Property Owner Name *
Phone Number *
Date of Home Inspection *
Date of Walk-through
Date of Closing *
Date of Move-in *
Seller’s Name (Previous Owner) *
Seller’s Phone Number
Sellers Current Address
List Price of Property *
Sale Price of Property *
Home Warranty Purchased? * -YesNo
Home Warranty Company
Insurance Company *
Homeowner Policy # *
Effective Date of Policy *
1. Detailed Description of Incident/Condition *
2. Was condition observable at time of inspection? * -YesNo
3. Date you first became aware of the condition? *
4. Did you learn of this condition prior to closing? * -YesNo
If yes, How?
5. Did Seller provide a Disclosure Form? * -YesNo
If yes, was this condition identified? * -YesNo
6. Did you conduct a final or pre-closing walk-through inspection? * -YesNo
If no, why not?
7. Did you notice the condition yourself? * -YesNo
If no, who first made you aware it?
8. Was any action taken on this condition prior to closing? * -YesNo
Was any action taken after closing? * -YesNo
If yes to either part of question 8, explain
9. Did other service providers/contractors perform any other inspections/services/repairs as part of the purchase process? * -YesNo
If yes, explain
10. Did you negotiate with Sellers based on any findings of the Home inspection? * -YesNo
If yes, how much did you negotiate for and over what issues?
11. Provide contact information for any contractors, servicepersons or other individuals that have identified, inspected or done work related to the conditions/concerns reported above?
12. Did you obtain an estimate to correct the condition? * -YesNo
If yes, What was the date and the amount of estimate? has any work been done? If work has been done please explain
Is the information in this form true to the best of your knowledge? * -YesNo
Your signature (name) *
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