Peconic Bay Region Community Preservation Fund Form

Peconic Bay Region Community Preservation Fund

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Schedule A - Information Relating to Conveyance

Name (individual; last, first, middle initial) Social Security Number

Mailing address Social Security Number

City State ZIP code Federal employer ident. number

Name (individual; last, first, middle initial) Social Security Number

Mailing address Social Security Number

City State ZIP code Federal employer ident. number

Location and description of property conveyed

Tax map designation Address Village Town

Dist Section Block Lot

Grantor

Individual
Corporation
Partnership
Other

Grantee

Individual
Corporation
Partnership
Other

Type of property conveyed

Improved Vacant land Date of conveyance

Condition of conveyance

a. Conveyance of fee interest

b. Acquisition of a controlling interest

c. Transfer of a controlling interest

d. Conveyance to cooperative housing corporation

e. Conveyance pursuant to or in lieu of foreclosure or enforcement of security interest

f. Conveyance which consists of a mere change of identity or form of ownership or organization

g. Conveyance for which credit (or tax previously paid will be claimed

h. Conveyance of cooperative apartment(s)

i. Syndication

j. Conveyance of air rights or development rights

k. Contract assignment

l. Option assignment or surrender

m. Leasehold assignment or surrender

n. Leasehold grant

o. Conveyance of an easement

p. Conveyance for which exemption is claimed

q. Conveyance of property partly within and partly without the state

r. Other

Schedule B - Community Preservation Fund

Part I - Computation of Tax Due

1. Enter amount of consideration for the conveyance

2. Allowance

3. Taxable consideration

4. 2% Community Preservation Fund

5. Property not subject to CPF Tax See Schedule C

Allowance:

East Hampton $250,000.00 Improved $100,000.00 Vacant Land (Unimproved)

Shelter Island $250,000.00 Improved $100,000.00 Vacant Land (Unimproved)

Southampton $250,000.00 Improved $100,000.00 Vacant Land (Unimproved)

Riverhead $150,000.00 Improved $75,000.00 Vacant Land (Unimproved)

Southold $150,000.00 Improved $75,000.00 Vacant Land (Unimproved)

Schedule C - Part II - Explanation of Exemption Claimed

The conveyance of real property is exempt from the real estate transfer tax for the following reason:

a. Conveyance is to the United Nations, the United States of America, the state of New York or any of their instrumentalities, agencies or political subdivisions

b. Conveyance is to secure a debt or other obligation

c. Conveyance is without additional consideration to confirm, correct, modify or supplement a prior conveyance

d. Conveyance of real property is without consideration and not in connection with a sale

e. Conveyance is given in connection with a tax sale

f. Conveyance is mere change of identity or form of ownership or organization where there is no change in beneficial ownership

g. Conveyance consists of deed of partition

h. Conveyance is given pursuant to the federal bankruptcy act

i. Conveyance consists of the execution of a contract to sell real property without the use or occupancy of such property or the granting of an option to purchase real property without the use or occupancy of such property

j. Conveyance of real property subject to restrictions for agriculture, recreation or conservation

k. Conveyance of real property for open space, parks, or historic preservation purposes

l. Other list explanations in space below

m. Approved exemption from the Community Preservation Transfer Tax

Town Attorney or other designated official

Signature (both the grantor(s) and grantee(s) must sign).

The undersigned certify that the above return, including any certification, schedule or attachment, is to the best of his/her knowledge, true and complete.

For recording officer's use

Amount received Date received Transaction number

Penalties and Interest

Penalties

Any grantor or grantee failing to file a return or to pay any tax within the time required shall be subject to a penalty of 10% of the amount of tax due plus an interest penalty of 2% of such amount of each month of delay or fraction thereof after the expiration of the first month after such return was required to be filed or the tax became due. However, the interest penalty shall not exceed 25% in the aggregate.

Interest

Daily compounded interest will be charged on the amount of the tax due not paid within the time required.