Form 250 - Act 250 Disclosure Statement - Vermont Environmental Board Page 2
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28. Will any family member listed in #6 above derive any profit or consideration, or acquire any other beneficial
interest from the partition or division of the land subject to this statement? (Read instructions before answering)
o
o
NO
YES
IF “YES,” LIST THE FAMILY MEMBER BELOW.
NAME OF FAMILY MEMBER
RELATIONSHIP TO SUBDIVIDER
9. List below in the space provided the name of all individuals and entities affiliated with the subdivider(s)
in the partition or division of the subject land, as that affiliation is conditioned and limited according to
§6001(14).
the definition of “person” in 10 V.S.A.
NAME
NATURE OF AFFILIATION
10. List below any partition or division of land by any individuals or entities now or previously affiliated with the
Subdivider(s) for benefit or profit which has occurred within the preceding five years (including this
transaction) and which is located within five miles of the land being divided or partitioned, or within the
jurisdictional area of the District Environmental Commission (see attached District Map).
NAME
LOCATION
DESCRIPTION OF LAND
NO. OF LOTS
NO. OF ACRES
DATE CREATED
11. NOTICE THAT AN ACT 250 PERMIT MAY BE REQUIRED
As the Subdivider(s) of this property, I/we hereby notify the buyer that an Act 250 permit may be required prior
to this partition or division of the property.
Prior to the partition or division of the land in question, the buyer may submit to the District Coordinator this
Disclosure Statement and other relevant information and should request a jusisdictional opinion from the District
Coordinator as to the applicability of Act 250 to this proposed partition or division of land.
12. If an Act 250 permit has been issued for the land being partitioned, enter the Land Use Permit Number.
I/we the Subdivider(s) hereby swear and affirm that this Disclosure Statement is true and complete to the best
of my/our knowledge. Knowing falsification of any statement contained herein is punishable pursuant to the
provisions of 10 V.S.A. §6003; 10 V.S.A. chapters 201 and 211; and 13 V.S.A. §3016.
DATE: _____________________________________
__________________________________________
__________________________________________
Signature(s) of Subdivider(s)
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