has a printable sample of a Disclosure Form
Disclosure Sample below
TO CONTINUE TO NEGOTIATING CONTRACT
Below is a sample Disclosure for information purposes to allow you to see what is in a Disclosure:
SAMPLE SELLER’S PROPERTY DISCLOSURE STATEMENT
For property located at:
Legal Description Subdivision_________________________
Lot _________, block _____________, commonly knows as address:__________________________________________
_________________________________________________
City________________________, State_________________ Zip:______________________________________________
Seller; All Names as they appear on the DEED: _________________________________________________
Notice to Buyer and Seller: This disclosure statement is designed to assist Seller in disclosing to Buyer all known material or adverse facts relating to the physical condition of the Property that are not readily observable. All questions are to be answered completely. If answers are affirmative, please explain in detail in the “Additional Explanations” section.
CIRCLE CORRECT RESPONSE YES NO DO NOT KNOW
1. What is the Occupancy of the Property?
a. Is Property vacant? YES NO DO NOT KNOW
b. If yes, when last did Seller occupy Property?
YES NO DO NOT KNOW
c. Are there any written or verbal leases on Property? ` YES NO DO NOT KNOW
If yes, enter termination dates of leases: _____________
2. Soil, Trees, Shrubs and Boundaries:
a. Other than normal settling, are you aware of any earth movements
such as sliding, upheavals, or sinkholes?YES NO DO NOT KNOW
b. Are you aware of any earth stability or expansive soil problems? YES NO DO NOT KNOW
c. Other than foundation backfill, are you aware of any landfill, burial pits, mine shafts, or well holes on Property? YES NO DO NOT KNOW
d. Are you aware of any dead or diseased trees or shrubs? YES NO DO NOT KNOW
e. Are you aware of any boundary line disputes, encroachments, or
unrecorded easement disputes regarding Property? YES NO DO NOT KNOW
3. Roof, Gutters and Downspouts:
a. Please enter the approximate age of roof in years: _________________
b. Has the roof been repaired or replaced while you owned Property? YES NO DO NOT KNOW
c. Are you aware of any leaks or other current problems with the roof, gutters or downspouts? YES NO DO NOT KNOW
4. Termites, Dry-Rot, Pests, and Wood-Destroying Organisms:
a. Are you aware of any past or present damage caused by infiltrating pests, termites, dry rot, or other wood-destroying organisms? YES NO DO NOT KNOW
b. Have you ever had the Property inspected for termites, dry-rot, pests or wood destroying organisms? YES NO DO NOT KNOW
If yes, enter date of inspection: ________________
c. Has the Property been treated for termites, dry rot, pest or wood destroying organisms. YES NO DO NOT KNOW
If yes, enter date of treatment: ________________
d. Is Property under a current warranty or other coverage for termites or other wood-destroying organisms by a licensed pest control company? YES NO DO NOT KNOW
If yes, enter name of company: _______________________________
5. Structural Items, Additions and Alterations:
a. When was the main residential dwelling constructed? Year:
_______ or DO NOT KNOW
b. Other than normal settling, are you aware of any movement, shifting, settling, cracking, deterioration, or other structural problems with any dwelling or garage on Property? YES NO DO NOT KNOW
c. Are you aware of any structural reinforcement having been added to any dwelling, garage OR other out building on Property?
YES NO DO NOT KNOW
d. Are you aware of any structural problems with retaining walls, driveways, walkways, or patios on Property? YES NO DO NOT KNOW
e. Have there been any additions, or major structural alterations to dwelling or garage on the Property? YES NO DO NOT KNOW
f. Are you aware of any work done to the Property that was not in compliance with building codes or zoning regulations, or where necessary permits or approvals were not obtained? YES NO DO NOT KNOW
g. Is asbestos contained in the exterior siding or cladding of any dwelling or garage on the Property? YES NO DO NOT KNOW
6. Drainage, Flooding and Moisture:
Have you been made aware:
a. of any water leakage, accumulation, or dampness within the basement, crawl space or other parts of the main dwelling below ground level? YES NO DO NOT KNOW
b. of any repairs being made to control water or dampness problems in the basement, crawl space, or other parts of the main dwelling at or below ground level? YES NO DO NOT KNOW
c. if the Property is located in a flood zone? YES NO DO NOT KNOW
d. of any drainage problems or flooding? YES NO DO NOT KNOW
e. of any problems with siding or exterior cladding retaining moisture, swelling, chipping or delaminating? YES NO DO NOT KNOW
f. of any mold appearing on interior portions of any dwelling other than on the walls, floors or ceilings of showers/bathtubs?
