQOSURE iORM MAV BE USED TO dPPLY FOR CERTAI.Y DEDUCTIONS
� � 1. Will this property be the buyer's primary
residence? Provide complete address of p imary
residence, ind din county:
815 S. Concorc� D�.
Addras (Number and SvretJ
Princeton 7N 47670 Cihann
[iry, S:ott ZIP [ade Counry
�� 2. Does the buyer have a homestead in Indiana to be
vaca[ed for this residence? If yes, provide
complete address o( residence being vacated,
�,��Q✓QIC[ntyc� Y—�V.i�
�dras (Numbe�and SveetJ
T : r<o ,-r-2--�r �t��7o ��h.v�n
Ciry, Sm[eZIPCOde Counry
Buyu2�NOmeaeappevrsontom�eyonr orument
h 1 gsl _�__ n Ave .
Address (Nvmber ar.d5tree[)
Princeton, If•1 47670
� �
THAT APPLY.
Hea[ing/Cooling System
❑ ❑X 5. VJind Power Device
❑ � 6. Hydroelectric Power Device
❑ � 7. Geothermal Energy Heating/Cooling Device
� � 8. Is [his property a residenrial ren[al property?
❑ � 9. Would you like to receive tax sta[emen[s for this
property via e-mail? (Provide conCact information
below. Please see instructions�or more information.
Not available in all counties.)
a�-//-iS� o?ao-oo3. � 39_ �a7
name
Under penal[ies of perjury, I hereby certify [hat this Sales Disclosure, to [he best of my knowledge and belief, is true, correct
and complete as required by law, and is prepared in accordance with IC 6-11-5.5, "Real Proper[y Sales Disclosure AcY'. (No[e:
Spouse information, Social Security and Driver's License/Other numbers are not necessary if no Homestead Deduction is
being fi,;ed.)
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LastSdigi[sofBuyerlDriver's State LastSDigicsafSociol5ecunryNum6er
Lirense/ID/Other Number
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Number License/ID/OtherNum6er