Fill and Sign the Student and Spouse Will Not File and Are Not Required to File a 2018 Income Tax Return with the Irs Form

Form LPC-1 Application for a Land Preservation Credit *VALPC1111888* Acknowledgment of receipt by the Department of Taxation of this application form does not Mail Form, Attachments (See What To Attach) constitute certification, approval, or validation of the donation or of the credit valuation. and Payment (if Applicable) To: Before completing Form LPC-1, please read the instructions. Virginia Department of Taxation To avoid delays at the time of annual return processing, Form LPC-1 should be filed by the applicant Tax Credit Unit within 90 days of the donation, but at least 90 days before filing your annual return. Applications for tax credits of $1 million or more should be submitted at least 120 days before filing an annual PO Box 715 return. Richmond, VA 23218-0715 • • • For General Assistance, Call 804-786-2992 Also Send a Copy of Form and Specified Attachments (See What To Attach) To: For Assistance regarding Sections IV, V Department of Conservation & Recreation, Tax Credit Program and Schedules B & C, call 804-371-5218 203 Governor Street, Suite 302, Richmond, VA 23219 Section I - Applicant Information A) Entity Type - Check One  Individual Taxpayer  Corporation  Multiple Donors  Pass-Through Entity  Non-Profit  Other Entity - Specify________________  Trust/Estate B) Applicant Name (As Shown on Deed) C) Applicant Identification Number (Check appropriate box and enter number.)  SSN  FEIN D) Street Address or PO Box Number City E) Contact Name, If Different From Above F) Phone Number State G) FAX Number ZIP Code H) E-mail Section II - Donation Questions II-A - Questions for a Donation Made on or After January 1, 2007 A) Are you a non-profit holder of easements as defined in Va. Code § 10.1-1009? IF YES, GO TO B; IF NO, GO TO C. B) Do you hold one or more conservation easements excluding this donation that were acquired pursuant to the authority conferred on a “holder” by Va Code § 10.1-1010? IF YES, STOP. YOU DO NOT QUALIFY. C) Have you applied for a Historic Rehabilitation Credit in the last five years on this property/building? IF YES, STOP. YOU DO NOT QUALIFY. D) In the past 11 years, have you, a family member or an affiliate applied for a credit for a conservation easement on any portion Yes No Yes No Yes No Yes No Yes No of this parcel(s)? IF YES, LP# _______________________ . DONATION MUST BE VERIFIED BY DCR. II-B - Questions for a Donation Made on or After July 1, 2010 A) In the past 3 years, has a donation of at least $250,000 been allowed or requested for this parcel or portion of this parcel of land ? IF YES, LP# _______________________ . DONATION MUST BE VERIFIED BY DCR. Section III - Property and Credit Information A) Type of Donation - Check One B) Bargain Sale - Check One  Fee Simple  Less-Than- Fee Simple  Facade  No  Yes (If Yes, Enter Amount Received) $ E) Property Street Address (No P. O. Box) Deed Book Reference D) Date Acquired .00 City F) Property Information - Attach additional pages, if needed. C) Number of Acres State Tax Map or PIN ZIP Code Locality 1. 2. 3. 4. G) Name(s) of Eligible Conservation Agency(ies) Receiving Donation H) Jurisdiction(s) Donation Was Recorded I) Date Recorded J) Appraisal Company Name K) Company’s FEIN or SSN L) Appraisal Evaluation Date M) Appraised Value of Donation Va. Dept. of Taxation LPC-1 W (Rev 05/11) N) Credit Amount Requested O) Assessed Value Per Acre P) Appraised Value Per Acre Form LPC-1 Page 2 Application for a Land Preservation Credit *VALPC1211888* Section IV - Conservation Information for Reporting Purposes A) Conservation Purpose: Identify the conservation purpose(s) protected by the donation by checking the applicable box(es). Also, specify the acreage of each use indicated. See Instructions for definitions of these conservation purpose categories. Conservation Purpose Check Applicable Boxes Acres 1. Agricultural Use 2. Forestal Use 3. Natural Habitat and Biological Diversity 4. Historic Preservation 5. Natural Resource Based Outdoor Recreation and Education 6. Watershed Preservation 7. Preservation of Scenic Open Space 8. Conservation and Open Space Lands Designated by Local Governments B) Public Benefit: Indicate how the donation will protect the conservation purpose(s) identified above and benefit the public. Indicate which of the following restrictions are included in the deed of donation: 1. Limitations on the number of property divisions [ ] Yes [ ] No 2. Limitations on the amount of new buildings and structures [ ] Yes [ ] No 3. Restrictions on the location of permitted new buildings and structures. [ ] Yes [ ] No 4. Restrictions on the location