Form Pa-36-A - Discretionary Preservation Easement Application
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3FOR REGISTER OF DEEDS USE ONLY
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
FORM
DISCRETIONARY PRESERVATION EASEMENT APPLICATION
PA-36-A
STEP 1 PROPERTY OWNER (S)
LAST NAME
FIRST NAME
LAST NAME
FIRST NAME
STREET ADDRESS
STREET (continued)
TOWN/CITY
STATE
ZIP CODE
STEP 2 PROPERTY LOCATION OF LAND AND HISTORIC AGRICULTURAL STRUCTURE BEING CLASSIFIED
STREET
TOWN/CITY
COUNTY
NUMBER OF ACRES
MAP #
LOT #
BOOK #
PAGE #
:
CHECK ONE
Original Application
Renewal
Tax Year
STEP 3 REASON FOR DISCRETIONARY PRESERVATION EASEMENT APPLICATION
Describe how the Historic Agricultural Structure meets one of the tests of public benefit per RSA 79-D:3. Submit additional
sheets, if necessary.
How many square feet will be subject to the easement?
STEP 4 SIGNATURES OF ALL PROPERTY OWNERS OF RECORD
TYPE OR PRINT NAME (in black ink)
SIGNATURE (in black ink)
DATE
TYPE OR PRINT NAME (in black ink)
SIGNATURE (in black ink)
DATE
TYPE OR PRINT NAME (in black ink)
SIGNATURE (in black ink)
DATE
TYPE OR PRINT NAME (in black ink)
SIGNATURE (in black ink)
DATE
PA-36-A
Page 1 of 3
Rev. 3/13
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