Fillable Form 250 - Act 250 Disclosure Statement 2008 (Page 2 of 2) in pdf

Form 250 - Act 250 Disclosure Statement 2008 Page 2

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8. Will any family member listed in #6 above derive any profit or consideration, or acquire any other beneficial interest from the

partition or division of the land subject to this statement? (Read instructions before answering.)

YES

IF “YES,” LIST THE FAMILY MEMBER BELOW.

NAME OF FAMILY MEMBER

RELATIONSHIP TO SUBDIVIDER

9. List below in the space provided the name of all individuals and entities affiliated with the subdivider(s) in the partition or

division of the subject land, as that affiliation is conditioned and limited according to the definition of “person” in 10 V.S.A.

§6001(14).

NAME

NATURE OF AFFILIATION

10. List below any partition or division of land by any individuals or entities now or previously affiliated with the Subdivider(s)

for benefit or profit which has occurred within the preceding five years (including this transaction) and which is located

within five miles of the land being divided or partitioned, within the jurisdictional area of the District Environmental Commis-

sion (see attached District Map), or within the same town.

NAME

LOCATION (TOWN)

DESCRIPTION OF LAND

NO. OF LOTS

DATE CREATED

11. NOTICE THAT AN ACT 250 PERMIT MAY BE REQUIRED

As the Subdivider(s) of this property, I/we hereby notify the buyer that an Act 250 permit may be required prior to this

partition or division of the property.

Prior to the partition or division of the land in question, the buyer may submit to the District Coordinator this Disclosure

Statement and other relevant information and should request a jurisdictional opinion from the District Coordinator as to the

applicability of Act 250 to this proposed partition or division of land.

12. If an Act 250 permit has been issued for the land being partitioned, enter the Land Use Permit Number.

I/we the Subdivider(s) hereby swear and affirm that this Disclosure Statement is true and complete to the best of my/our

knowledge. Knowing falsification of any statement contained herein is punishable pursuant to the provisions of 10 V.S.A.

§6003; 10 V.S.A. Chapters 201 and 211; and 13 V.S.A. §3016.

DATE: _____________________________________

__________________________________________

Signature(s) of Subdivider(s)

Form 250 - Act 250 Disclosure Statement 2008 Page 2

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