YES NO DO NOT KNOW
7. Plumbing Related Systems:
a. What is the type of sewage system: ___Public ___Private ___Septic
b. Is the main dwelling served by ___sewage pump ____ lift system
c. Has any septic tank or cesspool on the Property ever been professionally serviced and/or emptied? YES NO DO NOT KNOW
If yes, enter the date of last service: ______________
d. What is the drinking water source: __Public __Private __ on site Well
e. If your drinking water is from a well, has it been tested within the past twelve months. YES NO DO NOT KNOW
f. Do you have a water softener, filter or purifier? YES NO DO NOT KNOW
If yes, is it __Leased or __Owned
g. Are you aware of any past or present leaks, backups, or other problems relating to plumbing, water or sewage-related items?
YES NO DO NOT KNOW
h. Is there any polybutylene plumbing, other than the primary service line, on the Property?
YES NO DO NOT KNOW
8. Other Systems and Components:
a. What type of air conditioning system(s) serve(s) the main dwelling?
____Electric Heat Pump ____ Window Units
b. Approximate age of air conditioning system(s) _____ years
c. What type of heating system(s) serve the main dwelling?
____ Electric Heat Pump ____ Gas Forced Air ____ Oil Forced Air
____ Electric Radiant ____ Oil Radiator ____ Electric baseboard
____ Oil hot water baseboard ____ Gas hot water baseboard
d. Approximate age of heating system(s): ____ years
e. How is hot water heated in the main dwelling?
___Electric ___Gas ____Oil ___Solar
f. Approximate age of hot water heater: _____ years
g. Does the main dwelling have aluminum wiring other than the primary service line? YES NO DO NOT KNOW
h. Is there any system or appliance which is leased or which has a fee associated with its use? YES NO DO NOT KNOW
i. Are all fireplaces in good working order? YES NO DO NOT KNOW
j. When was the fireplace, wood stove or chimney last cleaned?
YES NO DO NOT KNOW
If yes Date: _____________
9. Toxic Substances:
To the best of you knowledge do you know:
a. of any underground tanks or toxic substances on Property such as asbestos, benzene, methane gas, polychlorinated biphenyls (PCBs), radioactive material, radon, urea-formaldehyde, or others? YES NO DO NOT KNOW
b. if Property has ever been tested for radon or other toxic substances?
YES NO DO NOT KNOW
If yes when was the test done and what were the results:
Date______________
RESULTS: _________________________________________________________
10. Covenants, fees and Assessments:
a. Is the Property part of a condominium subject to covenants, conditions and restrictions? YES NO DO NOT KNOW
b. Is the Property part of a community association subject to covenants conditions and restrictions, Governed by a Home Owners Association? YES NO DO NOT KNOW
c. Is there a mandatory annual assessed Association membership Fee?
YES NO DO NOT KNOW
If yes, enter the amount $________ due per ___________
d. In purchasing the Property, will any initiation, transfer, or similar fee be owed to an Association? YES NO DO NOT KNOW
If yes, enter the amount $______________
e. Are there any special assessments approved by but yet not owing or due to the Association? YES NO DO NOT KNOW
f. Are there any past due fees or dues owed the Association? YES NO DO NOT KNOW
g. Is there a copy of the Covenants and Restrictions available? YES NO DO NOT KNOW
11. TITLE ISSUES:
Has the Property or any part of it ever been the subject of litigation
including, but not limited to, construction defects, defective
building products, termites, or title problems?
