Fill and Sign the Minnesota Disclosure Statement 497312178 Form

WELL DISCLOSURE STATEMENT Date _____________________________________ Page 1 of _____ Pages: THE REQUIRED MAP IS ATTACHED HERETO AND MADE A PART HEREOF Minnesota Statutes Sec. 103I.235 requires that before signing an agreement to sell or transfer real property, the Seller must disclose information in writing to the Buyer about the status and location of all known wells on the property. This requirement is satisfied by delivering to the Buyer either a statement by the Seller that the Seller does not know of any wells on the property, or a disclosure statement indicating the legal description and county, and a map showing the location of each well. In the disclosure statement the Seller must indicate, for each well, whether the well is in use, not in use or sealed. Unless the Buyer and Seller agree to the contrary, in writing, before the closing of the sale, a Seller who fails to disclose the existence or known status of a well at the time of sale and knew or had reason to know of the existence or known status of the well, is liable to the Buyer for costs relating to sealing of the well and reasonable attorney fees for collection of costs from the Seller, if the action is commenced within six years after the date the Buyer closed the purchase of the real property where the well is located. Legal requirements exist relating to various aspects of location and status of wells. Buyer is advised to contact the local unit(s) of government, state agency, or qualified professional which regulates wells for further information about these issues. Instructions for completion of this form are on the reverse side. PROPERTY DESCRIPTION Street address: _________________________________________________________________ City County LEGAL DESCRIPTION ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ WELL DISCLOSURE STATEMENT (CHECK THE APPROPRIATE BOX.) The Seller certifies that the Seller does not know of any wells on the above described real property. (If this option is checked, then skip to the last line and sign and date this statement.) The Seller certifies that the following wells are located on the above described real property. MN Unique Well Year Of Well IN USE NOT IN SEALED Well No. Depth Const. Type USE Well 1 _________ _______ ________ ____________ - 1 - Well 2 _________ _______ ________ ____________ Well 3 _________ _______ ________ ____________ NOTE: See definition of terms ''IN USE,'' ''NOT IN USE,'' and ''SEALED'' on lines 82-88. If a well is not in use, it must be sealed by a licensed well contractor or a well owner must obtain a maintenance permit from the Minnesota Department of Health and pay an annual maintenance fee. If a well is operable and properly maintained, a maintenance permit is not required. SEALED WELL INFORMATION For each well designated as sealed above, complete this section. When was the well sealed? _______________________________________________________ Who sealed the well? ____________________________________________________________ Was a Sealed Well Report filed with the Minn. Dept. of Health? Yes ___ No ___ Unknown ___ MAP Complete the attached MAP showing the location of each well on the real property. This disclosure is not a warranty of any kind by the Seller(s) or any Agent(s) representing any Party(s) in this transaction, and is not a substitute for any inspections or warranties the Party(s) may wish to obtain. CERTIFICATION BY SELLER I certify that the information provided above is accurate and complete to the best of my knowledge. _______________________________________ ______________________________________ (Seller or Designated Representative) (Date) (Seller or Designated Representative) (Date) BUYER’S ACKNOWLEDGEMENT _______________________________________ ______________________________________ (Buyer) (Date) (Buyer) (Date) ORIGINAL COPY TO LISTING BROKER; COPIES TO SELLER, BUYER, SELLING BROKER - 2 -