Vacant Land Disclosure Statement Form
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3Original: Listing Broker Copies to Seller, Buyer, Selling Broker
VACANT LAND DISCLOSURE STATEMENT
Date: ______________________, 20 ___
Page _____ of _____
This seller’s disclosure statement concerns the real property located in the City of ______________________, County of
______________________________, State of __________________, described as ___________________________________
_______________________________________________________________________________________________________
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, FLOODING
1.
When did you purchase this land?
__________________
Has the land been surveyed? Yes or
2.
No
If yes, year surveyed __________
3.
What company or person performed the survey? Name: ______________________________________
Address: ___________________________________City/State/Zip _____________________________
Phone: (
) ______________________________
Yes
No or
Unknown
4. Is there a survey available?
If this is platted land, has a certificate of survey been completed? Yes or
No
5.
If yes, by whom? ________________________________________ When? ____________________
Yes
No or
Unknown
6.
Are there any encroachments or boundary line disputes ?
Are there any easements other than utility or drainage easements? Yes
No or
Unknown
7.
Is the property in a designated 100 year flood plain or wetland area? Yes
No or
Unknown
8.
Yes
No or
Unknown
9.
Has there ever been a flood or other disaster at the property?
10. Have there every been any drainage problems affecting this property or adjacent properties?
Yes
No or
Unknown
Yes
No or
Unknown
11. Is the property in an earthquake zone?
12. Give details if any of questions 5 through 10 were answered “YES” ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
Yes
No or
Unknown
13. Are there any navigation easements?
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 or Unknown
Yes
No or
Unknown
b. A right of first refusal to purchase?
Yes
No or
Unknown
c. Local municipality?
2.
If any of the above questions (B1) are answered “YES” do you have written copies of these covenants,
conditions, or restrictions? Yes
No or
Unknown
List which documents you have: _______________________________________________________
_________________________________________________________________________________
2.
Have you ever received notice from any person or authority as to any breach of any of these covenants,
Yes
No or
Unknown
conditions
or restrictions?
If “YES”, describe: __________________________________________________________________
_________________________________________________________________________________
C. CONDITION OF THE PROPERTY
Are there any structure improvements, or personal property located in the sale? Yes or
No
1.
If ‘YES” list all items: ________________________________________________________________
_________________________________________________________________________________
Yes No or Unknown
2.
Are there any defects or problems with any of these items?
If ‘YES” describe all problems and defects: ______________________________________________
_________________________________________________________________________________
3.
Are there any abandoned wells, buried storage tanks, or buried debris or waste on the property?
Yes
No or
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 or
Unknown
If “YES” give details: ________________________________________________________________
Initials: _________ Date: __________ Time: ________
IF YOU DO NOT UNDERSTAND THIS DOCUMENT, PLEASE CONSULT AN ATTORNEY
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