AB391,2,2323 1. .... .... .... I am aware of defects in the roof.
AB391,2,2524 2. .... .... .... I am aware of defects in the electrical
25 system.
AB391,3,4
13. .... .... .... I am aware of defects in part of the
2 plumbing system (including the water
3 heater, water softener and swimming
4 pool) that is included in the sale.
AB391,3,85 4. .... .... .... I am aware of defects in the heating
6 and air conditioning system
7 (including the air filters
8 and humidifiers).
AB391,3,109 5. .... .... .... I am aware of defects in the well,
10 including unsafe well water.
AB391,3,1211 6. .... .... .... I am aware that this property is served
12 by a joint well.
AB391,3,1513 7. .... .... .... I am aware of defects in the septic
14 system or other sanitary disposal
15 system.
AB391,3,2216 8. .... .... .... I am aware of underground fuel storage
17 tanks on the property. (If correct,
18 the owner, by law, must report the
19 location to the department of
20 industry, labor and human relations
21 at P.O. Box 7969, Madison,
22 Wisconsin, 53707.)
AB391,4,323 9. .... .... .... I am aware of an "LP" tank on the
24 property. (If correct, specify
25 in the additional information

1 space whether or not the owner
2 of the property either owns or
3 leases the tank.)
AB391,4,64 10. .... .... .... I am aware of defects in the basement
5 or foundation (including cracks,
6 seepage and bulges).
AB391,4,97 11. .... .... .... I am aware that the property is located
8 in a floodplain, wetland or
9 shoreland zoning area.
AB391,4,1110 12. .... .... .... I am aware of defects in the structure
11 of the property.
AB391,4,1512 13. .... .... .... I am aware of defects in mechanical
13 equipment included in the sale
14 either as fixtures or personal
15 property.
AB391,4,1916 14. .... .... .... I am aware of boundary or lot line
17 disputes, encroachments or
18 encumbrances (including a joint
19 driveway).
AB391,5,320 15. .... .... .... I am aware of a defect caused by
21 unsafe concentrations of, or
22 unsafe conditions relating to,
23 radon, radium in water supplies,
24 lead in paint, lead in soil, lead
25 in water supplies or plumbing

1 system or other potentially
2 hazardous or toxic substances
3 on the premises.
AB391,5,64 16. .... .... .... I am aware of the presence of asbestos
5 or asbestos-containing materials
6 on the premises.
AB391,5,117 17. .... .... .... I am aware of a defect caused by unsafe
8 concentrations of, unsafe conditions
9 relating to, or the storage of
10 hazardous or toxic substances on,
11 neighboring properties.
AB391,5,15 1218. .... .... .... I am aware that a structure on the
13property is designated as a historic
14building or that a part of the
15property is in a historic district.
AB391,5,1816 19. .... .... .... I am aware of current or previous
17 termite, powder-post beetle or
18 carpenter ant infestations.
AB391,5,2019 20. .... .... .... I am aware of defects in a
20 woodburning stove or fireplace.
AB391,6,221 21. .... .... .... I am aware either that remodeling
22 affecting the property's structure
23 or mechanical systems was done or
24 that additions to this property
25 were made during my period of

1 ownership without the required
2 permits.
AB391,6,63 22. .... .... .... I am aware of federal, state or
4 local regulations requiring repairs,
5 alterations or corrections of an
6 existing condition.
AB391,6,97 23. .... .... .... I have received notice of property
8 tax increases, other than normal
9 annual increases.
AB391,6,1210 24. .... .... .... I am aware that remodeling that may
11 increase the property's assessed
12 value was done.
AB391,6,1413 25. .... .... .... I am aware of proposed or pending
14 special assessments.
AB391,6,1815 26. .... .... .... I am aware of the proposed
16 construction of a public project
17 that may affect the use of the
18 property.
AB391,7,219 27. .... .... .... I am aware of subdivision homeowners'
20 associations, common areas coowned
21 with others, zoning violations
22 or nonconforming uses,
23 rights-of-way, easements or another
24 use of a part of the property by

1 nonowners, other than recorded
2 utility easements.
AB391,7,43 28. .... .... .... I am aware of other defects affecting
4 the property.
AB391,7,5 5additional information ....
AB391,7,86 .... (yes) .... (no) .... (not applicable) I am aware that a structure on the property
7is designated as a historic building or that a part of the property is in a historic
8district.
AB391,7,99 The owner has lived on the property for.... years.
AB391,7,10 10ADDITIONAL INFORMATION ....
AB391,7,1211 The owner certifies that the information in this report is true and correct to the
12best of the owner's knowledge as of the date on which the owner signs this report.
AB391,7,1413 Owner .... Date....
14 Owner .... Date ....
AB391,7,1815 A person other than the owner certifies that he or she has supplied information
16on which the owner relied for this report and that that information is true and correct
17to the best of that person's knowledge as of the date on which the person signs this
18report.
AB391,7,2119 Person .... Items .... Date ....
20 Person .... Items .... Date ....
21 Person .... Items .... Date ....
AB391,8,522 THE PROSPECTIVE BUYER AND THE OWNER MAY WISH TO OBTAIN
23PROFESSIONAL ADVICE OR INSPECTIONS OF THE PROPERTY AND TO
24PROVIDE FOR APPROPRIATE PROVISIONS IN A CONTRACT BETWEEN
25THEM WITH RESPECT TO ANY ADVICE, INSPECTIONS, DEFECTS OR

1WARRANTIES. THE PROSPECTIVE BUYER ACKNOWLEDGES THAT
2TECHNICAL KNOWLEDGE SUCH AS THAT ACQUIRED BY PROFESSIONAL
3INSPECTORS MAY BE REQUIRED TO DETECT CERTAIN DEFECTS SUCH AS
4THE PRESENCE OF ASBESTOS, BUILDING CODE VIOLATIONS AND
5FLOODPLAIN STATUS.
AB391,8,66 I ACKNOWLEDGE RECEIPT OF A COPY OF THIS STATEMENT
AB391,8,97 Prospective buyer .... Date ....
8 Prospective buyer .... Date ....
9 Prospective buyer .... Date ....
AB391,8,1010 (End)
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