SALESDISCLOSUREFORM
StateForm46021(R11/12‐11)
PrescribedbyDepartmentofLocalGovernmentFinance
PursuanttoIC6‐1.1‐5.5
PRIVACYNOTICE:ThetelephonenumbersandSocialSecuritynumbersofthepartiesonthisformareconfidential
accordingtoIC61.15.53(d).
SDFID
Count
y
Year
UniqueID
SDFDate:__________________________
PART1
–TobecompletedbyBUYER/GRANTEEandSELLER/GRANTOR
A.PROPERTYTRANSFERRED–MUSTBECONVEYEDONASINGLECONVEYANCEDOCUMENT
1.PropertyNumber
Checkboxifapplicableto
parcel
5.CompleteAddressofProperty 6.CompleteTaxBillingAddress(ifdifferentfrom
propertyaddress)
A.)
2.Split
3.Land
4.Improvement

7.LegalDescriptionofParcelA:
B.)
2.Split
3.Land
4.Improvement

7.LegalDescriptionofParcelB:
B.CONDITIONS–IDENTIFYALLTHATAPPL
Y
C.SALESDATA– DISCLOSEVALUEOFITEMSLISTEDINTABLEB,
ITEMS1‐15
Ifcondition1applies,filerissubjecttodisclosureandadisclosurefilingfee.
1.Conveyancedate(MM/DD/YYYY):_________________________________________________
2.Totalnumberofparcels:
_______________________________________________________
3.Describeanyunusualorspecialcircumstancesrelatedtothis
sale,includingthespecificationofanyless‐than‐complete
ownershipinterestandtermsofsellerfinancing.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
YES NO CONDITION
1.Atransferofrealpropertyinterestforvaluable
consideration.
2.Buyerisanadjacentpropertyowner.
3.Vacantland.
4.Exchangeforotherrealproperty("Trade").
5.Sellerpaidpoints.
(ProvidethevalueTableCItem12.)
6.Changeplannedintheprimaryuseofthe
property?
(DescribeinspecialcircumstancesinTableCItem3.)
7.Existenceoffamilyorbusinessrelationship
betweenbuyerandseller.
(CompleteTableCItem4.)
8.Landcontract.Contractterm
(YY):________________________
andcontractdate(MM/DD/YYYY):______________________________
9.Personalpropertyincludedintransfer.
(Providethevalue
TableCItem5.)
10.PhysicalchangestopropertybetweenMarch1
anddateofsale.
(DescribeinspecialcircumstancesinTableCItem3.)
11.Partialinterest.
(DescribeinspecialcircumstancesinTableCItem3.)
 12.Easementsorright‐of‐waygrants.
YES NO CONDITION
4.Familyorbusinessrelationshipexistingbetween
buyerandseller?
Amountofdiscount:$
________________________________________
Discloseactualvalueinmoney,property,aservice,anagreement,orotherconsideration.
Ifconditions1315apply,filersaresubjecttodisclosure,butnodisclosurefilingfee.
5.Estimatedvalueofpersonalproperty: $
YES NO CONDITION
6.Salesprice: $
13.Documentforcompulsorytransactionsasa
resultofforeclosureorexpressthreatof
foreclosure,divorce,courtorder,judgment,
condemnation,orprobate.
14.Documentsinvolvingthepartitionofland
betweentenantsincommon,jointtenants,or
tenantsbytheentirety.
15.Transfertoacharity,not‐for‐profitorganization,
orgovernment.
YES NO CONDITION
7.Isthesellerfinancingsale?Ifyes,answer
questions(8‐13).
8.Isbuyer/borrowerpersonallyliableforloan?
9.Isthisamortgageloan?
10.Amountofloan: $
11.Interestrate: %
12.Amountinpoints: $
13.Amortizationperiod:
Reset Form
INDIANASALESDISCLOSUREFORM SDFID:_________________________________ Page2
D.PREPARER
______________________________________________________________________________________________ ______________________________________________________________________________________________
PrepareroftheSalesDisclosureFormTitle
______________________________________________________________________________________________ ______________________________________________________________________________________________
Address(NumberandStreet)Company
______________________________________________________________________________________________ ______________________________________________________________________________________________
City,State,andZIPCodeTelephoneNumber Email

E.SELLER(S)/GRANTOR(S)
______________________________________________________________________________________________
Seller1Nameasappearsonconveyancedocument
______________________________________________________________________________________________
Address(NumberandStreet)
______________________________________________________________________________________________
City,State,andZIPCode
______________________________________________________________________________________________
TelephoneNumber Email
______________________________________________________________________________________________
Seller2Nameasappearsonconveyancedocument
______________________________________________________________________________________________
Address(NumberandStreet)
______________________________________________________________________________________________
City,State,andZIPCode
______________________________________________________________________________________________
TelephoneNumber Email
Underpenaltiesofperjury,IherebycertifythatthisSalesDisclosure,tothebestofmyknowledgeandbelief,istrue,correct
andcompleteasrequiredbylaw,andispreparedinaccordancewithIC61.15.5,"RealPropertySalesDisclosureAct".
______________________________________________________________________________________________
SignatureofSeller
______________________________________________________________________________________________
PrintedNameofSeller SignDate
(MM/DD/YYYY)
______________________________________________________________________________________________
SignatureofSeller
______________________________________________________________________________________________
PrintedNameofSeller SignDate
(MM/DD/YYYY)
F.BUYER(S)/GRANTEE(S)–APPLICATIONFORPROPERTYTAXDEDUCTIONS– IDENTIFYALLITEMSTHATAPPL
Y
______________________________________________________________________________________________
Buyer1Nameasappearsonconveyancedocument
______________________________________________________________________________________________
Address(NumberandStreet)
______________________________________________________________________________________________
City,State,andZIPCode
______________________________________________________________________________________________
TelephoneNumber Email
______________________________________________________________________________________________
Buyer2Nameasappearsonconveyancedocument
______________________________________________________________________________________________
Address(NumberandStreet)
______________________________________________________________________________________________
City,State,andZIPCode
______________________________________________________________________________________________
TelephoneNumber Email
THESALESDISCLOSUREFORMMAYBEUSEDTOAPPLYFORCERTAINDEDUCTIONSFORTHISPROPERTY.IDENTIFYALLOFTHOSETHATAPPLY.
YES NO CONDITION YES NO CONDITION
1.Willthispropertybethebuyer'sprimary
residence?Providecompleteaddressofprimary
residence,includingcounty:
______________________________________________________________________________________________
Address(NumberandStreet)
______________________________________________________________________________________________
City,StateZIPCodeCounty

