(765 ILCS 77/35)
    Sec. 35. Disclosure report form. The disclosures required of a seller by this Act shall be made in the following form:
RESIDENTIAL REAL PROPERTY DISCLOSURE REPORT
    NOTICE: THE PURPOSE OF THIS REPORT IS TO PROVIDE PROSPECTIVE BUYERS WITH INFORMATION ABOUT MATERIAL DEFECTS IN THE RESIDENTIAL REAL PROPERTY. THIS REPORT DOES NOT LIMIT THE PARTIES' RIGHT TO CONTRACT FOR THE SALE OF RESIDENTIAL REAL PROPERTY IN "AS IS" CONDITION. UNDER COMMON LAW, SELLERS WHO DISCLOSE MATERIAL DEFECTS MAY BE UNDER A CONTINUING OBLIGATION TO ADVISE THE PROSPECTIVE BUYERS ABOUT THE CONDITION OF THE RESIDENTIAL REAL PROPERTY EVEN AFTER THE REPORT IS DELIVERED TO THE PROSPECTIVE BUYER. COMPLETION OF THIS REPORT BY THE SELLER CREATES LEGAL OBLIGATIONS ON THE SELLER; THEREFORE THE SELLER MAY WISH TO CONSULT AN ATTORNEY PRIOR TO COMPLETION OF THIS REPORT.
Property Address: ............................................
City, State & Zip Code: ......................................
Seller's Name: ...............................................
    This Report is a disclosure of certain conditions of the residential real property listed above in compliance with the Residential Real Property Disclosure Act. This information is provided as of ...(month) ...(day) ...(year), and does not reflect any changes made or occurring after that date or information that becomes known to the seller after that date. The disclosures herein shall not be deemed warranties of any kind by the seller or any person representing any party in this transaction.
    In this form, "am aware" means to have actual notice or actual knowledge without any specific investigation or inquiry. In this form, "material defect" means a condition that would have a substantial adverse effect on the value of the residential real property or that would significantly impair the health or safety of future occupants of the residential real property unless the seller reasonably believes that the condition has been corrected.
    The seller discloses the following information with the knowledge that even though the statements herein are not deemed to be warranties, prospective buyers may choose to rely on this information in deciding whether or not and on what terms to purchase the residential real property.
    The seller represents that to the best of his or her actual knowledge, the following statements have been accurately noted as "yes" (correct), "no" (incorrect), or "not applicable" to the property being sold. If the seller indicates that the response to any statement, except number 1, is yes or not applicable, the seller shall provide an explanation, in the additional information area of this form.

YESNON/A
1................Seller has occupied the property

within the last 12 months.

(No explanation is needed.)
2................I am aware of flooding or recurring

leakage problems in the crawl

space or basement.
3................I am aware that the property is

located in a flood plain or that I

currently have flood hazard

insurance on the property.
4................I am aware of material defects in

the basement or foundation

(including cracks and bulges).
5................I am aware of leaks or material

defects in the roof, ceilings, or

chimney.
6................I am aware of material defects in

the walls, windows, doors, or floors.
7................I am aware of material defects in

the electrical system.
8................I am aware of material defects in

the plumbing system (includes

such things as water heater, sump

pump, water treatment system,

sprinkler system, and swimming

pool).
9................I am aware of material defects in

the well or well equipment.
10................I am aware of unsafe conditions in

the drinking water.
11................I am aware of material defects in

the heating, air conditioning, or

ventilating systems.
12................I am aware of material defects in

the fireplace or woodburning

stove.
13................I am aware of material defects in

the septic, sanitary sewer, or

other disposal system.
14................I am aware of unsafe concentrations

of radon on the premises.
15................I am aware of unsafe concentrations

of or unsafe conditions relating

to asbestos on the premises.
16................I am aware of unsafe concentrations

of or unsafe conditions relating

to lead paint, lead water pipes,

lead plumbing pipes or lead in

the soil on the premises.
17................I am aware of mine subsidence,

underground pits, settlement,

sliding, upheaval, or other earth

stability defects on the

premises.
18................I am aware of current infestations

of termites or other wood boring

insects.
19................I am aware of a structural defect

caused by previous infestations

of termites or other wood boring

insects.
20................I am aware of underground fuel

storage tanks on the property.
21................I am aware of boundary or lot line

disputes.
22................I have received notice of violation

of local, state or federal laws

or regulations relating to this

property, which violation has not

been corrected.
23................I am aware that this property has

been used for the manufacture

of methamphetamine as

defined in Section 10 of

the Methamphetamine Control

and Community Protection Act.
    Note: These disclosures are not intended to cover the common elements of a condominium, but only the actual residential real property including limited common elements allocated to the exclusive use thereof that form an integral part of the condominium unit.
    Note: These disclosures are intended to reflect the current condition of the premises and do not include previous problems, if any, that the seller reasonably believes have been corrected.
    If any of the above are marked "not applicable" or "yes", please explain here or use additional pages, if necessary:
..............................................................
..............................................................
..............................................................
    Check here if additional pages used: .....
    Seller certifies that seller has prepared this statement and certifies that the information provided is based on the actual notice or actual knowledge of the seller without any specific investigation or inquiry on the part of the seller. The seller hereby authorizes any person representing any principal in this transaction to provide a copy of this report, and to disclose any information in the report, to any person in connection with any actual or anticipated sale of the property.
Seller: ............................... Date: ................
Seller: ............................... Date: ................
    THE PROSPECTIVE BUYER IS AWARE THAT THE PARTIES MAY CHOOSE TO NEGOTIATE AN AGREEMENT FOR THE SALE OF THE PROPERTY SUBJECT TO ANY OR ALL MATERIAL DEFECTS DISCLOSED IN THIS REPORT ("AS IS"). THIS DISCLOSURE IS NOT A SUBSTITUTE FOR ANY INSPECTIONS OR WARRANTIES THAT THE PROSPECTIVE BUYER OR SELLER MAY WISH TO OBTAIN OR NEGOTIATE. THE FACT THAT THE SELLER IS NOT AWARE OF A PARTICULAR CONDITION OR PROBLEM IS NO GUARANTEE THAT IT DOES NOT EXIST. THE PROSPECTIVE BUYER IS AWARE THAT HE MAY REQUEST AN INSPECTION OF THE PREMISES PERFORMED BY A QUALIFIED PROFESSIONAL.
Prospective Buyer: .................. Date: ...... Time: ....
Prospective Buyer: .................. Date: ...... Time: ....
(Source: P.A. 98-754, eff. 1-1-15.)