North Carolina Residential Property Disclosure Statement - Instructions Page 2
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2Property Address/Description:
[Note: In this form, “property” refers only to dwelling unit(s) and not sheds, detached garages or other buildings.]
Regarding the property identified above, do you know of any problem (malfunction or defect) with any of the following:
Yes*
No No Repre
sentation
1.
FOUNDATION, SLAB, FIREPLACES/CHIMNEYS, FLOORS, WINDOWS (INCLUDING STORM
WINDOWS AND SCREENS), DOORS, CEILINGS, INTERIOR AND EXTERIOR WALLS,
ATTACHED GARAGE, PATIO, DECK OR OTHER STRUCTURAL COMPONENTS including
any modifications to them?............................................................................................................
a. Siding is:
Masonry
Wood
Composition/Hardboard
Vinyl
Synthetic Stucco
Other
b. Approximate age of structure
.........................................................................
2.
ROOF (leakage or other problem)?...............................................................................................
3.
WATER SEEPAGE, LEAKAGE, DAMPNESS OR STANDING WATER in the basement, crawl
space or slab?................................................................................................................................
4.
ELECTRICAL SYSTEM (outlets, wiring, panel, switches, fixtures, etc.)?.......................................
5.
PLUMBING SYSTEM (pipes, fixtures, water heater, etc.)?............................................................
6.
HEATING AND/OR AIR CONDITIONING?....................................................................................
a. Heat Source is:
Furnace
Heat Pump
Baseboard
Other............................
b. Cooling Source is:
Central Forced Air
Wall/Window Unit
Other.......................
c. Fuel Source is:
Electricity
Natural Gas
Propane
Oil
Other...............
7.
WATER SUPPLY (including water quality, quantity and water pressure)?...................................
a. Water supply is:
City/County
Community System
Private Well
Other.....
b. Water pipes are:
Copper
Galvanized
Plastic
Other
Unknown.........
8.
SEWER AND/OR SEPTIC SYSTEM?..........................................................................................
a. Sewage disposal system is:
Septic Tank
Septic Tank with Pump
Community
System
Connected to City/County System
City/County System available
Straight
pipe(wastewater does not go into a septic or other sewer system (note: use of this type of system
violates state law)
Other.......................................................................................................
9.
BUILT-IN APPLIANCES (RANGE/OVEN, ATTACHED MICROWAVE, HOOD/FAN,
DISHWASHER, DISPOSAL, etc.)?..............................................................................................
Also regarding the property identified above, including the lot, other improvements, and fixtures located thereon, do you know of any:
10.
PROBLEMS WITH PRESENT INFESTATION, OR DAMAGE FROM PAST INFESTATION OF
WOOD DESTROYING INSECTS OR ORGANISMS which has not been repaired?...................
11.
PROBLEMS WITH DRAINAGE, GRADING OR SOIL STABILITY OF LOT?..............................
12.
PROBLEMS WITH OTHER SYSTEMS AND FIXTURES: CENTRAL VACUUM, POOL, HOT
TUB, SPA, ATTIC FAN, EXHAUST FAN, CEILING FAN, SUMP PUMP, IRRIGATION SYSTEM,
TV CABLE WIRING OR SATELLITE DISH, OR OTHER SYSTEMS?.........................................
13.
ROOM ADDITIONS OR OTHER STRUCTURAL CHANGES?....................................................
14.
ENVIRONMENTAL HAZARDS (substances, materials or products) including asbestos,
formaldehyde, radon gas, methane gas, lead-based paint, underground storage tank, or
other hazardous or toxic material (whether buried or covered) contaminated soil or water
or other environmental contamination?........................................................................................
15.
COMMERCIAL OR INDUSTRIAL NUISANCES (noise, odor, smoke, etc.) affecting the property?
16.
VIOLATIONS OF BUILDING CODES, ZONING ORDINANCES, RESTRICTIVE COVENANTS
OR OTHER LAND-USE RESTRICTIONS?..................................................................................
17.
UTILITY OR OTHER EASEMENTS, SHARED DRIVEWAYS, PARTY WALLS OR
ENCROACHMENTS FROM OR ON ADJACENT PROPERTY?..................................................
18.
LAWSUITS, FORECLOSURES, BANKRUPTCY, TENANCIES, JUDGMENTS, TAX LIENS,
PROPOSED ASSESSMENTS, MECHANICS’ LIENS, MATERIALMEN’S LIENS, OR NOTICE
FROM ANY GOVERNMENTAL AGENCY that could affect title to the property?.........................
19.
OWNERS’ ASSOCIATION OR “COMMON AREA” EXPENSES OR ASSESSMENTS?..............
20.
FLOOD HAZARD or that the property is in a FEDERALLY-DESIGNATED FLOOD PLAIN?.......
*
If you answered “Yes” to any of the above questions, please explain (Attach additional sheets, if necessary):
Page 2 of 2
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