Fill and Sign the Vacant Land Disclosure Form

Vacant Land Disclosure Statement Original to Listing Broker; Copies to Seller, Buyer, Selling Broker IF YOU DO NOT UNDERSTAND THIS DOCUMENT, PLEASE CONSULT AN ATTORNEY Date: ______________________, 20 _____ Page _____ of _____ This seller’s disclosure statement concerns the real property located in the City of ______________________ (Name) , County of ______________________ (Name) , State of ______________________ (Name) , described as ____________________________________ (Legal Description of Property) Notice to Seller: Each Seller is obligated to disclose to a buyer all known facts that materially and adversely affect the value of the property being sold and that are not readily observable. This disclosure statement is designed to assist Seller in complying with disclosure requirements and to assist Buyer in evaluating the property being considered. The listing real estate broker, the selling real estate broker and their respective agents will also rely upon this information when they evaluate market and present Seller’s property to prospective buyers. Notice to Buyer: This is a disclosure of Seller’s knowledge of the condition of the property as of the date signed by Seller and is not a substitute for any inspections, tests or other investigation or warranties that Buyer may wish to obtain. It is not a warranty of any kind by Seller or a warranty or representation by listing broker, the selling broker, or their agents. A. Survey, Easement, and Flooding 1. When did you purchase this land? ______________________ (Date) 2. Has the land been surveyed? A. [ ] Yes If yes, year surveyed __________ B. [ ] No 3. What company or person performed the survey? A. Name: ______________________________________ B. Street Address: ___________________________________ C. City_________________ State________________ D. Zip Code ______________ Phone: ( ) ________________ 4. Is there a survey available? [ ] Yes [ ] No [ ] Unknown 5. If this is platted land? [ ] Yes [ ] No Has a certificate of survey been completed? [ ] Yes [ ] No If yes, by whom? ________________________________________ If yes, when was the survey completed? ______________________ 6. Are there any encroachments or boundary line disputes? [ ] Yes [ ] No [ ] Unknown 7. Are there any easements other than utility or drainage easements? [ ] Yes [ ] No [ ] Unknown 8. Is the property in a designated 100 year flood plain or wetland area? [ ] Yes [ ] No [ ] Unknown 9. Has there ever been a flood or other disaster at the property? [ ] Yes [ ] No [ ] Unknown 10. Have there ever been any drainage problems affecting this property or adjacent properties? [ ] Yes [ ] No [ ] Unknown 11. Is the property in an earthquake zone? [ ] Yes [ ] No [ ] Unknown 12. Give details if any of Questions 5 through 10 were answered YES. _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ 13. Are there any navigation easements? [ ] Yes [ ] No [ ] Unknown B. Use Restrictions 1. Do any of the following types of covenants, conditions, or restrictions affect the land? A. Subdivision or other recorded covenants, conditions, or restrictions? [ ] Yes [ ] No [ ] Unknown B. A right of first refusal to purchase? [ ] Yes [ ] No [ ] Unknown C. Local municipality? [ ] Yes [ ] No [ ] Unknown 2. If any of the above Questions B-1 is answered YES do you have written copies of these covenants, conditions, or restrictions? [ ] Yes [ ] No [ ] Unknown List which documents you have: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Have you ever received notice from any person or authority as to any breach of any of these covenants, conditions or restrictions? [ ] Yes [ ] No [ ] Unknown If “YES”, describe: ________________________________________________________________ ________________________________________________________________ C. Condition of the Property 1. Are there any structure improvements, or personal property located in the sale? [ ] Yes [ ] No If ‘YES” lists all items: _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ 2. Are there any defects or problems with any of these items? [ ] Yes [ ] No [ ] Unknown If ‘YES” describes all problems and defects: _________________________________________________________ _________________________________________________________ Initials: _________ Initials: _________ Date: __________ Time: ________ Property Address: _____________________________________________ Page ____ of _______ If you do not understand this document, please contact an attorney. 3. Are there any abandoned wells, buried storage tanks, or buried debris or waste on the property? [ ] Yes [ ] No [ ] Unknown (If YES give details): _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ 4. Is there any hazardous or toxic substance (including radon) in or on this property or any adjacent property? [ ] Yes [ ] No [ ] Unknown (If YES give details): _________________________________________________________ _________________________________________________________ _________________________________________________________ 5. Have any soil tests been performed? [ ] Yes [ ] No [ ] Unknown When? ______________ By Whom? ____________________________ Results: __________________________________________________ 6. Does the property have any fill or un-compacted soils? [ ] Yes [ ] No [ ] Unknown If YES describe location and depth ___________________________________________________ ________________________________________________________________ 7. Are there any settling or soil movement problems on this property or any adjacent property? [ ] Yes [ ] No [ ] Unknown (If YES give details): ________________________________________________________________ ________________________________________________________________ Initials: _________ Initials: _________ Date: __________ Time: ________ Property Address: _____________________________________________ Page ____ of _______ If you do not understand this document, please contact an attorney. 