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zA1 Orange County, <br />agricultural Districts Advisory Board <br />APPLICATION FOR CERTIFICATION AS QUA LEnaNG FARMLAND <br />AND DESIGNATION AS AN ORANGE COUNTY <br />VOLUNTARY AGRICULTURAL DISTRICT <br />INS'T'RUCTIONS: Before completing the application, ply review the provisions of the orange County Voluntary Farmland <br />PrOwmation Program ordinance, then fill out the form as scc mudy and completely as possible. Be sure to <br />sign and date the form, and rewrn it to the orange Courlry pkmling & InepeeWns Department, 306F Revere <br />Raid, Hillsborough, N.C. <br />n Q - IN 0"; 1' <br />Name: / -� A �l 1 <br />Address: S ^ _"" '2 C -Gf✓ ( �� �f C <br />City: Stater ZIP Code: G <br />Phone Number: (Home) (Work) <br />PROPERTY INFORMATION: <br />Property Location/Address: <br />Township: �Tax Map: y a Block: Lot: A/15 <br />Parcel Identification Number [PIN]: <br />Number of Acres: Deed gook: _ % / page_ <br />Does this land have a plan on file with the Soil Conservation Service or U.S. Forest Service? <br />Yes: No: If "no", please complete back of form. <br />Is this land listed for farm present use -value taxation with the Orange County Tax Office? <br />Yes: No: If "no% please complete back of form. <br />OWNER[S] CERTIFICATION: <br />I [We], the applicant[s], hereby certify that, to the best of my [our] ability, the foregoing <br />application is mplete and accurate. <br />Signature: Date: <br />Signature: <br />Please direct inquiries to: <br />Orange Soil & Water Conservation District <br />Cooperative Em scion Service <br />Orange Ccurrty Planning & Inspo=ons Departnma <br />HHL*woo& 73241819Cbs* HM 967401 eDudma 6S&70310,1 . ms 727.21131 <br />