Date (month, day, year)
Seller states that the information contained in this Disclosure is correct to the best of Seller's 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 (IC 32-21-5) 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, city, state, and ZIP code)
1. The following are in the conditions indicated:
C. WATER & SEWER SYSTEMA. APPLIANCES
None/Not
Included/
Rented
Defective
Not
Defective
Do Not
Know
Defective
Not
Defective
Built-in Vacuum System
Clothes Dryer
Clothes Washer
Dishwasher
Disposal
Freezer
Gas Grill
Hood
Microwave Oven
Oven
Range
Refrigerator
Room Air Conditioner(s)
Trash Compactor
TV Antenna / Dish
Other:
Cistern
Septic Field / Bed
Hot Tub
Plumbing
Aerator System
Sump Pump
Irrigation Systems
Water Heater / Electric
Water Heater / Gas
Water Heater / Solar
Water Purifier
Water Softener
Well
Septic & Holding Tank/Septic Mound
Geothermal and Heat Pump
Other Sewer System (Explain)
Swimming Pool & Pool Equipment
No
Do Not
Know
Are the structures connected to a public water system?
Are the structures connected to a public sewer system?
Are the improvements connected to a private/community
water system?
Are the improvements connected to a private/community
sewer system?
B. ELECTRICAL SYSTEM
Do Not
Know
Air Purifier
Burglar Alarm
Ceiling Fan(s)
Garage Door Opener / Controls
Inside Telephone Wiring and
Blocks / Jacks
Intercom
Light Fixtures
Sauna
Smoke / Fire Alarm(s)
Switches and Outlets
Vent Fan(s)
60 / 100 / 200 Amp Service
(Circle one)
Generator
D. HEATING & COOLING SYSTEM
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
Other Heating Source
NOTE: "Defect" means a condition that would have a significant adverse effect
on the value of the property, that would significantly impair the health or safety
of future occupants of the property, or that if not repaired, removed or replaced
would significantly shorten or adversely affect the expected normal life of the
premises.
SELLER'S RESIDENTIAL REAL ESTATE SALES DISCLOSURE
State Form 46234 (R6 / 6-14)
Are there any additions that may require improvements
to the sewage disposal system?
If yes, have the improvements been completed on the
sewage disposal system?
Page 1 of 2
Do Not
Know
Yes
Not
Defective
Defective
Do Not
Know
Not
Defective
Defective
None/Not
Included/
Rented
None/Not
Included/
Rented
None/Not
Included/
Rented
NOTE: This form has been modified from the version currently found at 876 IAC 9-1-2 to include questions regarding desclosure of contamination related to
controlled substances or methamphetamine as required by P.L. 180-2014. Rule revisions will be made to 876 IAC 9-1-2 to include these changes in
the near future, however the Commission has made this information available now through this updated form.
The information contained in this Disclosure has been furnished by the Seller, who certifies to the truth thereof, based on the Seller’s CURRENT
ACTUAL KNOWLEDGE. A disclosure form is not a warranty by the owner or the owners 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 settlement 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 Disclosure by signing below.
Signature of Seller
Signature of Buyer
Date (mm/dd/yy)
Date (mm/dd/yy)
Date (mm/dd/yy) Signature of Buyer
Date (mm/dd/yy)
Signature of Seller
The Seller hereby certifies that the condition of the property is substantially the same as it was when the Seller’s Disclosure form was originally provided to the Buyer.
Signature of Seller (at closing) Date (mm/dd/yy) Signature of Seller (at closing) Date (mm/dd/yy)
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4. OTHER DISCLOSURES
YES NO
DO NOT
KNOW
2. ROOF
YES NO
DO NOT
KNOW
Age, if known: ___________ Years.
Does the roof leak?
Is there present damage to the roof?
Is there more than one layer of shingles
on the house?
If yes, how many layers? ____________
3. HAZARDOUS CONDITIONS
NO
DO NOT
KNOW
Have there been or are there any
hazardous conditions on the property, such
as methane gas, lead paint, radon gas in
house or well, radioactive material, landfill,
mineshaft, expansive soil, toxic materials,
mold, other biological contaminants,
asbestos insulation, or PCB's?
Is there contamination caused by the
manufacture of a controlled substance on
the property that has not been certified as
decontaminated by an inspector approved
under IC 13-14-1-15?
Has there been manufacture of
methamphetamine or dumping of waste
from the manufacture of methamphetamine
in a residential structure on the property?
Explain:
Do structures have aluminum wiring?
Are there any foundation problems
with the structures?
Are there any encroachments?
Are there any violations of zoning,
building codes, or restrictive covenants?
Is the present use a non-conforming use?
Explain:
Have you received any notices by any
governmental or quasi-governmental
agencies affecting this property?
Are there any structural problems with
the building?
Have any substantial additions or
alterations been made without a required
building permit?
Are there moisture and/or water problems
in the basement, crawl space area, or any
other area?
Is there any damage due to wind, flood,
termites or rodents?
Have any structures been treated for
wood destroying insects?
Are the furnace/woodstove/chimney/flue
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)?
Is the homeowner a licensed real estate
salesperson or broker?
Is there any threatened or existing
litigation regarding the property?
Is the property subject to covenants,
conditions and/or restrictions of a
homeowner's association?
Is the property located within one (1) mile
of an airport?
The information contained in this Disclosure has been furnished by the Seller, who certifies to the truth thereof, based on the Seller's CURRENT
ACTUAL KNOWLEDGE. 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 settlement 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 Disclosure by
signing below.
Is the access to your property via a
private road?
Is the access to your property via a
public road?
Is the access to your property via
an easement?
YES
E. ADDITIONAL COMMENTS AND/OR EXPLANATIONS:
(Use additional pages, if necessary)
Property address (number and street, city, state, and ZIP code)
Page 2 of 2
Signature of Seller Signature of Buyer Date (mm/dd/yy)Date (mm/dd/yy)
Date (mm/dd/yy) Signature of Buyer Date (mm/dd/yy)
The Seller hereby certifies that the condition of the property is substantially the same as it was when the Seller’s Disclosure form was originally provided to the Buyer.
Signature of Seller (at closing) Date (mm/dd/yy) Signature of Seller (at closing) Date (mm/dd/yy)
Signature of Seller
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