Replacement Sign Form Historical Society Of Michigan (Page 3 of 4) in pdf

Replacement Sign Form Historical Society Of Michigan Page 3

SECTION 5: REPLACEMENT SIGN REQUEST

By submitting this completed form, I am requesting either a Sesquicentennial or a Centennial replacement sign from the

Historical Society of Michigan (HSM). I understand that, to qualify for a replacement Centennial or Sesquicentennial sign,

a property must be a working farm of 10 or more acres that has been continuously owned by the same family for at least

100 or 150 years, respectively. These are replacement signs only. The property must already be certified as a Centennial

Farm through the Centennial Farm Program. If purchasing a Sesquicentennial sign, the property must already be certified

as a Sesquicentennial Farm.

The information submitted on this form is accurate to the best of my ability. I understand that HSM may attempt to verify

the history of ownership with an outside organization or business, and I give my permission to share information from this

form for this purpose. HSM may also contact me for additional information or missing information.

Furthermore, I agree to allow HSM to make information available about my property, including historical information about

the farm, the address of the property as part of a list of certified farms, and the name of the owner(s) and original owner

as indicated above. I also agree to allow HSM to use information provided as part of the application in HSM publications.

I have enclosed the following materials to complete this application:

A completed Michigan Centennial Farm Program: Replacement Sign Form

A non-refundable application fee* of $91.50 (per Centennial Replacement Sign) and/or $46.10

(per Sesquicentennial Replacement Sign)

Proof of current ownership (i.e., a recent tax bill, deed, mortgage, or land contract)

Documentation (i.e., deeds, mortgages, or land contracts) to support any changes in the farm’s

ownership since its last certification through the Centennial Farm Program

Signed:

Date:

Return the completed application and application fee* to:

Centennial Farm Program

The Historical Society of Michigan

5815 Executive Drive

Lansing, MI 48911

Phone (517) 324-1828

*Your application fee can be submitted via check or money order. Do NOT send cash. To charge your application fee to a

major credit card (Visa, MasterCard, Discover or American Express), please see the next page.

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