Fill and Sign the New York Residential Real Estate Sales Disclosure Statement Form

New York State Department of State Division of Licensing Services P.O. Box 22001 Albany, NY 12201-2001 Customer Service: (518) 474-4429 www.dos.ny.gov Property Condition Disclosure Statement Name of Seller or Sellers: Property Address: General Instructions: The Property Condition Disclosure Act requires the seller of residential real property to cause this disclosure statement or a copy of 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 conc erning the property known to the seller. This Disclosure Statem ent is not a warranty of any kind by the seller or by an y 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 pr ofessional 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 receiv e upon the transfer of title a credit of $500 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 resident of one or more persons, but shall not refer to (a) unimproved real property upon which such dwellings are to be construction or (b) condominium units or cooperative apartments or (c) property on a homeowners’ associatio n that is not owned in fee simple by the seller. Instruction 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 “ Unknown.” Seller’s Statement: The seller makes the following representatio ns to the buyer based upon the seller’s actual knowledge at the time of signing this document. The seller authorized his or her agent, if any, to prov ide 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 I NFORMATION 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 befor e 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 availabl e in the public record, such as rights to use a road or path or cut trees or crops? ……………………………………………………….. \  Yes  No  Unknown  NA 5. Does anybody else claim to own any part of your property? If yes, explain below …………………..  Yes  No  Unknown  NA 6. Has anyone denied you access to the property or made a formal legal claim challenging your title to the property? If yes, explain below ………………………………………………\ ……………………..  Yes  No  Unknown  NA DOS-1614-f (Re v. 10/15) Page 1 of 6 Property Condition Disclosure Statement 7. Are there any features of the property shared in common with adjoining landowners or a home- owner’s association, such as walls, fences or driveways? If yes, describe below ………………….....  Yes  No  Unknown  NA 8. Are there any electric or gas utility surcharges for line extensions, special assessments or home- owner or other associati on fees that apply to the property? If yes, describe below …………………..  Yes  No  Unknown  NA 9. Are there certificates of oc cupancy related to the property? If no, explain below …………………….  Yes  No  Unknown  NA ENVIRONMEN TAL Note to Seller: In this section, you will be asked questions regarding petroleum products and hazardous or toxic substances that you know to h ave been spilled, leaked or otherwise been released on the property or fr om the property onto any other property. Petroleum products ma y include, but are not limited to, gasoline, diesel fuel, hom e heating fuel, and lubricants. Hazardous or toxic substances are products that could pose short or long-term danger to personal health or the environment if they are not properly disposed of, applied or stored. These include, but are not limited to, fertilizers, pesticides and insecticides, paint includin g paint thinner, varnish remover and wood preservatives, treated wood, construction materials such as asphalt and roofing materials, antifreeze and other automotive products, batteries, cleaning sol vents including septic tank cleaners, household cleaners and pool c hemicals and products containing mercury and lead. Note to Buyer: If contamination of this property from pet roleum products and/or hazardous or toxic su bstances is a concern to you, you are urged to consider soil and groundwater testing of this property. 10. Is any or all of the property located in a designated floodplain? If yes, explain below ……………..  Yes  No  Unknown  NA 11. Is any or a ll of the property located in a designated wetland? If yes, explain below ………………..  Yes  No  Unknown  NA 12. Is the property located in an agricultural district? If yes, explain below ……………………………...  Yes  No  Unknown  NA 13. Was the property ever the site of a landfill? If yes, explain below ……………………………………..  Yes  No  Unknown  NA 14. Are there or have there ever been fuel storage tanks above or below the ground on the property?  Yes  No  Unknown  NA ● If yes, are they currently in use? ……………………………………………………\ ………………….  Yes  No  Unknown  NA ●Location(s) ● Are they leaking or h ave they ever leaked? If yes, explain below ………………………………….  Yes  No  Unknown  NA 15. Is there asbestos in the structure? If yes, state location or locations below ………………………...  Yes  No  Unknown  NA DOS-1614-f (Rev. 10/15) Page 2 of 6 Property Condition Disclosure Statement 16. Is lead plumbing present? If yes, state location or locations below ………………………………… ..  Yes  No  Unknown  NA 17. Has a radon test bee n d one? If yes, attach a copy of the report ……………………………………. ..  Yes  No  Unknown  NA 18. Has motor fuel, motor oil, home he ating fuel , lubricating oil or any other petroleum product, methane gas, or any hazardous or toxic s ubstance spilled, leaked or otherwise been released on the property or from the property onto any other property? If yes, describe below …………………  Yes  No  Unknown  NA 19. Has the propert y been tested for the presence of motor fuel, motor oil, home heating fuel, lubricating oil, or any other petroleum product, methane gas, or any hazardous or toxic substance? If yes, attach report(s) ………………………………………………\ ………………………..  