AV-56 - Application for Wildlife Conservation Program

10 AV - 56 Application for Wildlife Conservation Program Web GS 105 - 27715 11 - 22 County of , NC Tax Year Full Name of Owner s Mailing Address of Owner City State Zip Code Email Address Phone Number Check the program s included in this application , then enter the following information for each corresponding tax parcel Species Protection Habitat Protection Wildlife Reserve Homesite All Other Total Parcel ID Acres Acres Acres Acres Acres Acres List any other land you own in this county that is also in the wildlife conservation program Parcel IDs Yes No ? Did one of the applicants reside on the property on January 1 of the year for which this application is made If YES , provide name of resident Property must be owned by one of these four qualifying forms of ownership or by a tenancy in common of the four qualifying ownerships Indicate the publicly recorded ownership of the property If a tenancy in common , check all that apply Note A business entity is defined as a corporation , limited liability company , general partnership , or limited partnership Individual s Spouses As Tenants by the Entirety Family Business Entity ies Family Trust s For each business entity or trust that is part of the publicly recorded ownership , answer the two following questions Attach additional copies of this section as needed Yes No Are any of the members of the business entity or beneficiaries of the trust either a business entity or a trust ie not an ? individual If YES , you must attach a complete description of the ownership structure of the business entity or trust which shows the individual level of ownership interest Yes No Once you have determined the individual level of ownership interest , are all of the individuals relatives of each other See GS ? 105 - 2772 5a at wwwnclegnet for the definition of relative List all of the individuals 1 2 3 4 5 6 You must submit a complete copy of your wildlife habitat conservation agreement with this application AFFIRMATION OF APPLICANT – I , the undersigned , declare under penalties of law that this application and any attachments are true and correct to the best of my knowledge and belief I have read the governing exclusion statute I fully understand that an ineligible transfer of the property or failure to meet the requirements of the wildlife conservation program will result in the loss of eligibility I fully understand that loss of eligibility will result in removal from the program and the immediate billing of deferred taxes Signature of Owner Printed Name and Title Date Signature of Owner Printed Name and Title Date The Tax Assessor may contact you for additional information after reviewing this application FOR OFFICE USE ONLY APPROVED DENIED BY _______________________ REASON FOR DENIAL _________________________________________Page