Nebraska Real Estate Commission Seller Property Condition Disclosure Statement (Page 2 of 4) in pdf

Page 2 of 4

7/2012

Do Not

None /

Do Not

None /

Section C - Heating and Cooling Systems

Section D - Water Systems

Not

Know If

Not

Know If

Not

Working

Included

Working

Included

1. Air purifier

1. Hot tub / whirlpool

2. Attic fan

2. Plumbing (water supply)

3. Whole house fan

3. Swimming pool

4. Central air conditioning

4. a. Underground sprinkler system

______ year installed (if known)

b. Back-flow prevention system

5. Heating system

______ year installed (if known)

5. Water heater ______ year installed (if known)

______ Gas

______ Electric

______ Other (specify _______________ )

6. Water purifier ______ year installed (if known)

6. Fireplace / Fireplace Insert

7. Water softener ______ Rent ______ Own

8. Well system

7. Gas log (fireplace)

8. Gas starter (fireplace)

Do Not

None /

Section E - Sewer Systems

Not

Know If

Not

9. Heat pump

Working

Included

______ year installed (if known)

1. Plumbing (water drainage)

10. Humidifier

2. Sump pump (discharges to ______________ )

11. Propane Tank

______ year installed (if known)

3. Septic System

______ Rent ______ Own

12. Wood-burning stove

______ year installed (if known)

PART II - In Sections A, B, C, and D if the answer to any item is “YES”, explain the condition in the comments Section in PART III of this disclosure statement.

Section A. Structural Conditions - If there is more than one of any item listed in this Section, the statement made applies to each and all of such items unless otherwise

noted in the comment section in PART III of this disclosure statement.

Do Not

Section A - Structural Conditions

YES

Know

YES

Know

N / A

1. Age of roof (if known) _______ year(s)

N / A

10. Year property was built _________ (if known)

2. Does the roof leak?

11. Has the property experienced any moving or

------

settling of the following:

3. Has the roof leaked?

- Foundation

4. Is there presently damage to the roof?

5. Has there been water intrusion in the

- Floor

basement or crawl space?

- Wall

6. Has there been any damage to the real

property or any of the structures thereon

- Sidewalk

due to the following occurrences including,

but not limited to, wind, hail, fire, flood,

- Patio

wood-destroying insects, or rodents?

7. Are there any structural problems with the

- Driveway

structures on the real property?

8. Is there presently damage to the chimney?

- Retaining wall

9. Are there any windows which presently

12. Any room additions or structural changes?

leak, or do any insulated windows have any

broken seals?

Section B. Environmental Conditions - Have any of the following substances, materials, or products been on the real property? If tests have been conducted for any of the

following, provide a copy of all test results, if available.

Do Not

Section B - Environmental Conditions

YES

Know

YES

Know

5. Radon gas

1. Asbestos

6. Toxic materials

2. Contaminated soil or water

(including drinking water)