OWNERS: The owner must give a completed and signed Disclosure Statement to the buyer no later than the time the buyer makes
an oer to purchase property. If the owner does not, the buyer can, under certain conditions, cancel any resulting contract. An owner
is responsible for completing and delivering the Disclosure Statement to the buyer even if the owner is represented in the sale of the
property by a licensed real estate broker and the broker must disclose any material facts about the property that the broker knows or
reasonably should know, regardless of the owner’s response.
The owner should keep a copy signed by the buyer for their records. If something happens to make the Disclosure Statement incorrect or
inaccurate (for example, the roof begins to leak), the owner must promptly give the buyer an updated Disclosure Statement or correct the
problem. Note that some issues, even if repaired, such as structural issues and re damage, remain material facts and must be disclosed
by a broker even after repairs are made.
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Buyer Initials ________________ Owner Initials ________________
Buyer Initials ________________ Owner Initials ________________
North Carolina law N.C.G.S. 47E requires residential property owners to complete this Disclosure Statement and provide it to the buyer
prior to any oer to purchase. There are limited exemptions for completing the form, such as new home construction that has never
been occupied. Owners are advised to seek legal advice if they believe they are entitled to one of the limited exemptions contained in
N.C.G.S. 47E-2.
An owner is required to provide a response to every question by selecting Yes (Y), No (N), No Representation (NR), or Not Applicable
(NA). An owner is not required to disclose any of the material facts that have a NR option, even if they have knowledge of them.
However, failure to disclose latent (hidden) defects may result in civil liability. The disclosures made in this Disclosure Statement are
those of the owner(s), not the owner’s broker.
◦ If an owner selects Y or N, the owner is only obligated to disclose information about which they have actual knowledge. If an
owner selects Y in response to any question about a problem, the owner must provide a written explanation or attach a report from
an attorney, engineer, contractor, pest control operator, or other expert or public agency describing it.
◦ If an owner selects N, the owner has no actual knowledge of the topic of the question, including any problem. If the owner selects N
and the owner knows there is a problem or that the owner’s answer is not correct, the owner may be liable for making an intentional
misstatement.
◦ If an owner selects NR, it could mean that the owner (1) has knowledge of an issue and chooses not to disclose it; or (2) simply
does not know.
◦ If an owner selects NA, it means the property does not contain a particular item or feature.
REC 4.22
REV 5/24
Property Address/Description:
Owner’s Name(s):
BUYERS: The owner’s responses contained in this Disclosure Statement are not a warranty and should not be a substitute for conducting
a careful and independent evaluation of the property. Buyers are strongly encouraged to:
• Carefully review the entire Disclosure Statement.
• Obtain their own inspections from a licensed home inspector and/or other professional.
DO NOT assume that an answer of N or NR is a guarantee of no defect. If an owner selects N, that means the owner has no actual
knowledge of any defects. It does not mean that a defect does not exist. If an owner selects NR, it could mean the owner (1) has
knowledge of an issue and chooses not to disclose it, or (2) simply does not know.
BROKERS: A licensed real estate broker shall furnish their seller-client with a Disclosure Statement for the seller to complete in
connection with the transaction. A broker shall obtain a completed copy of the Disclosure Statement and provide it to their buyer-client to
review and sign. All brokers shall (1) review the completed Disclosure Statement to ensure the seller responded to all questions, (2) take
reasonable steps to disclose material facts about the property that the broker knows or reasonably should know regardless of the owner’s
responses or representations, and (3) explain to the buyer that this Disclosure Statement does not replace an inspection and encourage
the buyer to protect their interests by having the property fully examined to the buyer’s satisfaction.
• Brokers are NOT permitted to complete this Disclosure Statement on behalf of their seller-clients.
• Brokers who own the property may select NR in this Disclosure Statement but are obligated to disclose material facts they know or
reasonably should know about the property.
For purposes of completing this Disclosure Statement: “Dwelling” means any structure intended for human habitation, “Property”
means any structure intended for human habitation and the tract of land, and “Not Applicable” means the item does not apply to the
property or exist on the property.
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Buyer Initials ________________ Owner Initials ________________
Buyer Initials ________________ Owner Initials ________________
REC 4.22
REV 5/24
A6. Is there a leakage or other problem with the dwelling’s roof or related existing damage?
Yes No NR
A1. Is the property currently owner-occupied?
Date owner acquired the property:
If not owner-occupied, how long has it been since the owner occupied the property?
A9. Is there a problem, malfunction, or defect with the dwelling’s:
Explanations for questions in Section A (identify the specic question for each explanation):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
NA Yes No NR NA Yes No NR NA Yes No NR
Foundation Windows Attached Garage
Slab Doors Fireplace/Chimney
Patio Ceilings Interior/Exterior Walls
Floors Deck Other:
Yes No NR
B1. Is there a problem, malfunction, or defect with the dwelling’s electrical system (outlets, wiring,
panels, switches, xtures, generator, etc.)?
