Form 250 - Act 250 Disclosure Statement 2008
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2ACT 250 DISCLOSURE STATEMENT
VERMONT NATURAL RESOURCES BOARD
MONTPELIER, VERMONT 05602
NOTE: IF THIS TRANSACTION DOES NOT INVOLVE THE PARTITION OR DIVISION OF LAND, THIS ACT 250 DISCLOSURE STATE-
MENT IS NOT REQUIRED. REFER TO 10 V.S.A. §6001(14)(a) and (b).
1. SUBDIVIDER’S (TRANSFEROR) FULL NAME(S)
MAILING ADDRESS
NAME OF CONTACT PERSON FOR SUBDIVIDER
MAILING ADDRESS
TELEPHONE NO.
2. BUYER’S (TRANSFEREE) FULL NAME(S)
MAILING ADDRESS
3. DESCRIPTION OF PROPERTY
TOWN
ROAD
NUMBER OF ACRES
4. State the total number of lots or parcels the Subdivider intends to create as part of this partition or division of land.
NUMBER OF LOTS
5. Has the Subdivider divided or partitioned any other land within the past five years which is located within the same town or
district or is located within five miles (if in a different district)?
See map on page 34.
Lots within the same town?
NO
YES
NUMBER OF LOTS ___________
Lots within the same district?
NO
YES
NUMBER OF LOTS ___________
Lots within five miles?
NO
YES
NUMBER OF LOTS ___________
6. Have the Subdivider’s parents or children (natural or adoptive) or spouse divided or partitioned any other land within the
past five years which is located within the same town or district or is located within five miles (if in a different district) of the
land being partitioned?
NO
YES IF “YES,” COMPLETE THE FOLLOWING ABOUT THE FAMILY MEMBER
NAME
ADDRESS
RELATIONSHIP
7. Did the Subdivider profit or derive any consideration or financial benefit from the partition or division of the land of that
family member as listed in #6 above.
NO
YES IF “YES,” COMPLETE THE FOLLOWING ABOUT THE FAMILY MEMBER
NAME
ADDRESS
RELATIONSHIP
FORM 250
(Rev. 11/08)
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