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Rhode Island Department of Environmental Management Division of Planning and Development Land Acquisition Program Application for Sale of Real Estate/Interest in Land Tillinghast Pond Thank you for your interest in selling property to the State of Rhode Island. The Department of Environmental Management’s Division of Planning and Development works with private landowners to conserve open space, natural resources, and agricultural lands. RHODE ISLAND DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Division of Planning and Development 235 Promenade Street, Providence, RI 02908-5767 401-222-2776, fax 401-222-2069 http://www.dem.ri.gov/programs/bpoladm/plandev/index.htm Application for Sale of Real Estate Return to: RIDEM, Division of Planning & Development Providence, RI 02908-5767 Contact: (401) 222-6825 Fax: (401) 222-2069 Web: http://www.dem.ri.gov/programs/bpoladm/plandev/index.htm For DEM Use Only Date Received: Approved: Denied: Owner Information Property Owner’s Name: Daytime Telephone: Full name Co-Owner’s Name Daytime Telephone: Full name Property Owner’s Mailing Address: City, State & Zip Code: If applicable, check if the property is owned by a(n): Estate Partnership Corporation Property Information Municipality: County: Please provide the following information, which is available from your most recent tax bill(s): Block # Lot # Assessed Value Farm, Forest, Open Space Assessed? Annual Property Taxes $ Yes / No $ $ Yes / No $ $ Yes / No $ $ Yes / No $ Acres per Lot Total Acres: Property Address or Nearest Street: Municipal Zoning District: (available from municipal zoning officer) Date you acquired title to the property: Are there any structures located on the property? Yes No Yes No Yes No Yes No If yes, describe & provide photos of all outstanding structures -if available Current use of property: Have any commercial activities ever taken place on this property? If yes, please describe: Are there any leases, rental agreements, easements or deed restrictions affecting the property? If yes, please describe: Are there any mortgages or liens on the property? If yes, please describe: Have you ever applied here or elsewhere to sell this property for preservation? Yes No Yes No If yes, please describe: Have you pursued, or are you pursuing, any subdivision or development approvals on the property? If yes, please describe: Dates of Prel. & Final Approvals: (Provide documentation of approvals) Is the property currently listed for sale with a realtor? Yes No If yes, please provide name and phone #: What is your asking price for this property?(required)* *NOTE: While the asking price is a key element in the evaluation of this property, it is non-binding, and is not a commitment on the part of the State of Rhode Island to pay this amount should this property be selected for acquisition. Please tell us about your property, including any unique or special environmental features, known historical associations, and any bodies of water on the property or bordering the property. (Use back of application if more space needed.) Representative Information Do you authorize a person to act as your representative in all matters pertaining to this application? Yes No What is this person’s relationship to you (i.e., family member, realtor, attorney)? Name of Representative: Representative’s Street Address: City, State, Zip Code: Telephone: Signature of Representative: Attachments Copies of the following documents are requested for application: Tax Map: REQUIRED Title Insurance Policy: Yes No Deed of Property: REQUIRED Survey: Yes No Structure Photos: Yes No Owner Certification I hereby certify that the information included in this application is true, that I am the legal owner of the property described above, that I have marketable title to the property and that I have the legal right to sell the property. I hereby authorize the staff of the DEM to conduct such site inspections on the property as are necessary to this application. Signature of Owner (Applicant) 7/12/2007 Date Signature of Owner (Co-Applicant) Date