A3. Have there been any structural additions or other structural or mechanical changes to the
dwelling(s)?
A4. The dwelling’s exterior walls are made of what type of material? (Check all that apply)
A7. Is there water seepage, leakage, dampness, or standing water in the dwelling’s basement, crawl
space, or slab?
A8. Is there an infestation present in the dwelling or damage from past infestations of wood
destroying insects or organisms that has not been repaired?
B2. Is there a problem, malfunction, or defect with the dwelling’s heating and/or air conditioning?
B3. What is the dwelling’s heat source? (Check all that apply; indicate the year of each system
manufacture)
A5. In what year was the dwelling’s roof covering installed?
A2. In what year was the dwelling constructed?
Brick Veneer Vinyl Stone Fiber Cement Synthetic Stucco Composition/Hardboard
Concrete Aluminum Wood Asbestos Other:
Furnace [ # of units] Year: Heat Pump [ # of units] Year:
Baseboard [ # of bedrooms with units] Year: Other: Year:
SECTION A.
STRUCTURE/FLOORS/WALLS/CEILING/WINDOW/ROOF
SECTION B.
HVAC/ELECTRICAL
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Buyer Initials ________________ Owner Initials ________________
Buyer Initials ________________ Owner Initials ________________
REC 4.22
REV 5/24
B4. What is the dwelling’s cooling source? (Check all that apply; indicate the year of each system
manufacture)
Explanations for questions in Section B (identify the specic question for each explanation):
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
B5. What is the dwelling’s fuel source? (Check all that apply)
Electricity Natural Gas Solar Propane Oil Other:
C5. Is there a problem, malfunction, or defect with the dwelling’s:
C4. What is the dwelling’s sewage disposal system? (Check all that apply)
Straight pipe (wastewater does not go into a septic or other sewer system) *Note: Use of this type of
system violates State Law.
C2. The dwelling’s water pipes are made of what type of material? (Check all that apply)
C3. What is the dwelling’s water heater fuel source? (Check all that apply; indicate the year of each
system manufacture)
Yes No NR
C1. What is the dwelling’s water supply source? (Check all that apply)
If the dwelling’s water supply source is supplied by a private well, identify whether the private well
has been tested for: (Check all that apply).
City/County Shared well Community System Private well Other:
Quality Pressure Quantity
Septic tank with pump Community system Septic tank Drip system
Connected to City/County System City/County system available Other:
NA Ye s No NR NA Ye s No NR
Septic system Plumbing system (pipes, xtures, water heater, etc.)
Sewer system Water supply (water quality, quantity, or pressure)
Explanations for questions in Section C (identify the specic question for each explanation):
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Copper Galvanized Plastic Polybutylene Other:
Gas: Electric: Solar: Other:
If the dwelling is serviced by a septic system, how many bedrooms are allowed by the septic system
permit? No Records Available
Date the septic system was last pumped:
If the dwelling’s water source is supplied by a private well, what was the date of the last water
quality/quantity test?
SECTION C.
PLUMBING/WATER SUPPLY/SEWER/SEPTIC
Yes No NR
Central Forced Air: Year: Wall/Windows Unit(s): Year:
Other: Year:
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Buyer Initials ________________ Owner Initials ________________
Buyer Initials ________________ Owner Initials ________________
REC 4.22
REV 5/24
Yes No NR
E1. Is there a problem, malfunction, or defect with the drainage, grading, or soil stability of the
property?
E2. Is the property in violation of any local zoning ordinances, restrictive covenants, or local
land-use restrictions (including setback requirements?)
E3. Is the property in violation of any building codes (including the failure to obtain required
permits for room additions or other changes/improvements)?
E4. Is the property subject to any utility or other easements, shared driveways, party walls,
encroachments from or on adjacent property, or other land use restrictions?
E5. Does the property abut or adjoin any private road(s) or street(s)?
Explanations for questions in Section E (identify the specic question for each explanation):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Yes No NR
F1. Is there hazardous or toxic substance, material, or product (such as asbestos, formaldehyde,
radon gas, methane gas, lead-based paint) that exceed government safety standards located on or
which otherwise aect the property?
E6. If there is a private road or street adjoining the property, are there any owners’ association or
maintenance agreements dealing with the maintenance of the road or street?
NA
SECTION F.
ENVIRONMENTAL/FLOODING
SECTION E.
