Michigan Form Es 012 – Fill Out and Use This PDF

A.Personal Information:

1)Name(s) of Applicant: _______________________________________________________________

(Owner of Record) LastFirstInitial

Spouse’s Name: ___________________________________________________________________

LastFirstInitial

2) Mailing address: ___________________________________________________________________

Street

City

State

Zip Code

3)Telephone Number: (Area Code) ( ) _______________________________________________

4)__________________________________ __________________________________________

Social Security Number

Spouse’s Social Security Number

5)Federal Employer Identification Number (if applicable): ____________________________________

6)Farmland Development Rights Agreement # _____________________________________________

B. Property Location: (Can be taken from the deed.)

7) County:__________________________ 8) Township, city or village: _________________________

9)Section No.: _______________; Town #: __________________; Range #: ______________________

C. Legal Information:

10)Attach a copy of the deed or land contract (may be a photo copy).

11)Attach a copy of the most recent property tax assessment notice or tax bill.

12) Is there a tax lien against the land described above? (may be photo copy) Yes No If “Yes,” please explain circumstances: ____________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

13) Is land being purchased under land contract?	Yes	No
a) If “Yes,” indicate vendor (seller):

Name: ______________________________________________________________________________

Mailing Address: ______________________________________________________________________

Street

City

State

Zip Code

b)Part 361 of the Natural Resources and Environmental Protection Act, 1994 Act 451 as amended, states that the vendor (seller) must agree to allow the land cited in the application to be released from the program. Please have the land contract seller sign below.

I, the undersigned, understand and agree to permit the land cited in this application to be released from the Farmland and Open Space Preservation Act.

____________________	________________________________________
(Date)	(Land Contract Seller’s Signature)

ES-012.

Rev. 5/02

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.)

____________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________

______________________________________________________________________________________________________

_____________________________________________________________________________________________________

________________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________

______________________________________________________________________________________________________

_____________________________________________________________________________________________________

________________________________________________________________________________________________________

______________________________________________________________________________________________________

(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.)

2

E. Signatures:

17)The undersigned declare that this application, including any accompanying informational materials, has been examined by them and to the best of their knowledge and belief is true and correct.

(Signature of Applicant(s))

(Corporation Name if Applicable)

(Signature of Co-Owner(s))

(Signature of Corporate Officer)

(Date)

(Title)

RESERVED FOR LOCALGOVERNMENT USE, CLERK PLEASE COMPLETEALL SPACES - SECTION IAND II

I. Action by Local Governing Body: Jurisdiction: ___________________________________________

County, Township, City or Village

Date received by clerk: _________________________________________________________________

This application is ____________________ approved, ____________________rejected.

(If rejected, see attached statement by Local Governing Body.)

Date of approval or rejection: ___________ Clerk’s signature and seal: __________________________

Property Appraisal: The current fair market value of the real property in this application has been determined to be $ ____________________

4