Psegli Easement Information Request Form

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PSEGLI EASEMENT INFORMATION REQUEST FORM
(Please Print all Information in Black Ink)
1. CUSTOMER INFORMATION
FIRST NAME:
MIDDLE INITIAL
LAST NAME:
SERVICE ADDRESS:
PHONE:
VILLAGE/TOWN/CITY:
STATE: NY
ZIP CODE:
Township: Babylon
Brookhaven
E. Hampton*
Hempstead
Huntington
Islip
No. Hempstead
Oyster Bay
(Check One) Queens
Riverhead*
Shelter Is.*
Smthtown
Southampton*
Southold*
Other (Please Print)
*These townships require Peconic Bay Region Community Preservation Fund forms completed and submitted with Easement
MAILING ADDRESS:
PHONE:
VILLAGE/TOWN/CITY
STATE
ZIP CODE
2. PROPERTY OWNER INFORMATION (Please use the Same Names as Indicated on the Property Deed)
Ownership: Property is held in the name of: (Check one):
Corporation
Partnership
Individual
Other
Identification: Provide Federal Employer Identification # or Social Security # for TP584/NYS Real Property Gains Tax Affidavit
FED ID #
SS#
Provide Owner Information: If more than two owners of record, use the back of the form for additional information.
Name (Individual – Print as name appears on owner’s deed or survey)
Name and Title of Officer of Corporation who will sign the Easement:
Current Street Address (Do not use PO Box)
Village/Town/City
State
Zip Code
Name
Current Street Address (Do not use PO Box)
Village/Town/City
State
Zip Code
Is there a filed map of property with County?
Yes
No
PLEASE PROVIDE Copy of filed map
If yes please supply the following information.
Map Name
Filed Number
Filed Date

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