Property Condition Disclosure Statement

Name of seller or sellers: ______________________________________________________________________

Property address: ____________________________________________________________________________

The Property Condition Disclosure Act requires the seller of residential real property to cause this disclosure

statement or a copy thereof to be delivered to a buyer or buyer's agent prior to the signing by the buyer of a binding

contract of sale.

Purpose of Statement:

This is a statement of certain conditions and information concerning the property known to the seller. This disclosure

statement is not a warranty of any kind by the seller or by any agent representing the seller in this transaction. It is not

a substitute for any inspections or tests and the buyer is encouraged to obtain his or her own independent professional

inspections and environmental tests and also is encouraged to check public records pertaining to the property.

A KNOWINGLY FALSE OR INCOMPLETE STATEMENT BY THE SELLER ON THIS FORM MAY SUBJECT THE

SELLER TO CLAIMS BY THE BUYER PRIOR TO OR AFTER THE TRANSFER OF TITLE. IN THE EVENT A

SELLER FAILS TO PERFORM THE DUTY PRESCRIBED IN THIS ARTICLE TO DELIVER A DISCLOSURE

STATEMENT PRIOR TO THE SIGNING BY THE BUYER OF A BINDING CONTRACT OF SALE, THE BUYER

SHALL RECEIVE UPON THE TRANSFER OF TITLE A CREDIT OF FIVE HUNDRED DOLLARS AGAINST THE

AGREED UPON PURCHASE PRICE OF THE RESIDENTIAL REAL PROPERTY.

"Residential real property" means real property improved by a one to four family dwelling used or occupied, or

intended to be used or occupied, wholly or partly, as the home or residence of one or more persons, but shall not refer

to (a) unimproved real property upon which such dwellings are to be constructed or (b) condominium units or

cooperative apartments or (c) property on a homeowners' association that is not owned in fee simple by the seller.

Instructions to the seller:

(a) Answer all questions based upon your actual knowledge.

(b) Attach additional pages with your signature if additional space is required.

(c) Complete this form yourself.

(d) If some items do not apply to your property, check "NA" (non-applicable). If you do not know the answer check

"UNKN" (unknown).

Seller's Statement:

The seller makes the following representations to the buyer based upon the seller's actual knowledge at the time of

signing this document. The seller authorizes his or her agent, if any, to provide a copy of this statement to a

prospective buyer of the residential real property. The following are representations made by the seller and are not the

representations of the seller's agent.

General Information

1. How long have you owned the property? ____________________________________________

2. How long have you occupied the property? __________________________________________

3. What is the age of the structure or structures? _______________________________________

Note to buyer- If the structure was built before 1978 you are encouraged to investigate for the presence of lead

based paint.

4. Does anybody other than yourself have a lease, easement or any other right to use or occupy any part of your

property other than those stated in documents available in the public record, such as rights to use a road or path or

cut trees or crops? Yes No UNKN NA

5. Does anybody else claim to own any part of your property? Yes No UNKN NA (if yes, explain below)

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