Form Pa-36-A - Discretionary Preservation Easement Application Page 2
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NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
PA-36-A
DISCRETIONARY PRESERVATION EASEMENT APPLICATION
(CONTINUED)
STEP 5 TO BE COMPLETED BY THE LOCAL ASSESSORS
APPROVED
Pending approval of Discretionary Preservation Easement Agreement by
landowner and assessing officials.
DENIED
Comments:
STEP 6 APPROVAL OF A MAJORITY OF SELECTMEN/ASSESSORS
TYPE OR PRINT NAME (ink black ink)
SIGNATURE (in black ink)
DATE
TYPE OR PRINT NAME (ink black ink)
SIGNATURE (in black ink)
DATE
TYPE OR PRINT NAME (ink black ink)
SIGNATURE (in black ink)
DATE
TYPE OR PRINT NAME (ink black ink)
SIGNATURE (in black ink)
DATE
TYPE OR PRINT NAME (ink black ink)
SIGNATURE (in black ink)
DATE
STEP 7 DOCUMENTATION
Is a map of the entire parcel showing the property location, orientation, overall
Yes
No
boundaries and acreages clearly showing easement area requested submitted?
PA-36-A
Page 2 of 3
Rev. 3/13
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