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MINNESOTA DEPARTMENT OF HEALTH <br /> 'Wh Muni»mak Wjhk ®.fat®kb'b.fit.auk.MMM' A 41Z�M--44 air 1 J <br /> WELL DISCLOSURE CERTIFICATE <br /> K&ASE TYn OR PRii/,VT At L INFOR aATION <br /> Penon tiling deed most attach n $20 fee payable to the county recorder. <br /> A. PROPERTY DESCRIPTION <br /> Arach a leWl description of the property if the property does not ha" a lot number, block number, <br /> and addition name. <br /> CTv LOT NUMBERBLOCK-NUMBER ADOITION NAME <br /> iaj <br /> f l �u��e o 1 v3b <br /> CITE NATE ZIP CODE P.I.N.NO.(OPTIONAL) <br /> B_ PROPERTY BUYER MAILING ADDRESS AFTER CLOSING <br /> fiWir NAME MIDDLE INITIAL LAST E <br /> 5 <br /> -7 - <br /> CWPAVY XMIE(IF APPLICABLE) <br /> ABORESs <br /> CITY STATE ZIP CODE TELEPHONE NUMBER <br /> �i��a-z��� ✓'S�- SS 3� t <br /> C- CERTIFICATION BY SELLER <br /> `I <br /> 1 cer*that the information provided on this certificate is accurate and complete to the best of my knowledge. <br /> i <br /> •�� o ��.5�©01 <br /> Signature of Seller or Designated Representative of Seller Date <br /> D. CERTIFICATION BY BUYER r <br /> The buyer or person authorized to act on behalf of the buyer, must sign a Well Disclosure Certificate for all deeds given In fulfillment of a <br /> twb act for deed if there is a well on the property. <br /> In the absem of a seller's signature,the buyer,or person authorized to act on behalf of the buyer may sign this well certificate. <br /> No signature is required by the buyer if the seller has signed above. <br /> Based on disdosure information provided to me by the seller or other available information, I certify that the information on this certificate <br /> its accurate and complete to the best of my knowledge. <br /> V <br /> Signature of Guyer or Designated Representative of Buyer Date <br /> (OVER) <br />