Yes  No  Unknown  NA STRUCTURAL 20. Is there any rot or water damage to the structure or structures? If yes, explain below ……………..  Yes  No  Unknown  NA 21. Is there any fire or smoke damage to the structure or structures? If yes, explain below ……………  Yes  No  Unknown  NA 22. Is there any termite, insect, r odent or pest infestation or dama ge? If yes, explain below …………..  Yes  No  Unknown  NA 23. Has the propert y been tested for termite, insect, rodent or pest infestation or damage? ………… ..  Yes  No  Unknown  NA If yes, please attached report(s) 24. What is the type of roof/roof co vering (slate, asphalt, other)? …………………………\ ………………. ● Any known material defects? ………………………………………\ ………………………………… .. ● How old is the roof? ………………………………………………\ ……………………………………… ● Is there a transferable warrantee on the roof in effect now? If yes, explain below ………………. DOS-1614-f (Rev. 10/15) Page 3 of 6 Property Condition Disclosure Statement 25. Are there any known material defects in any of the following structural systems: footings, beams, girders, lintels, columns or partitions? ………………………………………………\ ……………………  Yes  No  Unknown  NA MECHANICAL SYSTEMS AND SERVICES 26. What is the water source? (Check all that apply) ……………………………………………………\ …  Well  Private  Municipal  O ther: ● If municipal, is it metered? ………………………………………………\ ……………………………….  Yes  No  Unknown  NA 27. Has the water quality and/or flow rate been tested? ………………………………………………\ ……  Yes  No  Unknown  NA 28. What is the type of sewage system? (Check all that apply) ……………………………………………  Public Sewer  Private Sewer  Septic  Cesspool ● If septic or cesspool, age? ……………………………\ ………………………………………………\ ... ● Date last pumped? ……………………………………\ ………………………………………………\ ... ● Frequency of pumping? ………………………………………………\ ………………………………... ● Any known material defects? If yes, explain below ………………………………………………\ …  Yes  No  Unknown  NA 29. Who is your electric service provider? ………………………………………………\ …………………… ● What is the amperage? ……………………………………\ ………………………………………….... ● Does it have circuit breakers or fuses? ………………………………………………\ ………………. ● Private or public poles? ………………………………………………\ ……………………………….. ● Any known material defects? If yes, explain below ………………………………………………\ …  Yes  No  Unknown  NA 30. Are there any flooding, dr ainage or grading pr oblems that resulted in standing water on any portion of the property? If yes, state locations and explain below ………………………………….....  Yes  No  Unknown  NA 31. Does the basement have seepage that results in standing w ater? If yes, explain below …………  Yes  No  Unknown  NA DOS-1614-f (Rev. 10/15) Page 4 of 6 Property Condition Disclosure Statement Are there any kn own material defects in any of the following? If yes, explain below. Use additional Sheets if necessary ………………………………………………\ ………………………………………………\ . 32. Plumbing system? ……………………………………………………\ ……………………………………..  Yes  No  Unknown  NA 33. Security system? ………………………………………………………\ …………………………………….  Yes  No  Unknown  NA 34. Carbon monoxide detector? ………………………………………………\ ……………………………….  Yes  No  Unknown  NA 35. Smoke detector? ………………………………………………\ ……………………………………………  Yes  No  Unknown  NA 36. Fire sprinkler system? ………………………………………………\ ………………………………………  Yes  No  Unknown  NA 37. Sump pump? … ………………………………………………\ ……………………………………………..  Yes  No  Unknown  NA 38. Foundation/slab? ………………………………………………\ ……………………………………………  Yes  No  Unknown  NA 39. Interior walls/ceilings? ………………………………………………\ ………………………………………  Yes  No  Unknown  NA 40. Exterior walls or siding? ………………………………………………\ ……………………………………  Yes  No  Unknown  NA 41. Floors? ………………………………………………\ ………………………………………………\ ……….  Yes  No  Unknown  NA 42. Chimney/fireplace or stove? ………………………………………………\ ………………………………  Yes  No  Unknown  NA 43. Patio/deck? ………………………………………………\ ………………………………………………\ ….  Yes  No  Unknown  NA 44. Driveway? ………………………………………………………………\ ……………………………………  Yes  No  Unknown  NA 45. Air conditioner? ………………………………………………\ …………………………………………….. \  Yes  No  Unknown  NA 46. Heating system? ………………………………………………………\ ……………………………………  Yes  No  Unknown  NA 47. Hot water heater? ………………………………………………\ …………………………………………..  Yes  No  Unknown  NA 48. The prop erty is located in the following school district Note: Buyer is encouraged to check public records concerning the property (e.g. tax records and wetland and floodplain maps). The seller should use this area to further explain any item a bove. If necessary, attach additional pages and indicate here the number of additional pages attached. DOS-1614-f (Rev. 10/15) Page 5 of 6 Property Condition Disclosure Statement SELLER’S CERTIFICATION: Seller certifies that the information in this Property Condition Disclosure Statement is true and complete to the seller’s actu al knowledge as of the date signed by the seller. I f a seller of residential real property acquires knowledge which renders materially ina ccurate a Property Condition Disclosure Statement provided previously, the seller shall deliver a revise d Property Condition Disclosure Statement to the buyer as soon as practicable. In no event, however, shall a seller be required to provide a revised Property Condition Disclosure State ment after the transfer of title from the seller to the buyer or occupancy by the buyer, whichever is earlier. Seller’s Signature X Date Seller ’s Signature X Date BUYER’S ACKNOWLEDGMENT: Buyer acknowledges receipt of a copy of this statemen t and buyer understands that this information is a statement of certain conditions and information concerning the property known to the seller. It is not a warranty of any kind by the seller or seller’s agent and is not a substitute for any home, pest, radon or other inspections or testing of the prope rty or inspection of the public records. Buyer’s Signature X Date Buyer’ s Signature X Date DOS-1614-f (Rev. 10/15) Page 6 of 6