Form Pa-61 - Inconsistent Use Penalty On Conservation Restriction Land

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FOR REGISTER OF DEEDS USE ONLY
FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
PA-61
INCONSISTENT USE PENALTY ON CONSERVATION RESTRICTION LAND
STEP 1 PROPERTY OWNER (S)
LAST NAME
FIRST NAME
LAST NAME
FIRST NAME
STREET ADDRESS
ADDRESS (continued)
TOWN/CITY
STATE
ZIP CODE
STEP 2 PROPERTY LOCATION
STREET
TOWN/CITY
COUNTY
ACRES IN PARCEL
MAP #
LOT #
BOOK #
PAGE #
OWNER NAME OF RECORD WHEN LAND WAS FIRST GRANTED CONSERVATION RESTRICTION ASSESSMENT
CONSERVATION RESTRICTION RECORDED IN:
CHECK ONE:
PARTIAL RELEASE
FULL RELEASE
BOOK #
PAGE #
STEP 3 ACRES UNDER CONSERVATION RESTRICTION ASSESSMENT
(b) Number of Acres Original Assessment
(c) Number of Acres Previously Disqualified
(d) Acres Disqualified per this Assessment
(e) Number of Acres Remaining in Conservation Restriction
[3(b) minus 3(c) and 3(d)]
STEP 4 ASSESSMENT OF INCONSISTENT USE PENALTY
(a) Narrative description of the disqualification (ex. forest land converted to house lots):
(b) Actual date of change in use (
)
MM/DD/YYYY
(c) Full and True Value at time of inconsistent use
$
(d) Inconsistent Use Penalty
$
PA-61
Page 1 of 3
Rev. 3/13

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