LAND/ZONING
Explanations for questions in Section D (identify the specic question for each explanation):
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
NA Yes No NR NA Yes No NR NA Yes No NR NA Yes No NR
Attic fan, exhaust
fan, ceiling fan
Irrigation
system
Sump
pump
Garage door
system
Elevator system
or component
Pool/hot tub
/spa
Gas
logs
Security
system
Appliances to be
conveyed
TV cable wiring
or satellite dish
Central
vacuum
Other:
_ _ _ _ _ _ _ _ _
D2. Is there a problem, malfunction, or defect with the dwelling’s:
Yes No NR
D1. Is the dwelling equipped with an elevator system?
If yes, when was it last inspected?
SECTION D.
FIXTURES/APPLIANCES
Date of last maintenance service:
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Buyer Initials ________________ Owner Initials ________________
Buyer Initials ________________ Owner Initials ________________
REC 4.22
REV 5/24
F3. Is there debris (whether buried or covered), an underground storage tank, or an environmentally
hazardous condition (such as contaminated soil or water or other environmental contamination)
located on or which otherwise aect the property?
F4. Is there any noise, odor, smoke, etc., from commercial, industrial, or military sources that
aects the property?
F5. Is the property located in a federal or other designated ood hazard zone?
F6. Has the property experienced damage due to ooding, water seepage, or pooled water
attributable to a natural event such as heavy rainfall, coastal storm surge, tidal inundation, or river
overow?
F7. Have you ever led a claim for ood damage to the property with any insurance provider,
including the National Flood Insurance Program?
F8. Is there a current ood insurance policy covering the property?
F9. Have you received assistance from FEMA, U.S. Small Business Administration, or any other
federal disaster ood assistance for ood damage to the property?
F10. Is there a ood or FEMA elevation certicate for the property?
NOTE: An existing ood insurance policy may be assignable to a buyer at a lesser premium than a new policy. For properties that
have received disaster assistance, the requirement to obtain ood insurance passes down to all future owners. Failure to obtain ood
insurance can result in an owner being ineligible for future assistance.
Explanations for questions in Section F (identify the specic question for each explanation):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
F2. Is there an environmental monitoring or mitigation device or system located on the property?
Yes No NR
G1. Is the property subject to any lawsuits, foreclosures, bankruptcy, judgments, tax liens, proposed
assessments, mechanics’ liens, materialmens’ liens, or notices from any governmental agency that
could aect title to the property?
Explanations for question in Section G (identify the specic question for each explanation):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
SECTION G.
MISCELLANEOUS
G2. Is the property subject to a lease or rental agreement?
G3. Is the property subject to covenants, conditions, or restrictions or to governing documents
separate from an owners’ association that impose various mandatory covenants, conditions, and or
restrictions upon the lot or unit?
Yes No NR
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REC 4.22
REV 5/24
Owner(s) acknowledge(s) having reviewed this Disclosure Statement before signing and that all information is true and
correct to the best of their knowledge as of the date signed.
Owner Signature: Date
Owner Signature: Date
Buyers(s) acknowledge(s) receipt of a copy of this Disclosure Statement and that they have reviewed it before signing.
Buyer Signature: Date
Buyer Signature: Date
Yes No NR
a. (specify name) whose regular assessments (“dues”) are
$ per .
The name, address, telephone number, and website of the president of the owners’ association or the
association manager are:
b. (specify name) whose regular assessments (“dues”) are
$ per _____________________ .
The name, address, telephone number, and website of the president of the owners’ association or the
association manager are:
c. Are there any changes to dues, fees, or special assessment which have been duly approved and to
which the lot is subject?
If “yes,” state the nature and amount of the dues, fees, or special assessments to which the property
is subject:
Explanations for questions in Section H (identify the specic question for each explanation):
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
If you answer ‘Yes’ to question H1, you must complete the remaining questions in Section H. If you answered ‘No’ or ‘No
Representation’ to question H1, you do not need to answer the remaining questions in Section H.
H1. Is the property subject to regulation by one or more owners’ association(s) including, but not
limited to, obligations to pay regular assessments or dues and special assessments?
If “yes,” please provide the information requested below as to each owners’ association to which
the property is subject [insert N/A into any blank that does not apply]:
H2. Is there any fee charged by the association or by the association’s management company in
connection with the conveyance or transfer of the lot or property to a new owner?
If “yes,” state the amount of the fees:
H3. Is there any unsatised judgment against, pending lawsuit, or existing or alleged violation of the
association’s governing documents involving the property?
If “yes,” state the nature of each pending lawsuit, unsatised judgment, or existing or alleged
violation:
H4. Is there any unsatised judgment or pending lawsuits against the association?
If “yes,” state the nature of each unsatised judgment or pending lawsuit:
SECTION H.
OWNERS’ ASSOCIATION DISCLOSURE