of permitted new roads or access ways 5. Limitations on alterations, demolition, and ground disturbing activity that may impact historic, cultural, or natural heritage resources. [ ] Yes [ ] No 6. Limitations on utility placement [ ] Yes [ ] No [ ] Yes [ ] No 7. Please list any other restrictions specifically donated to protect the conservation purposes and benefit to the public. C) Land Currently Being Used For Production Agriculture and Silviculture. Acres 1. Provide an estimate of the number of acres of the land currently being used in production agriculture (See instructions for definition): 2. Provide an estimate of the number of acres of the land currently being used in production silviculture (See instructions for definition): D) Onsite Operational Water Quality Best Management Practices. Yes No Does the land have onsite operational best management practices that are designed to reduce the amount of nutrients and sediment entering public waters? If Yes, indicate which of the following BMPs are being practiced, and whether the terms of the deed of easement require their continued practice. Agriculture Best Management Practice Currently Practiced Deed Requires Continued Practice 1. Nutrient Management Plan Writing and Implementation 2. Cover Crop Practices 3. Livestock Exclusion Practices 4. Riparian Buffer Practices Silviculture Best Management Practice 5. Streamside Management Zones 6. Forest Roads 7. Stream Crossings 8. Harvest Planning 9. Other Agriculture or Silviculture BMP’s, please see instructions section D and provide appropriate practice number(s): E) Forest Management: Is the property fully or partially forested? Yes No If Yes, is a forest management plan included in the terms of the donation? Yes No Form LPC-1 Page 3 Application for a Land Preservation Credit *VALPC1311888* Section V - Fee Simple Donation Check Applicable Boxes A). The donation is a full or partial gift in fee simple to a public or private conservation agency. (If the application is for $1 million or more, also complete Schedule C.) Conservation Agency Name: __________________________________________________ B). The donation is a full or partial gift to a “holder” as defined in Va. Code § 10.1-1009, and documentation is included that the agency agrees that subsequent conveyances of the fee interest in the property will be made subject to a conservation easement or will be made to the Commonwealth of Virginia or a federal conservation agency. Conservation Agency Name: __________________________________________________ Section VI - Less-Than-Fee Simple Donation Explain how this donation meets the requirements of §170 (h) of the United States Internal Revenue Code of 1986, as amended. Attach additional pages if needed. Section VII - Declaration, Signature and Notarization DCR - All Donations (2007 & After) Attachment Checklist TAX - All Donations A copy of LPC Application Original LPC Application IRS Form 8283 Recorded deed Recorded deed A copy or CD of Full appraisal DCR - Donations of $1 million or more (2007 & After) IRS Form 8283 Baseline documentation Signed Statement or Affidavit from Appraiser I (we) the undersigned declare, under the penalties provided by law, that this form (including any accompanying schedules, statements, and attachments) has been examined by me (us) and is, to the best of my (our) knowledge and belief, a true, correct, and complete application, made in good faith pursuant to the income tax laws of the Commonwealth of Virginia. I (we) understand that the Department of Taxation will record the information submitted on this application; however, acceptance of this application does not constitute certification, approval, or validation of the donation or valuation of the credit by the Department of Taxation. If a person other than the taxpayer prepares this application, their declaration is based on all information of which they have knowledge. I authorize the Department of Taxation to discuss my application with the contact person listed in Section I of Schedule A, my broker, and share and/or discuss this application with DCR, if applicable. Further, I authorize the Department of Conservation and Recreation to discuss my application with the contact person, the holder of the conservation easement, or the holder’s representative, if applicable. Signature of Applicant Must Be Signed in Presence of Notary Signature of Applicant Print Name Print Name Title Date Title Date Notary Information Subscribed and sworn before me this ___________day of ____________________________, 20 _____ , in the (City/County) ____________________________, of _________________________. Notary Public Signature Date Notary Public Name Printed My Commission Expires