Clean And Green Application Form - Adamss County, Pennsylvania Department Of Agriculture Page 2
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1
2Agricultural Reserve: Noncommercial open space lands used for outdoor recreation or the enjoyment of scenic or natural beauty and
open to the public for such use, without charge or fee, on a nondiscriminatory basis and such land is not less than ten contiguous acres.
Forest Reserve: Land, ten acres or more, stocked by forest trees of any size and capable of producing timber or other wood products.
8.
If you have documentation supporting soil types or timber types, such as a conservation plan or a forestry management
plan, please supply copies of this information with your application. This is not, however, a requirement for submitting
an application.
9.
For any additional land you own which might be eligible for use-value assessment but for which you do not intend to
apply, give acreage.___________________
10.
Has the land represented on this worksheet been actively devoted to agricultural use for the past three years?
Yes_____________
No______________
10A.
If your answer is yes, who is farming this property? _______________________________________________________
(PLEASE LIST NAME AND TELEPHONE NUMBER OF FARMER)
10B.
If this property is being farmed, what agricultural commodities/products are being produced on this farm? ____________
_________________________________________________________________________________________________________________________
11.
Do you or anyone else currently conduct a non-agricultural commercial business on this property?
No________ Yes________ Explain: __________________________________________________________________
12.
IN THE EVENT OF A CHANGE IN OWNERSHIP OF A PORTION OF THE LAND, OR OF ANY TYPE DIVISION OR
CONVEYANCE OF THE LAND, THE APPLICANT HEREBY ACKNOWLEDGES THAT, IF HIS APPLICATION IS
APPROVED FOR PREFERENTIAL ASSESSMENT, ROLL-BACK TAXES UNDER SECTION 5.1 OF THE ACT MAY BE DUE
FOR A CHANGE IN USE OF THE LAND, A CHANGE IN OWNERSHIP OF ANY PORTION OF THE LAND, OR ANY TYPE
OF DIVISION OR CONVEYANCE OF THE LAND.
The applicant for preferential assessment hereby agrees, if his application is approved for preferential assessment, to
submit thirty days notice to the county assessor of a proposed change in use of the land, a split-off portion of the land, or
a conveyance of the land.
The undersigned declares that this application, including all accompanying schedules and statements, has been examined by him/her
and to the best of his/her knowledge and belief is true and correct.
__________________________________ _____________ __________________________________ _____________
Signature of Owner/Corporate Officer
Date
Signature of Owner/Corporate Officer
Date
__________________________________ _____________ __________________________________ _____________
Signature of Owner/Corporate Officer
Date
Signature of Owner/Corporate Officer
Date
*************************************************************************************************
State of ___________________________
ss.
County of _________________________
On this, the ___________ day of _____________________ , _________ , before me, the undersigned officer, personally appeared
___________________________________________________________________________________________________________
Known to me (or satisfactorily proven) to be the person___ whose name____ __________ subscribed to the within instrument, and
acknowledged that ________________ executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
_____________________________________________
My Commission expires________________________________________
*************************************************************************************************
NOTARIZED APPLICATION MUST BE SUBMITTED ON OR BEFORE JUNE 1, WITH A RECORDING AND
PROCESSING FEE OF $68.50 MADE PAYABLE TO:
COUNTY OF ADAMS
C/O TAX SERVICES DEPARTMENT
ADAMS COUNTY COURTHOUSE
117 BALTIMORE STREET ROOM 202
GETTYSBURG, PA 17325
TELEPHONE: 717-337-9837
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