Are your aware:
a. of any award or payment of money in lieu of repairs for such as
defective building product? YES NO DO NOT KNOW
b. if any release has been signed that would limit a future owner from
making any claims in connection with Property?
YES NO DO NOT KNOW
c. of any fire, flood or wind damage which required repairs to Property
in excess of $500.00? YES NO DO NOT KNOW
d. if any fixtures or appliances included in the sale that are in need of
repair? YES NO DO NOT KNOW
e. of any repairs that need to be made to the electrical, plumbing, or
heating and air condition system? YES NO DO NOT KNOW
f. Have there been any inspections of the Property in the past year? YES NO DO NOT KNOW
12. Lead-Based Paint:
Was the dwelling or any part of the residential improvements to the
Property constructed prior to 1978? YES NO DO NOT KNOW
If “yes” or “Don’t Know,” Seller shall provide Buyer with a separate
warning and information regarding lead-base paint and lead-base paint
hazards. To be attached to contract.
13. Agricultural Disclosure:
Is any part of the Property within or adjacent to property zoned or
legally designated for agricultural or forestry use? YES NO DO NOT KNOW
Warning: Normal farm and forest activities such as disposal of manure, application of chemical fertilizers, herbicides, and pesticides, all may cause discomfort, and one or more of these inconveniences may occur as the result of farm or forest activities which are in conformance with existing laws and regulations and accepted customs and standards.
14. Notice:
Many local law enforcement authorities maintain the locations of persons
such as sex offenders who might be required to register their addresses.
You may contact local law enforcement authorities for information about
the presence of these individuals in any neighborhood.
15. Fixtures and Other Items:
The Property includes the fixtures and other items checked below. If there
is more than one of a particular item (such as a second chandelier
or third air conditioner put number of items on the line) It is understood that all checked items will convey with the property. Items that are not checked although they may be on the property do not convey and will be removed by the seller.
Exterior
_____ Storage Building _____ Gazebo _____ Garden Shed
_____ Free standing deck _____ Lawn Benches
_____ Hot Tub _____ Free standing _____ Built in
_____ Does Hot Tub include Locking safety cover yes/no
_____ Built in masonry Grill natural gas charcoal propane other
_____ Built in fire pit natural gas wood propane
_____ Free standing fire pit
_____ Propane Gas Tanks
_____ Barn or other out building
_____ Work Shop (wood working or art studio)
_____ In ground Swimming Pool _____ Above ground Swimming Pool
_____ Fence around Swimming Pool _____ Pool Cover
_____ Diving Board _____ Swimming Pool Accessories
_____ Swimming Pool Heating System
_____ Separate enclosed Pool filtering system
_____ Boat Dock _____ Boat House _____ Tree House _____ Playhouse
_____ Security Gate(s) _____Fence
_____ Invisible Fence __ Fence Pet Collar
_____ Birdhouses _____ Mailbox _____ Swing Set
_____ Trellis _____ Awning
_____ Basketball Post & Goal _____ Landscaping Lights
_____ Flag Pole _____ Sprinkler System _____ Weather Vane
_____ Statuary _____ Well Pump
_____ Satellite Dish/Receiver
_____ Screen Doors _____ Screens
_____ Storm Doors _____ Storm window
_____ Door and Window Hardware
_____
_____
_____
_____
INTERIOR HOUSE SYSTEMS
_____ Basement Sump Pump
_____ Air Purifier _____ Built-in ____ Free Standing
_____ Dehumidifier free standing or built in
_____ Humidifier free standing or built in
_____ Intercom System built in
_____Stereo System built in _____ Pre-Wired Speakers
_____ Water Purification System whole house built in or under sink
_____ Water Softener System whole house built in or under sink
_____ Alarm System burglar Surface mounted or Whole House Wired
_____ Smoke Detectors _____ Carbon Monoxide Detectors
_____ Telephone Jacks/Wires
_____ Television Antenna _____ Television Cable/Jacks
_____ Whole House Vacuum _____ Vacuum Attachments
_____ Garage Door Opener _____ Remote Control
__ Attic Fan (Whole House Fan) __ Built-in __ Free Standing
__ Attic Ventilator Fan
__ Water Heater ___ Gas ___ Electric
Interior
