Form Rec 4.22 - Residential Property And Owners' Association Disclosure Statement Page 3
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1
2
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4No
Yes
No
Representation
21. Is there any problem with present infestation of the dwelling, or damage from past infestation of wood
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destroying insects or organisms which has not been repaired?..........................................................................
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22. Is there any problem, malfunction or defect with the drainage, grading or soil stability of the property?..........
23. Are there any structural additions or other structural or mechanical changes to the dwelling(s) to be conveyed
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with the property?...........................................................................................................................................
24. Is the property to be conveyed in violation of any local zoning ordinances, restrictive covenants, or other land-
use restrictions, or building codes (including the failure to obtain proper permits for room additions or other
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changes/improvements)?...................................................
25. Are there any hazardous or toxic substances, materials, or products (such as asbestos, formaldehyde, radon
gas, methane gas, lead-based paint) which exceed government safety standards, any debris (whether buried or
covered) or underground storage tanks, or any environmentally hazardous conditions (such as contaminated
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soil or water, or other environmental contamination) which affect the property?.............................................
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26. Is there any noise, odor, smoke, etc. from commercial, industrial, or military sources which affects the property?
27. Is the property subject to any utility or other easements, shared driveways, party walls or encroachments from
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or on adjacent property?..................................................................................................................................
28. Is the property the subject of any lawsuits, foreclosures, bankruptcy, leases or rental agreements, judgments, tax
liens, proposed assessments, mechanics' liens, materialmens' liens, or notices from any governmental agency that
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could affect title to the property?...........................................................................................................................
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29. Is the property subject to a flood hazard or is the property located in a federally-designated flood hazard area?
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30. Does the property abut or adjoin any private road(s) or street(s)?....................................................................
31. If there is a private road or street adjoining the property, is there in existence any owners’ association or maintenance
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agreements dealing with the maintenance of the road or street?..................................................................................
If you answered “yes” to any of the questions listed above (1-31) please explain (attach additional sheets if necessary):
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
In lieu of providing a written explanation, you may attach a written report to this Disclosure Statement by a public agency, or by an
attorney, engineer, land surveyor, geologist, pest control operator, contractor, home inspector, or other expert, dealing with matters within
the scope of that public agency’s functions or the expert’s license or expertise.
The following questions pertain to the property identified above, including the lot to be conveyed and any dwelling unit(s), sheds,
detached garages, or other buildings located thereon.
No
Yes
No
Representation
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32. To your knowledge, is the property subject to regulation by one or more owners’ association(s) or governing
documents which impose various mandatory covenants, conditions, and restrictions upon the lot, including,
but not limited to obligations to pay regular assessments or dues and special assessments? If your answer is
“yes,” please provide the information requested below as to each owners’ association to which the property is
subject [insert N/A into any blank that does not apply]:
•(specify name)__________________________________________________ whose regular assessments
(“dues”) are $______________ per ________________. The name, address, and telephone number of the
president of the owners’ association or the association manager are_______________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.
•(specify name)_________________________________________________ whose regular assessments
(“dues”) are $______________ per ________________. The name, address, and telephone number of the
president of the owners’ association or the association manager are____________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________.
* If you answered “Yes” to question 32 above, you must complete the remainder of this Disclosure Statement. If you answered
“No” or “No Representation” to question 32 above, you do not need to answer the remaining questions on this Disclosure
Statement. Skip to the bottom of the last page and initial and date the page.
Owner Initials and Date______________________________
Owner Initials and Date______________________________
Purchaser Initials and Date____________________________
Purchaser Initials and Date____________________________
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