Seller __________ makes the following disclosures about the property at __________ (built __________), based on Seller's actual knowledge. This is not a warranty and does not replace a professional inspection.

1. Roof

__________

2. Water Damage

__________

3. Systems

__________

4. Environmental Hazards

__________

For homes built before 1978, a separate federal lead-based paint disclosure is required.

5. Other Defects

__________

6. Acknowledgment

Buyer acknowledges receiving this statement. This disclosure is made under the laws of the State of __________.