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State Form 46234 (R/1293) 0
Seller states that the information contained in this Disclosure is correct to the best of Sellers CURRENT ACTUAL KNOWLEDGE as of the above
date. The prospective buyer and the owner may wish to obtain professional advice or inspections of the property and provide for appropriate
provisions in a contract between them concerning any advice, inspections, defects, or warranties obtained on the property. The representations in
this form are the representations of the owner and are not the representations of the agent, if any. This information is for disclosure only and is
not intended to be a part of any contract between the buyer and the owner. Indiana law tIC 24-4.6-2) generally requires sellers of 1-4 unit
residential property to complete this form regarding the known physical condition of the property. An owner must complete and sign the disclosure
form and submit the form to a prospective buyer before an offer is accepted for the sale of the real estate.
Property address (number and street, dty, state, ZiP code)
[ ~t II E tl/~T~, ST.
1. The following are in the conditions indicated:
A. APPLIANCES
Built-in Vacuum System
Clothes Dryer
Clothes Washer
Dishwasher
Disposal
Freezer
Gas Grill
Hood
Oven
Range
Refrigerator
Room Air Conditioner(s)
Trash Compactor
TV Antenna/Dish
:
Air Purifier
Burglar alarm X
Ceiling Fan(s) X
Garage Door Opener / Controls X
Inside Telephone ~ring and X
Blocks / Jacks
Intercom X
Light Figures X
Sauna X
Smoke / Fire Alan(s) ~
Switches and Outlets X
Vent Fan(s) X
60 / 1 oo / ~0 Amp Se~ice
(Cite one)
Not
Know
X
:NQ~ "Defect' mesnS i c~r~41on that would have a significant adverse
eff~c~:~n:th~:VajUe d ~e ~r~erly that would slgni~c~tly impair the
health or safe/, of bture occupants of the property, or that II not repel red,
remoVed or replaced would sign ficaotly shorten or adversely affect the
expected norngt I~e ~f the prerdses.
eREALTOR
Approved by and restricted to use by Members of the Indiana Association of REALTORS®, Inc. IAR 1999 #3
(office use only)
Page I of 4
C. WATER & SEWER SYSTEM D
Cistern
Septic Field / Bed
Hot Tub
Plumbing
Aerator System
Sump Pump
Irrigation Systems
Water Heater / Electdc
Water Heater / Gas
Water Heater / Solar
Water Pud~er
Water Softener
Weft
Other Sewer System (Explain)
Do Not
Yes No Know
Are the improvements connected to a public water systemT~ X
Aretheimprovementsconnectedtoapub[icsewersystern. ~ X
Are the improvements connected to a
private/community water system? X
Are the improvements connected to a
private/community sewer system? /%('
:D. HEATING NOne/Not Defective Not:
Attic Fan
Central Air Conditioning
Hot Water Heat
Furnace Heat / Gas
Furnace Heat / Electric
Solar House-Heating
Woodburning Stove
Fireplace
Fireplace Insert
Air Cleaner
Humidifier
Propane Tank
Age, if known: Years.
Does the roof leak?
Is there present damage to the roof?
X
:::!~: !::~:~::~::i:::!!~i~!i::~::~:~!~:~i!~ ::
Are there any existing hazardous condi-
tions on the property, such as methane
gas, lead paint, radon gas in house or
weft, radioactive material, landffil,
mineshaft, expansive soil, toxic materi-
als, asbestos insulation or PCB's?
Is there more than one roof on the house?
If so, how many? roofs.
X
YES No
Do
Not
Know
(office use only)
Page 2 of 4
4. OTHER DISCLOSURES :::! :::~:~:: :~::YE :: ~:~ O
Do improvements have aluminum wiring?
Are there any foundation
problems with the improvements?
Are there any encroachmonte?
Are there any violations of zoning,
building codes or restrictive covenants?
X
Is the present use a non-conforming
use? Explain:
X
Have you received any notices by any
governmental or quasi-governmental
agencies affecting this property?
Are there any structural problems with
the buildings?
Have any substantial additions or
alterations been made withost a required
building permit?
Are there moisture and/or water
problems in the basement or crawl space
area?
is there any damage due to wind, flood.
termites or rodents?
Are the furnacelwoodstovelchimneylflue
all in working order?
is the property in a flood plain?
Do you currently pay flood insurance?
Does the property contain
underground storage tank(s)?
X
{s the seller a licensed real
estate salesperson or broker?
Is there any threatened or existing
litigation regarding the property?
Is the property subject to convenants,
conditions and/or restrictions of a
homeowners association?
Is the property located within one (1)
mile of an airport?
X
X
(office use only)
Page 3 of 4
E. ADDITIONAL COMMENTS AND/OR EXPLANATIONS: (Use additional pages If necessary.)
The information contained in this Disclosure has been furnished by the Seller, who certifies to the truth thereof, based on the Sellers CURRENT
ACTUAL KNOVVLEDGE. A disclosure form is not a warranty by the owner or the owner's agent, if any. and the disclosure form may not be used
as a substitute for any inspections or warranties that the prospective buyer or owner may later obtain. At or before settlement, the owner is
required to disclose any material change in the physical condition of the property or certify to the purchaser at seffiement that the condition of the
property is substantially the same as it was when the disclosure form was provided. Seller and Purchaser hereby acknowledge receipt of this
Date uyer Date
Signature of Seller Date Signature of Seller Date
(office use only)
Page 4 of 4
(Indiana Real Estate Commission; 876 IAC 1-4-2, 17 IR 2352)
REV. 12195
IN WITNESS WHEREOF, the parties hereto have made and executed this Agreement as follows:
CITY OF CARMEL, INDIANA
by and through its Board of Public
Works and Safety
ATT~ .S~
Diana Cordray, IAMC, 'Cl~-Treasurer
Date: