Fillable Printable Property Condition Disclosure Statement -New York

Property Condition Disclosure Statement -New York

DOS-1614 (Re v. 8/06) PAGE 1 OF 6

NYS Department of State

Division of Licensing Se rvices

P.O. Box 22 0 01

Alba ny, NY 12201-2001

(518) 474-4429

www.dos.state.ny.us

Property Condition Disclosure Statement

N ame of Se lle r o r Se lle rs:

Property Address:

G eneral I nstructions :

The Property Conditi on D isc losure Act requ ires the seller of res i dent ial real p rop erty to caus e this disc losu re s tatement or

a c opy thereof to b e delivered t o a b uyer or b uyer’ s agent prior to the s i gning b y the b uyer of a binding c ontrac t of s ale.

Purpo s e o f St atement:

This is a statement of certain conditions and information concerning the property known to the seller. This Disclosure

Statement is not a warranty of any kind by the seller or by any agent representing the seller in this transaction. It is not a

substitute for any inspections or tests and the buyer is encouraged to obtain his or her own independent professional inspections

and environment al tes ts and also is enc ouraged to check pub lic records pertaining to the property.

A knowingly f alse or inc omp let e s tatement by the s eller on this f orm may sub ject the s eller to c laims b y the b u yer prior to

or after the transfer of title. In the event a seller fails to perform the duty prescribed in this article to deliver a Disclosur e

Statement prior to the signing by the buyer of a binding contract of sale, the buyer shall receive upon the transfer of title a credit

of $500 aga inst the a gr eed upon pur cha se price of the residential rea l pr operty.

“Residential real property” means real property improved by a one to four family dwelling used or occupied, or intended to

b e u sed or oc c upied, wholly or partly, as the home or res i dence of one or more persons, but shall not refer to ( a) unimp roved

real property upon which such dwellings a re to be constructed or (b) condominium units or cooperative apartments or (c)

p roperty on a homeowners’ ass oc i ation that is not owned in f ee simp le b y the s eller.

Inst ructions to the S eller:

a. Answer all ques tions based u pon you r ac tual knowledge.

b . Attac h additi onal pages with your s i gnature if additional spac e is requ ired.

c. Complete this form yourself.

d. If some items do not apply to your property, check “NA” (Non-applicable). If you do not know the answer check “Unkn”

(Unknown).

S eller’s S t atement:

The selle r m akes the following represe ntations to the buyer based upon the seller’s actual knowledge at the time of signing

this doc ument. The s eller au thoriz es his or her agent, if any, to provide a c op y of this statement to a p rosp ective b uyer of the

r esidentia l r ea l p r oper ty. T he following a r e r epr esent a tions ma de by t he s eller a nd are no t the r ep r esent a tions of t he s eller ’s

agent.

GENERAL INFORMATION

1. How long have you owned the property?......................................

2. How long have you occupied the property? ....................................

3. What is the age of the structure or structures? ..................................

Note to buyer – If the structure was built before 1978 you are encouraged to investigate for

the presenc e of l ead based pai nt . .

4 . D oe s anybod y othe r than yours e lf have a leas e, eas e me nt or any othe r right to u se or oc c up y

any part o f your prop erty othe r than those stated in doc u ments available in the p u blic re co rd,

such as rights to use a road or path or cut trees or crops? ..........................

Yes

Unkn

5 . Does anybody else clai m to own a ny part of your p roperty? If Yes, explain below ........

Yes

Unkn

Property Condition Disclosure Statement

DOS-1614 (Rev. 8/06) PAGE 2 OF 6

6. Has anyone d enied you ac ce ss to the prop erty or made a f ormal legal claim c halle nging you r

title to th e proper ty? If Yes, explain below .....................................

Yes

Unkn

7. Are there any features of the property shared in common with adjoin in g landowners or a

h omeown er ’s association, such as walls, fen ces or driveways? If Yes, describe be low .....

Yes

Unkn

8. Are there any electric or gas utility surcharges for line extensions, special assessments or

h omeown er or other association fees th at apply to th e proper ty? If Yes, explain below .....

Yes

Unkn

9 . Are there certi fi cates of occu p ancy rela ted to t he p roperty? If No, explain below .........

Yes

Unkn

ENVI RONM ENTAL

Note to S eller:

In this section, you will be asked questions regarding petroleum products and hazardous or toxic substances that you know

to have been spilled, leaked or otherwise been rele ased on the property or from the property onto any other property. Petroleum

products may include, but are not limited to, gasoline, diesel fuel, home heating fuel, and lubricants. Hazardous or toxic

substances are products that could pose short or long-term danger to personal health or the environment if they are not properly

disposed of, applied or stored. These include, but are not limited to, fertilizers, pesticides and insecticides, paint including pain t

thinner, varnish remover and wood preservatives, treated wood, construction materials such as asphalt and roofing m aterials,

antifreeze and other automotive products, batteries, cleaning solvents including septic tank cleaners, household cleaners and pool

c hemic als and produ c ts c ontaining merc ury and lead.

Note to B uyer:

If contamination of this property from petroleum products and/or hazardous or toxic substances is a concern to you, you are

u rged t o c onsider soil and groundwater tes ting of this prop erty.

10. Is an y or a l l of the proper t y l ocat ed in a designa ted fl oodplai n? If Yes, explain below .....

Yes

Unkn

11. Is an y or all of th e property located in a design ated wetland? If Yes, explain below ......

Yes

Unkn

12. Is th e property located in an agr icultur al district? If Yes, explain below ...............

Yes

Unkn

13. Was the property ever th e site of a lan dfill? If Yes, explain below ...................

Yes

Unkn

Property Condition Disclosure Statement

DOS-1614 (Rev. 8/06) PAGE 3 OF 6

14. Are there or have there ever been fuel storage tanks above or below the ground on the

property? ..............................................................

• If Yes, are they currently in use? .........................................

• Location(s)

• Are they l eak ing or have t hey ever l eak ed? If Yes, explain below .................

Yes

Unkn

1 5 . I s there as best os in the s tructu re? If Yes, stat e l oc ati on or loc ati ons bel ow .............

Yes

Unkn

16. Is lead pl um bing pr esent ? If Yes, state l ocat i on or locat i ons below ..................

Yes

Unkn

17. Ha s a radon test been don e? If Yes, att ac h a c opy of t he report .....................

Yes

Unkn

18. Has motor f u el, moto r oil, ho me he ating fue l, lu bric ating oil or any o the r pe trole um p ro d u ct,

methan e gas, or any hazardous or toxic substan ce spilled, leaked or other wise been released

on the property or from the property onto any othe r p roperty? If Yes, describe be low .....

Yes

Unkn

19. Has the property been tested for the presence of motor fuel, motor oil, home heating fuel,

lubricating oil, or any other petroleum product, methane gas, or any hazardous or toxic

substance? I f Yes, a t t a c h re p o rt (s) ...........................................

Yes

Unkn

STRUCTURAL

2 0 . I s there any rot or wa ter d am ag e to t he stru ctu re or stru ctu res ? If Yes, explain below .....

Yes

Unkn

2 1 . I s there any fi re or s moke d amag e t o the s truct u re or s tru ctures ? If Yes, explain below ....

Yes

Unkn

22. Is ther e an y termite, in sect, r odent or pest infestation or damage? If Yes, explain below ...

Yes

Unkn

23. Has th e property been tested for termite, insect, r odent or pest infestation or damage? ....

If Yes, p l ea se at ta ch rep o rt (s)

Yes

Unkn

24.What is the type of roof/roof covering (slate, asphalt, other)? .......................

• Any known material defects?............................................

• How old is the roof?...................................................

Property Condition Disclosure Statement

DOS-1614 (Rev. 8/06) PAGE 4 OF 6

• I s there a trans ferabl e wa rrant ee on t he roof i n effect now? If Yes, explain below .....

Yes

Unkn

25. Are there any know material defects in any of the following structural systems: footings,

beams, girders, lintels, column s or partitions? If Yes, explain below ..................

Yes

Unkn

MECHANICAL SYSTEMS AND SERVICES

2 6 . What i s the wa ter sou rce? (Circle al l that appl y) ................................. well, private, municipal,

other:

• If municipal, is it metered? .............................................

Yes

Unkn

2 7. H as the water quality and/or f l ow rate b een t ested? If Yes, describe below ........

Yes

Unkn

2 8 . What i s the type of sewa g e s ys tem ? (Circl e all t hat appl y ) ......................... public sewer, private sewer,

septic, ce sspo ol

• If septic or cesspool, age? ..............................................

• Date last pumped? ....................................................

• Frequency of pumping? ................................................

• An y known ma t eria l defects? If Yes, explain below ...........................

Yes

Unkn

29.Who is your electrical service provider? .......................................

• What is the amperage? ................................................

• Does it have circuit breakers or fuses? .....................................

• Private or public poles? ................................................

• An y known ma t eria l defects? If yes, explain below ............................

Yes

Unkn

30. Ar e ther e any flooding, drai nage or gr a di ng pr oblems that resulted in sta nding wa ter on any

por tion of th e proper ty? If Yes, state l oc ati ons and ex plai n be low ....................

Yes

Unkn

31. Does th e basement have seepage that results in stan ding water? If Yes, explain below ....

Yes

Unkn

Are there any known material defects in any of the following? If Yes, explain below. Use additional

she et s i f n e ce ssa ry ..........................................................

32.Plumbing system?........................................................

Yes

Unkn

33.Security system?.........................................................

Yes

Unkn

34.Carbon monoxide detector? ................................................

Yes

Unkn

Property Condition Disclosure Statement

DOS-1614 (Rev. 8/06) PAGE 5 OF 6

35.Smoke detector? .........................................................

Yes

Unkn

36.Fire sprinkler system? .....................................................

Yes

Unkn

37.Sump pump? ...........................................................

Yes

Unkn

38.Foundation/slab? ........................................................

Yes

Unkn

39. In terior walls/ceilin gs? ....................................................

Yes

Unkn

40.Exterior walls or siding?...................................................

Yes

Unkn

41.Floors? ................................................................

Yes

Unkn

42.Chimney/fireplace or stove? ................................................

Yes

Unkn

43.Patio/deck?.............................................................

Yes

Unkn

44.Driveway? .............................................................

Yes

Unkn

45. Air con dition er ? .........................................................

Yes

Unkn

46.Heating system? .........................................................

Yes

Unkn

47.Hot water heater? ........................................................

Yes

Unkn

48. The pr operty is located in the followin g school district

Unkn

Note: Buyer is encouraged to check public records concerning the property (e.g. tax records and wetland and floodplain

maps).

The seller should use this area to further explain any item above. If necessary, attach additional pages and indicate

here the number of additional pages attached.

Property Condition Disclosure Statement

DOS-1614 (Rev. 8/06) PAGE 6 OF 6

Selle r ’s Ce r tif ic ation:

Seller certifies that the information in this Property Condition Disclosure Statement is true and complete to the seller’s actual

knowledge as of the date signed by the seller. If a seller of residential real property acquires knowledge which renders materially

inaccurate a Property Condition Disclosure Statement provided previously, the seller shall deliver a revised Property Condition

D isc losu re Statement to the b uyer as soon as p rac ti c able. In no event, however, shall a seller be required t o provide a revis ed

Property Condition Disclosure Statement a ft er t he t r a nsfer of title fr om the seller to the buyer or occupancy by the buyer,

whichever is earlier.

Sel le r’s Signature

X Date

Sel le r’s Signature

X Date

Buyer’s Acknowledgment:

Buyer acknowledges receipt of a copy of this statement and buyer understands that this information is a statement of certain

conditions and information concerning the property known to the seller. It is not a warranty of any kind by the seller or seller’s

agent and is not a substitute for any home, pest, radon or other inspections or testing of the property or inspection of the public

records.

Buy er’s Signature

X Date

Buy er’s Signature

X Date