2.DoesthebuyerhaveahomesteadinIndianatobe
vacatedforthisresidence?Ifyes,provide
completeaddressofresidencebeingvacated,
includingcounty:
______________________________________________________________________________________________
Address(NumberandStreet)
______________________________________________________________________________________________
City,StateZIPCodeCounty
3.Homestead
4.SolarEnergyHeating/CoolingSystem
5.WindPowerDevice
6.HydroelectricPowerDevice
7.GeothermalEnergyHeating/CoolingDevice
8.Isthispropertyaresidentialrentalproperty?
 9.Wouldyouliketoreceivetaxstatementsforthis
propertyviae‐mail?(Providecontactinformation
below.Pleaseseeinstructionsformoreinformation.
Notavailableinallcounties.)
____________________________________________________________________________________________
PrimarypropertyownercontactnameEmail
Underpenaltiesofperjury,IherebycertifythatthisSalesDisclosure,tothebestofmyknowledgeandbelief,istrue,correct
andcompleteasrequiredbylaw,andispreparedinaccordancewithIC61.15.5,"RealPropertySalesDisclosureAct".(Note:
Spouseinformation,SocialSecurityandDriver’sLicense/Othernu
mbersarenotnecessaryifnoHomesteadDeductionis
beingfiled.)
______________________________________________________________________________________________
SignatureofBuyer1
______________________________________________________________________________________________
PrintedLegalNameofBuyer1 SignDate(MM/DD/YYYY)
______________________________________________________________________________________________
Last5digitsofBuyer1Driver’sStateLast5DigitsofSocialSecurityNumber
License/ID/OtherNumber
______________________________________________________________________________________________
SignatureofBuyer2/Spouse
______________________________________________________________________________________________
PrintedLegalNameofBuyer2/SpouseSignDate
(MM/DD/YYYY)
______________________________________________________________________________________________
Last5digitsofBuyer2/SpouseDriver’sStateLast5DigitsofSocialSecurity
NumberLicense/ID/OtherNumber
INDIANASALESDISCLOSUREFORM SDFID:_________________________________ Page3
PART2‐COUNTYASSESSOR
Thecountyassessormustverifyandcompleteitems1through14andstampthesalesdisclosureformbeforesendingtotheauditor:
1.Property 2.AVLand 3.AVImprovement 4.ValueofPersonal
Property
5.AVTotal 6.Property
ClassCode
7.Neighborhood
Code
8.TaxDistrict 9.Acreage
A.)
 
B.)
 
AssessorStamp
10.IdentifyphysicalchangestopropertybetweenMarch1and
dateofsale._____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
YES NO CONDITION
 11.Isformcompleted?
 12.Statesalesfeerequired?
13.Dateofsale
(MM/DD/YYYY):
________________________________________________
14.Dateformreceived
(MM/DD/YYYY):
________________________________________________
Items15through18aretobecompletedbytheassessorwhenvalidatingthissale:
15.Ifapplicable,identifyanyadditionalspecialcircumstancesrelatingtovalidationofsale._________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
YES NO CONDITION
 16.Salevalidfortrending?
 17.Validationofsalecomplete?
18.Validatedby:______________________________
PART3‐COUNTYAUDITOR
AuditorStamp
1.Disclosurefeeamountcollected:$__________________________________
2.OtherLocalFee:$____________________________________________________
3.TotalFeeCollected:$_________________________________________________
4.Auditorreceiptbooknumber:______________________________________
5.Dateoftransfer
(MM/DD/YYYY):_______________________________________
YES NO CONDITION
 6.Isformcompleted?
 7.Isstatefeecollected?
 8.Attachmentscomplete?
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _
PART4–RECEIPTFORSTATEMENTOFDEDUCTIONOFASSESSEDVALUATION
______________________________________________________________________________________________
SDFID SDFDate
(MM/DD/YYYY)
______________________________________________________________________________________________
ParcelNumber
______________________________________________________________________________________________
Buyer1Nameasappearsonconveyancedocument
______________________________________________________________________________________________
AddressofProperty(NumberandStreet)
______________________________________________________________________________________________
City,State,andZIPCodeofProperty
______________________________________________________________________________________________
AuditorSignature Date(MM/DD/YYYY)
Checkallthatapply:
HomesteadSolarEnergyWindPower
HydroelectricGeothermalRentalProperty
ElectronicStatement(e‐mail)______________________________________________
Apersonwhoknowinglyandintentionallyfalsifiesvalueoftransferredrealproperty,oromitsorfalsifiesanyinformationrequiredtobeprovidedin
thesalesdisclosureformcommitsaClassCfelony.
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