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DOS-1614 (Rev. 8/06) PAGE 1 OF 6 NYS Department of State Division of Licensing Services P.O. Box 22001 Albany, NY 12201-2001 (518) 474-4429 www.dos.state.ny.us Property Condition Disclosure Statement
Name of Seller or Sellers: Property Address: General Instructions: The Property Condition Disclosure Act requires the seller of residential real property to cause this disclosure statement or a copy thereof to be delivered to a buyer or buyer’s agent prior to the signing by the buyer of a binding contract of sale. Purpose of Statement: 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 environmental tests and also is encouraged to check public records pertaining to the property. A knowingly false or incomplete statement by the seller on this form may subject the seller to claims by the buyer 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 Disclosure 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 against the agreed upon purchase price of the residential real property. “Residential real property” means real property improved by a one to four family dwelling used or occupied, or intended to be used or occupied, wholly or partly, as the home or residence of one or more persons, but shall not refer to (a) unimproved real property upon which such dwellings are to be constructed or (b) condominium units or cooperative apartments or (c) property on a homeowners’ association that is not owned in fee simple by the seller. Instructions to the Seller: a. Answer all questions based upon your actual knowledge. b. Attach additional pages with your signature if additional space is required. 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). Seller’s Statement: The seller makes the following representations to the buyer based upon the seller’s actual knowledge at the time of signing this document. The seller authorizes his or her agent, if any, to provide a copy of this statement to a prospective buyer of the residential real property. The following are representations made by the seller and are not the representations of the seller’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 presence of lead based paint. ”Yes ”No ”Unkn ”NA 5. Does anybody else claim to own any part of your property? If Yes, explain below . . . . . . . . ”Yes ”No ”Unkn ”NA Property Condition Disclosure Statement DOS-1614 (Rev. 8/06) PAGE 2 OF 6 6. Has anyone denied you access to the property or made a formal legal claim challenging your title to the property? If Yes, explain below . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ”Yes ”No ”Unkn ”NA 7. Are there any features of the property shared in common with adjoining landowners or a homeowner’s association, such as walls, fences or driveways? If Yes, describe below . . . . . ”Yes ”No ”Unkn ”NA 8. Are there any electric or gas utility surcharges for line extensions, special assessments or homeowner or other association fees that apply to the property? If Yes, explain below . . . . . ”Yes ”No ”Unkn ”NA 9. Are there certificates of occupancy related to the property? If No, explain below . . . . . . . . . ”Yes ”No ”Unkn ”NA ENVIRONMENTAL Note to Seller: 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 released 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 paint thinner, varnish remover and wood preservatives, treated wood, construction materials such as asphalt and roofing materials, antifreeze and other automotive products, batteries, cleaning solvents including septic tank cleaners, household cleaners and pool chemicals and products containing mercury and lead. Note to Buyer: If contamination of this property from petroleum products and/or hazardous or toxic substances is a concern to you, you are urged to consider soil and groundwater testing of this property. 10. Is any or all of the property located in a designated floodplain? If Yes, explain below . . . . . ”Yes ”No ”Unkn ”NA 11. Is any or all of the property located in a designated wetland? If Yes, explain below . . . . . . ”Yes ”No ”Unkn ”NA 12. Is the property located in an agricultural district? If Yes, explain below . . . . . . . . . . . . . . . ”Yes ”No ”Unkn ”NA 13. Was the property ever the site of a landfill? If Yes, explain below . . . . . . . . . . . . . . . . . . . ”Yes ”No ”Unkn ”NA 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 leaking or have they ever leaked? If Yes, explain below . . . . . . . . . . . . . . . . . ” Yes ” Yes ” Yes ” No ” No ” No ” Unkn ” Unkn ” Unkn ” NA ” NA ” NA 15. Is there asbestos in the structure? If Yes, state location or locations below . . . . . . . . . . . . . ”Yes ”No ”Unkn ”NA 16. Is lead plumbing present? If Yes, state location or locations below . . . . . . . . . . . . . . . . . . ”Yes ”No ”Unkn ”NA 17. Has a radon test been done? If Yes, attach a copy of the report . . . . . . . . . . . . . . . . . . . . . ”Yes ”No ”Unkn ”NA 18. Has motor fuel, motor oil, home heating fuel, lubricating oil or any other petroleum product, methane gas, or any hazardous or toxic substance spilled, leaked or otherwise been released on the property or from the property onto any other property? If Yes, describe below . . . . . ”Yes ”No ”Unkn ”NA 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? If Yes, attach report(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ”Yes ”No ”Unkn ”NA STRUCTURAL 20. Is there any rot or water damage to the structure or structures? If Yes, explain below . . . . . ”Yes ”No ”Unkn ”NA 21. Is there any fire or smoke damage to the structure or structures? If Yes, explain below . . . . ”Yes ”No ”Unkn ”NA 22. Is there any termite, insect, rodent or pest infestation or damage? If Yes, explain below . . . ”Yes ”No ”Unkn ”NA 23. Has the property been tested for termite, insect, rodent or pest infestation or damage? . . . . If Yes, please attach report(s) ” Yes ”No ”Unkn ”NA 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 • Is there a transferable warrantee on the roof in effect now? If Yes, explain below . . . . . ”Yes ”No ”Unkn ”NA 25. Are there any know material defects in any of the following structural systems: footings, beams, girders, lintels, columns or partitions? If Yes, explain below . . . . . . . . . . . . . . . . . . ”Yes ”No ”Unkn ”NA MECHANICAL SYSTEMS AND SERVICES 26. What is the water source? (Circle all that apply) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . well, private, municipal,
other: • If municipal, is it metered? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ”Yes ”No ”Unkn ”NA 27. Has the water quality and/or flow rate been tested? If Yes, describe below . . . . . . . . ”Yes ”No ”Unkn ”NA 28. What is the type of sewage system? (Circle all that apply) . . . . . . . . . . . . . . . . . . . . . . . . . public sewer, private sewer,
septic, cesspool • If septic or cesspool, age? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Date last pumped? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Frequency of pumping? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Any known material defects? If Yes, explain below . . . . . . . . . . . . . . . . . . . . . . . . . . . ”Yes ”No ”Unkn ”NA 29.Who is your electrical service provider? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • What is the amperage? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Does it have circuit breakers or fuses? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Private or public poles? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Any known material defects? If yes, explain below . . . . . . . . . . . . . . . . . . . . . . . . . . . . ”Yes ”No ”Unkn ”NA 30. Are there any flooding, drainage or grading problems that resulted in standing water on any portion of the property? If Yes, state locations and explain below . . . . . . . . . . . . . . . . . . . . ”Yes ”No ”Unkn ”NA 31. Does the basement have seepage that results in standing water? If Yes, explain below . . . . ”Yes ”No ”Unkn ”NA Are there any known material defects in any of the following? If Yes, explain below. Use additional
sheets if necessary 32. Plumbing system? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ”Yes ”N
