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PT-48-5-7.7 (Aug 2011) FOREST LAND CONSERVATION USE ASSESSMENT COVENANT Section A: Application To the Board of Tax Assessors of In accordance with the provisions of O.C.G.A. § 48-5-7.7, I submit this application and the completed questionnaire on the back of this application for consideration of Forest Land Conservation Use value assessment on the property described herein. Name of owner(s): Owner’s mailing address City, State, Zip Page 1 of 4 OWNERSHIP INFORMATION PROPERTY IDENTIFICATION Property physical location Total number of acres included in this application: County Parcel ID # District Land Lot Deed Book/Page Plat Book/Page Acres AUTHORIZED SIGNATURE I, the undersigned, do hereby solemnly swear, covenant and agree that all the information contained above, as well as the information provided on the questionnaire, is true and correct to the best of my knowledge and that the above described property qualifies under the ownership and land use provisions of O.C.G.A. § 48-5-7.7. I further swear that I am authorized to sign this application on behalf of the owner(s) making application. I am aware that certain penalty provisions are applicable if this covenant is breached pursuant to O.C.G.A. § 16-10-20. Signature of Owner or Owner’s Authorized Representative Date Application Filed Signature of Owner or Owner’s Authorized Representative *Additional owners may sign on back of form Sworn to and subscribed before me this day of Notary Public FOR TAX ASSESSORS USE ONLY Covenant: Begins: Jan. 1 Ends: Dec. 31 Covenant # (Year) (County Code) (Covenant Based on the information submitted and provided on the questionnaire, the County Board of Tax Assessors has considered such information and has made the following final determination of this application: Approved: Date: Board of Tax Assessors Date Denied: Date: If denied, O.C.G.A. § 48-5-7.7 provides that the County Board of Tax Assessors shall issue a notice to the owner(s) in the same manner as all other notices are issued pursuant to O.C.G.A. § 48-5-306 which can be appealed pursuant to O.C.G.A. § 48-5-311. PRINT CLEAR ---PAGE BREAK--- PT-48-5-7.7 (Aug 2011) FOREST LAND CONSERVATION USE ASSESSMENT COVENANT Section B: Questionnaire • Page 2 of 4 Additional Owner Signatures (if needed) Print Name Signature/Date OTHER COUNTIES AND ACREAGE included in this application for FOREST LAND PROTECTION COVENANT County Name/Application # Property Description/Other County Parcel #/Acreage Check Appropriate Ownership Type: [ ] One or more individuals (includes executors, administrators and trustees) [ ] Entity registered to do business in the State of Georgia (county tax official may request verification of registration: such verification may include sales tax number, FEI number, etc.) In addition to the primary use of the property as specified in the application, specific secondary uses are permitted. Please indicate if any of the following are applicable to the property covered by this application and the total amount of acreage used: [ ] Promotion, preservation, or management of wildlife habitat. [ ] Carbon sequestration. Is the property listed on the Georgia Carbon Sequestration Registry ( ) Yes ( ) No [ ] Mitigation or conservation use banking to restore or conserve wetlands and other natural resources. [ ] Production or maintenance of ecosystem products and services such as, but not limited to, clean air and water. ( ) Yes ( ) No Is this property or any portion thereof currently being leased? If yes, briefly explain how the property is being used by the lessee, as well as the amount of acreage of the property leased. _ ( ) Yes ( ) No Is the property or any portion thereof currently being used for fishing purposes where admission is charged? If yes, please indicate amount of acreage so used. ( ) Yes ( ) No Is the property or any portion thereof being used for production of pine straw? If yes, indicate amount of acreage so used. ( ) Yes ( ) No Is there a residence on the property? If yes, provide the street address. ( ) Yes ( ) No Are there other real property improvements located on this property? If yes, briefly list and describe these real property improvements on a separate sheet and attach to this application. ( ) Yes ( ) No Is there any type of business operated on this property? If yes, indicate business name, type of business, and amount of acreage so used. ---PAGE BREAK--- PT-48-5-7.7 (Aug 2011) FOREST LAND CONSERVATION USE ASSESSMENT COVENANT Section C: Covenant In consideration of my receiving the preferential assessment of forest land provided in O.C.G.A. § 48-5-7.7, I (We), the undersigned do hereby solemnly swear, and covenant that: 1. I (we) have personal knowledge of the property described herein, and the primary use is good faith subsistence or commercial production of trees, timber, or other wood and wood fiber products. 2. I (we) will maintain this property as forest land conservation use property, as defined by O.C.G.A. § 48-5-7.7, for a period of 15 years to begin on January 1st of the first year for which conservation use assessment is approved, and to continue through the last day of December of the final year of the Covenant period. 3. I (we) will notify the Board of Tax Assessors, in writing, in the event there is a change in the “qualifying use” of said property. 4. I (we) understand that if this Covenant is breached, penalties and interest will be assessed as provided for by law and such penalties and interest levied against myself and against the property will constitute a lien against the property subject of this Covenant. 5. I (we) understand that a breach occurring in one or more counties shall be considered a breach of the entire tract subject to this Covenant, regardless of the nature or the location of the breach. 6. I (we) understand that if the tract is located in more than one county, each county where the tract is located must enter into a Covenant. If a county denies the application, then the land in that county shall not receive Forest Land Protection Act of 2008 designation and the other remaining tract or tracts must meet all the requirements and qualifications set forth in O.C.G.A. § 48-5-7.7, and all applicable regulations. 7. All information set forth on this document is true, correct, and complete. The following information is for the portion of the tract located in THIS COUNTY with Covenant Number Parcel Identification Number County Physical Address Detailed description of the use of the property in this County: We hereby adopt and ratify the Covenant for the tract of real property located in County and described herein, and adopt the ratification of this Covenant for tracts located in any other counties, if applicable. Date Signature for the County Board of Assessors I hereby certify, adopt, and affirm the Covenant for the tract or tracts of real property described herein. Date Signature of Owner #1 Printed Name of Owner Sworn to and subscribed before me This day of Notary Public I hereby certify, adopt and affirm the Covenant for the tract or tracts of real property described herein. Date Signature of Owner #2 Printed Name of Owner Sworn to and subscribed before me This day of Notary Public Page 3 of 4 ---PAGE BREAK--- PT-48-5-7.7 (Aug 2011) The following information pertains to ANY OTHER COUNTY where the tract is located and for which an application and this Covenant may be filed. Parcel Identification Number County #1 Physical Address Detailed description of the use of the property in the county: We hereby adopt and ratify the Covenant for the tract of real property located in County and described herein, and adopt the ratification of this Covenant for tracts located in any other counties. Date Signature for the County Board of Assessors Parcel Identification Number County #2 Physical Address Detailed description of the use of the property in the county: We hereby adopt and ratify the Covenant for the tract of real property located in County and described herein, and adopt the ratification of this Covenant for tracts located in any other counties. Date Signature for the County Board of Assessors NOTE: If additional space is needed for signatures and ratifications, you may attach another covenant section to this form. Pursuant to O.C.G.A. 48-5-7.7(b)(1), if your tract is divided by a county boundary, public roadway, public easement, public right of way, natural boundary, land lot line, or railroad track then you may, at the time of the initial application, make a one-time election to divide such tract for the purpose of entering such tract in a Forest Land Conservation Use Covenant. Additional Parcel Identification Numbers Additional Parcel Identification Numbers Page 4 of 4 may be filed.