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) SS:

The undersigned ***Sellers Name TE***, hereinafter called “Vendor,” being first duly
sworn, says that Vendor is the owner, in fee simple, of the following described real estate in
***Real Estate County MC*** County, Indiana:

***Real Estate Property Description TE***

Vendor further states that: (i) Vendor has full authority and capacity to convey the above-
described real estate: (ii) Vendor’s predecessors in title have been in actual, open, notorious,
exclusive, adverse, undisputed and continuous possession thereof, and have paid all real estate
taxes levied thereon, for more than ten (10) years; (iii) no person, including tenants in possession
of any part of the above-described real estate, claims any rights adverse to the Vendor; (iv) that
the real estate is located upon, or has access to a public road; (v) that no boundary lines are
disputed by adjoining owners; and (vi) that no improvement thereon encroaches upon adjoining

Vendor further states that the above-described real estate, including the improvements,
crops and fixtures, is not now subject to any unfiled or unrecorded liens, easements, rights-of-
way, conditional sales contracts, financing statements, leases, mechanics or materialmens liens,
or unrecorded mortgages, except: _________________________________________________.

Vendor further states that there is no judgment in any State or Federal Court that is or
may become a lien on said real estate; that Vendor is not now a party to any litigation pending in
any court in the State of Indiana; and that Vendor is not principal or surety on any bond payable
to the State of Indiana.

Vendor intends that each of the statements made herein shall be construed as a
representation. Each of the representations is made for the purpose of inducing to purchase the
above-described real estate; and for the further purpose of inducing ***Mortgagee Name TE***
to extend a mortgage loan upon the security of such real estate; and also to induce ***Title Ins
company TE*** to issue a final policy of owner’s title insurance, insuring the title of in the
amount of the purchase price of such real estate, and a final policy of mortgage title insurance,
insuring the security of such mortgage.

Dated: ____ day of _______________, ______.

***Sellers Name TE***

) SS:
___________________ COUNTY )

Subscribed and sworn to by ***Sellers Name TE*** before me, a Notary Public in and
for said County and State, this ____ day of ____________, _____.
Witness my hand and notarial seal.

Signed: ______________________________________
Printed: ____________________________, Notary Public
Residing in ____________________________ County,
My Commission Expires: ____________________________