Minnesota Disclosure Statement

PRIVATE SEWER SYSTEM DISCLOSURE

Date

Page 1 of Pages: THE REQUIRED MAP IS ATTACHED HERETO & MADE PART HEREOF

Property located at in the City of

County of State of , legally described as follows or on attached sheet (the "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.

Buyer(s) and Seller(s) may wish to obtain professional advice and/or inspections of the sewer system and to provide for appropriate provisions in a contract between Buyer(s) and Seller(s) with respect to any advice/inspection/defects.

Seller's Information:

The following Seller disclosure satisfies Minnesota Statutes Chapter 115.55. The Seller discloses the following information with the knowledge that even though this is not a warranty, prospective Buyers may rely on this information in deciding whether and on what terms to purchase the Property. The Seller(s) authorizes any Agent(s) representing any parties to the sale to inspect the Property. 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 an individual sewage treatment system at the time of sale, and who knew or had reason to know of the existence or known status of the system, is liable to the Buyer for costs relating to bringing the system into compliance with individual sewage treatment system rules and for reasonable attorney fees for collection of costs from the Seller. An action under this subdivision must be commenced within two years after the date on which the Buyer closed the purchase of the real property where the system is located.

Legal requirements exist relating to various aspects of location and status of individual sewage treatment systems. Buyer is advised to contact the local unit(s) of government, state agency or qualified professional which regulates individual sewage treatment systems for further information about these issues.

The following are representations made by the Seller(s) to the extent of the Seller(s) actual knowledge. This information is a disclosure and is not intended to be part of any contract between the Buyer and Seller.

TYPE (Check appropriate box(es) and indicate location on attached MAP)

Septic Tank with drain field with mound system seepage tank

with open end Sealed System (holding tank) Other (Describe):

Is the sewer system(s) currently in use? Yes No

NOTE: If any water use appliance, bedroom or bathroom has been added to the Property, the system may no longer comply with applicable sewage treatment system laws and rules.

Is the sewer system(s) in compliance with applicable sewage treatment system laws and rules? Yes Unknown No

When was the sewer system installed? Installer Name/Phone

Where is tank located?

What is tank size? When was tank last pumped? How often is tank pumped?

Where is the drain field located?

What is the drain field size?

Describe work performed to the system since you have owned the Property.

Date work performed/by whom:

Is sewer system entirely within Property boundary lines, including set back requirements?

Is the system shared? How many units on system? Annual fee?

Comments:

On this Property:

Approximate number of: people using the sewer system showers/baths taken per week wash loads per week

Distance between well and sewer system:

Have you received any notices from any government agencies relating to the sewer system? Yes No (if yes, see attached notice.)

Are there any known defects in the sewer system? Yes No if yes, please explain:

Seller's Statement: (To be signed at time of listing)

I/We, Seller(s) of the Property acknowledge the above Private Sewer System Disclosure and MAP and authorize Listing Broker to disclose this information to prospective Buyers.

Buyer's Acknowledgment: (To be signed at time of purchase agreement)

I/We, the Buyer(s) of the Property acknowledge receipt of the Private Sewer System Disclosure and agree that no representation regarding the condition of the Private Sewer System have been made, other than those made above. LISTING BROKER AND AGENTS MAKE NO REPRESENTATIONS AND ARE NOT RESPONSIBLE FOR ANY CONDITIONS EXISTING IN THE PRIVATE SEWER SYSTEM.

Seller's Acknowledgment: (To be signed at time of purchase AS OF THE DATE OF THE ACCEPTANCE OF THE PURCHASE AGREEMENT)

I/we, the Seller(s) of the above Property, agree that the condition of the private sewer system is the same as noted above, including changes indicated above which have been initialed and dated.