Form Lpc-1 - Application For A Land Preservation Credit Page 3

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Form LPC-1

*VALPC1313888*

Application for a Land Preservation Credit

Page 3

Section V - Fee Simple Donation

Check Applicable Boxes

A) The donation is a full or partial gift in fee simple to a public or private conservation agency. (If the application

is for $1 million or more, also complete Schedule C.)

Conservation Agency Name: __________________________________________________

B) The donation is a full or partial gift to a “holder” as defined in Va. Code § 10.1-1009, and documentation is

included that the agency agrees that subsequent conveyances of the fee interest in the property will be made subject

to a conservation easement or will be made to the Commonwealth of Virginia or a federal conservation agency.

Conservation Agency Name: __________________________________________________

Section VI - Less-Than-Fee Simple Donation

Explain how this donation meets the requirements of § 170(h) of the United States Internal Revenue Code of 1986, as amended.

Attach additional pages if needed.

Section VII - Declaration, Signature and Notarization

Attachment Checklist

DCR - All Donations (2007 & After)

TAX - All Donations

A Copy of LPC Application Original LPC Application

IRS Form 8283 Recorded Deed

Recorded Deed A Copy or CD of Full Appraisal

(2007 & After)

IRS Form 8283

DCR - Donations of $1 Million or More

Baseline Documentation Signed Statement or Affidavit from Appraiser

I (we) the undersigned declare, under the penalties provided by law, that this form (including any accompanying schedules, statements, and

attachments) has been examined by me (us) and is, to the best of my (our) knowledge and belief, a true, correct, and complete application, made

in good faith pursuant to the income tax laws of the Commonwealth of Virginia. I (we) understand that the Department of Taxation will record the

information submitted on this application; however, acceptance of this application does not constitute certification, approval, or validation of the

donation or valuation of the credit by the Department of Taxation. If a person other than the taxpayer prepares this application, their declaration is

based on all information of which they have knowledge.

I authorize the Department of Taxation to discuss my application with the contact person listed in Section I of Schedule A, my broker,

and share and/or discuss this application with DCR, if applicable. Further, I authorize the Department of Conservation and Recreation to

discuss my application with the contact person, the holder of the conservation easement, or the holder’s representative, if applicable.

Signature of Applicant

Must Be

Print Name

Signed in

Presence

of notary

Title

Date