Form 250 - Act 250 Disclosure Statement - Vermont Environmental Board
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2ACT 250 DISCLOSURE STATEMENT
VERMONT ENVIRONMENTAL BOARD
MONTPELIER, VERMONT 05602
NOTE: IF THIS TRANSACTION DOES NOT INVOLVE THE PARTITION OR DIVISION OF LAND, THIS ACT 250
DISCLOSURE STATEMENT IS NOT REQUIRED. REFER TO 10 V.S.A. §6001(14)(a) and (b).
1. SUBDIVIDER’S (TRANSFEROR) FULL NAME(S)
MAILING ADDRESS
NAME OF CONTACT PERSON FOR SUBDIVIDER
MAILING ADDRESS
TELEPHONE NO.
2. BUYER’S (TRANSFEREE) FULL NAME(S)
MAILING ADDRESS
3. DESCRIPTION OF PROPERTY
TOWN
ROAD
NUMBER OF ACRES
4. State the total number of lots or parcels the Subdivider intends to create as part of this partition or
division of land.
NUMBER OF LOTS
5. Has the Subdivider divided or partitioned any other land within the past five years which is located
within the same District or is located within five miles (if in a different district)?
c NO
c YES
See map on page 34.
NUMBER OF LOTS
6. Have the Subdivider’s parents or children (natural or adoptive) or spouse divided or partitioned any other land
within the past five years which is located within the same District or is located within five miles (if in a different
District) of the land being partitioned?
c NO
c YES
IF “YES,” COMPLETE THE FOLLOWING ABOUT THE FAMILY MEMBER
NAME
ADDRESS
RELATIONSHIP
7. Did the Subdivider profit or derive any consideration or financial benefit from the partition or division of the
land of that family member as listed in #6 above.
c NO
c YES
IF “YES,” COMPLETE THE FOLLOWING ABOUT THE FAMILY MEMBER
NAME
ADDRESS
RELATIONSHIP
FORM 250 (8/02)
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