_____ Stove __ Gas __ Electric __ Built-in __ Free Standing
_____ Surface Unit Cook Top __ Gas __ Electric
_____ Vent Hood outside vented re-circulating
_____ Microwave Oven __ Built-in __ Free Standing
_____ Refrigerator __ Built-in __ Free Standing Ice Maker
_____ Dishwasher __ Built-in __ Free Standing
_____ Trash Compactor__ Built-in __ Free Standing
_____ Washer
_____ Dryer ___ Gas ___ Electric
_____ Garbage Disposal
_____ Cabinets
_____ Shelving Unit & Closet System
_____ Interior Door & Window Hardware
_____ Jetted tub
_____ Mirrors
_____Over toilet Cabinet
_____ Vanity
_____ Shower rod
_____ Shower head/sprayer
_____ Sauna Insert
_____ Light Fixtures _____ Switch Plate Covers
_____ Chandelier
_____ Ceiling Fan
_____ Radiators plug in
_____ Freestanding fireplace
_____ Ceramic Logs in Fireplace
_____ Fireplace tool set
_____ Firewood
_____ Firewood holder
_____ Wood Burning Insert
_____ Fireplace Blower
_____ Window Drapes/curtains
_____ Window Blinds
_____ Window Shutters
_____ Window Shades
List other fixtures not listed above that will be removed and will not convey with the property.
____________________________________________________________
____________________________________________________________
___________________________________________________________
___________________________________________________________
____________________________________________________________
___________________________________________________________
Those items and fixtures that will not convey with the property shall remain
YES NO DO NOT KNOW the personal property of Seller and shall be removed according to the provisions of the contract in a timely fashion prior to closing. Seller shall lose the right to remove any such fixtures or items not removed on a timely basis. In removing fixtures and items, Seller shall use reasonable care to prevent damage and, if necessary, restore Property to its original condition.
16. Natural Hazards:
a. Is property located in a flood hazard zone subject to unusual
flood risk? YES NO DO NOT KNOW
b. Is property in an inundation zone subject to flooding in the
event of a dam failure? YES NO DO NOT KNOW
c. Is property on a Federal Emergency Map and described as a high fire-hazard severity zone?
YES NO DO NOT KNOW
d. Is property in a wildlife fire area where the state has responsibility for fire suppression? YES NO DO NOT KNOW
e. Is property in an earthquake fault zone ? YES NO DO NOT KNOW
f. Is property in a seismic hazard zone subject to unusual ground movement during earthquakes? YES NO DO NOT KNOW
17. Special Hazards:
a. Is property within one mile of past or present military training
facilities that may contain potentially explosive munitions ?
YES NO DO NOT KNOW
b. Is property near any existing or planned mining sites, toxic
waste sites or other environmental hazards ?
YES NO DO NOT KNOW
18. Additional Explanations or Disclosures:
If it is necessary to further describe repairs or problems attach separate sheets.
Seller’s representation:
Seller warrants that to the best of seller’s knowledge the above information is complete and accurate as of the date signed by below.
However, this Disclosure is not to be construed as a substitute for inspection and/or to imply any warranties.
Seller:______________________________________Date:_____________
Seller:______________________________________Date:_____________
Buyer’s receipt and acknowledgement:
I acknowledge receipt of this Disclosure. I understand that except
as stated in the Purchase and Sale Agreement with Seller, the property is being sold in its present condition only, without warranties implied or otherwise or guarantees of any kind by Seller. No representations concerning the condition of the property are being relied upon by me except as disclosed herein or stated in the Purchase and Sale Agreement.
Buyer:_______________________________________Date:_____________
Buyer:_______________________________________Date:_____________
Be sure to get a Disclosure form that complies with your State's Regulations.
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