Property Address: _____________________________________________________________



Purpose of Statement: This statement is a disclosure of the condition of the property in compliance with the seller disclosure act. This statement is a disclosure of the condition and information concerning the property, known by the seller. Unless otherwise advised, the seller does not possess any expertise in construction, architecture, engineering, or any other specific area related to the construction or condition of the improvements on the property or the land. Also, unless otherwise advised, the seller has not conducted any inspection of generally inaccessible areas such as the foundation or roof. This statement is not a warranty of any kind by the seller or by any agent representing the seller in this transaction, and is not a substitute for any inspections or warranties the buyer may wish to obtain.

Seller's Disclosure: The seller discloses the following information with the knowledge that even though this is not a warranty, the seller specifically makes the following representations based on the seller's knowledge at the signing of this document. Upon receiving this statement from the seller, the seller's agent is required to provide a copy to the buyer or the agent of the buyer. The seller authorizes its agent(s) to provide a copy of this statement to any prospective buyer in connection with any actual or anticipated sale of property. The following are representations made solely by the seller and are not the representations of the seller's agent(s), if any. This information is a disclosure only and is not intended to be a part of any contract between buyer and seller.

Instructions to seller: (1) Answer ALL questions. (2) Report known conditions affecting the property. (3) Attach additional pages with your signature if additional space is required. (4) Complete this form yourself. (5) If some items do not apply to your property check N/A (non-applicable). If you do not know the facts, check UNKNOWN. FAILURE TO PROVIDE A PURCHASER WITH A SIGNED DISCLOSURE STATEMENT WILL ENABLE A PURCHASER TO TERMINATE AN OTHERWISE BINDING PURCHASE AGREEMENT.

Appliances/Systems/Services: The items below are in working order:

                      Yes              No            Unknown        N/A (Does not apply)

Range/Oven ___________ ___________ ___________ ___________

Dishwasher ___________ ___________ ___________ ___________

Refrigerator ___________ ___________ ___________ ___________

Hood/Fan ___________ ___________ ___________ ___________

Disposal ___________ ___________ ___________ ___________

TV antenna, TV dish & controls ___________ ___________ ___________ ___________

Electrical system ___________ ___________ ___________ ___________

Garage door opener & remote control ___________ ___________ ___________ ___________

Alarm system ___________ ___________ ___________ ___________

Intercom ___________ ___________ ___________ ___________

Central vacuum ___________ ___________ ___________ ___________

Attic fan ___________ ___________ ___________ ___________

Pool heater, wall liner & equipment ___________ ___________ ___________ ___________

Microwave ___________ ___________ ___________ ___________

Trash compactor ___________ ___________ ___________ ___________

Ceiling fan ___________ ___________ ___________ __________

Sauna/hot tub ___________ ___________ ___________ ___________

Lawn sprinkler system ___________ ___________ ___________ ___________

Water heater ___________ ___________ ___________ ___________

Plumbing system ___________ ___________ ___________ ___________

Water softener/conditioner ___________ ___________ ___________ ___________

Well & Pump ___________ ___________ ___________ ___________

Septic tank & drain field ___________ ___________ ___________ ___________

Sump pump ___________ ___________ ___________ ___________

City Water system ___________ ___________ ___________ ___________

City Sewer system ___________ ___________ ___________ ___________

Central air conditioning ___________ ___________ ___________ ___________

Central heating system ___________ ___________ ___________ ___________

Furnace ___________ ___________ ___________ ___________

Humidifier ___________ ___________ ___________ ___________

Electronic air filter ___________ ___________ ___________ ___________

Solar heating system ___________ ___________ ___________ ___________

Fireplace & chimney ___________ ___________ ___________ ___________

Wood burning system ___________ ___________ ___________ ___________

Explanations (attach additional sheets if necessary):





Property conditions, improvements & additional information:

1. Basement: Has there been evidence of water? If yes, please explain: _______________________________________
2. Insulation: Describe, if known _______________________________ Urea Formaldehyde Foam Insulation (UFFI) is installed? _____
3. Roof: Leaks? ______  Approximate age if known _____________________________________
4. Well: Type of well (depth/diameter, age and repair history, if known __________________________ _________________________________ Has the water been tested? _________
5. Septic tanks/drain fields: Condition, if known _______________________________________________________
6. Heating system: Type/approximate age: _________________________
7. Plumbing system: Type: copper _____ galvanized _____ other _____ Any known problems? ________________________________________
8. Electrical system: Any known problems?___________________________________________________________________________________
9. History of infestation, if any: (termites, carpenter ants, etc.) ____________________________________________
10. Environmental Problems: Substances, materials or products that may be an environmental hazard such as, but not limited to, asbestos, radon gas, formaldehyde, lead-based paint, fuel or chemical storage tanks and contaminated soil on the property. If yes, please explain:______________________________________________________________________________________
Other Items: Are you aware of any of the following:
1. Features of the property shared in common with the adjoining landowners, such as walls, fences, roads and driveways, or other features whose use or responsibility for maintenance may have an effect on the property?
2. Any encroachments, easements, zoning violations, or nonconforming uses?
3. Any "common areas" (facilities like pools, tennis courts, walkways, or other areas co-owned with others), or a homeowners' association that has any authority over the property?
4. Structural modifications, alterations, or repairs made without necessary permits or licensed contractors?
5. Settling, flooding, drainage, structural, or grading problems?
6. Major damage to the property from fire, wind, floods, or landslides?
7. Any underground storage tanks?
8. Any area environmental concerns (i.e., proximity to a landfill, airport, shooting range, etc.)?
If the answer to any of these questions is yes, please explain. Attach additional sheets, if necessary:






The most recent state equalized valuation of the property provided by the local taxing unit to the seller was $___________ as of _____________ (date). The seller has lived in the residence on the property from __________ (date) to __________ (date). The seller has owned the property since _________ (date) and makes representation only since that date. The seller has indicated above the history and condition of all the items based on that information known to the seller. If any changes occur in the structural/mechanical/appliance systems of this property from the date of this form to the date of closing, seller will immediately disclose the changes to buyer. In no event shall the parties hold the broker liable for any representations not directly made by the broker or broker's agent.

Seller certifies that the information in this statement is true and correct to the best of seller's knowledge as of the date of seller's signature.



Seller __________________________________________________ Date _____________

Seller __________________________________________________ Date _____________

Buyer has read and acknowledges receipt of this statement.

Buyer ___________________________________________________ Date _____________ Time ____________

Buyer ___________________________________________________ Date _____________ Time ____________