14)If you meet one of the following, please check the appropriate box and complete the following (Not applicable to an individual not meeting one of the categories - please leave blank):
Corporation |
Business Trust |
Estate |
Trust |
Partnership |
Association |
2 or more persons having a joint or common interest in the land
List the following: President, Vice President, Secretary and Treasurer, or present income beneficiaries:
Name: ____________________________ Title: _________________________________________________
Mailing Address: ___________________________________________________________________________
StreetCityStateZip
Name: ____________________________ Title: _________________________________________________
Mailing Address: ____________________________________________________________________________
StreetCityStateZip
Name: ____________________________ Title: _________________________________________________
Mailing Address: ____________________________________________________________________________
StreetCityStateZip
Name: ____________________________ Title: _________________________________________________
Mailing Address: ____________________________________________________________________________
Street |
City |
State |
Zip |
|
(Additional Names may be attached on separate sheet.) |
|
D. Reasons for Withdrawal of Land From Program:
Section 36111A indicates eight requirements, one of which must be met, in order to receive approval to withdraw land from the program earlier than the specified expiration date in the agreement contract. (See application instruc- tions for the text of the stated rule containing this procedure.)
15)Please provide a detailed explanation of why the land should be released from the agreement contract. (Supporting documentation should be attached to this form.)
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(Continued explanations may be attached.)
16)Please draw a map (sketch) of the property, showing boundaries, structures and natural or man-made features such as lakes, ponds, swamps, streams, rivers, woodlots, roads, or gravel pits. (Use space provided on page 4 or attach separate sheet.)