8. Are there any dead or diseased trees on the property? [ ] Yes [ ] No [ ] Unknown (If YES give details): ________________________________________________________________ ________________________________________________________________ D. Utilities 1. Have any percolation tests been performed? If YES , When? ______________ By Whom? ___________________________ Results: ________________________________________________________ 2. Are any of the following presently existing within the property? A. Connection to public water? [ ] Yes [ ] No [ ] Unknown B. Connection to public sewer? [ ] Yes [ ] No [ ] Unknown C. Connection to private water system off property? [ ] Yes [ ] No [ ] Unknown D. A water well? [ ] Yes [ ] No [ ] Unknown E. Septic tank? [ ] Yes [ ] No [ ] Unknown F. Connection to electricity? [ ] Yes [ ] No [ ] Unknown G. Connection to natural gas services? [ ] Yes [ ] No [ ] Unknown 3. Are any of the following presently existing at the boundary of the property? A. Public water system access? [ ] Yes [ ] No [ ] Unknown B. Private water system access? [ ] Yes [ ] No [ ] Unknown C. Electric service access? [ ] Yes [ ] No [ ] Unknown D. Natural gas access? [ ] Yes [ ] No [ ] Unknown E. Telephone system access? [ ] Yes [ ] No [ ] Unknown 4. Have any utility access charges been paid? [ ] Yes [ ] No [ ] Unknown If “YES” which charges have been paid? _________________________ Initials: _________ Initials: _________ Date: __________ Time: ________ Property Address: _____________________________________________ Page ____ of _______ If you do not understand this document, please contact an attorney. E. Other Matters 1. Is there a Homeowners Association? [ ] Yes [ ] No [ ] Unknown 2. If yes, what are the dues or assessments? $____________ paid _______________ (monthly or yearly) ? 3. Is there road maintenance? [ ] Public [ ] Private or [ ] Unknown 4. Are there any recorded maintenance agreements? [ ] Yes [ ] No [ ] Unknown 5. Is there a bus or other public transportation system? [ ] Yes [ ] No [ ] Unknown Where is the pick up? ________________________________________ Is there anything else that may materially and adversely affect the value or desirability of the property, e.g., pending claims or litigation, notice from any governmental authority for violation of any law or regulation, proposed zoning changes, street changes, threat of condemnation, or neighborhood noise or nuisance? [ ] Yes [ ] No [ ] Unknown (If YES give details): _____________________________________________________________ _____________________________________________________________ F. SELLER’S STATEMENT (To be signed at time of listing) The undersigned Seller represents that the information set forth in the foregoing disclosure statement is accurate and complete. Sellers do not intend this disclosure statement to be a warranty or guaranty of any kind. Seller hereby authorizes that this information be provided to prospective buyers of this property and to the real estate brokers and sales people. Seller understands and agrees that Seller will notify in writing immediately if any information set forth in this disclosure statement becomes inaccurate or incorrect in any way through the passage of time or the discovery of additional information. G. BUYER’S RECEIPT AND ACKNOWLEDEGMENT (To be signed at time of purchase agreement) I carefully inspected the property. I have been advised to have the property examined by professional inspectors and to investigate every aspect of the property which could be important to me. I acknowledge that neither any Broker or Agent involved in this transaction is an expert at detecting the condition of the property or its suitability for my intended use. Initials: _________ Initials: _________ Date: __________ Time: ________ Property Address: _____________________________________________ Page ____ of _______ If you do not understand this document, please contact an attorney. I understand that unless stated otherwise in my contract with Seller, the property is being sold in its present condition only, without warranties or guarantees of any kind by Seller or any Broker or Agent. I state that no representations concerning the condition of the property are being relied upon by me except as disclosed or stated within the sales contract. Witness our signatures this the ______ day of _______________, 20____. _______________________ _______________________ (Printed Name of Seller) (Printed Name of Seller) _______________________ _______________________ (Signature of Seller) (Signature of Seller) _______________________ _______________________ (Printed Name of Buyer) (Printed Name of Buyer) _______________________ _______________________ (Signature of Buyer) (Signature of Buyer)