SECTION 1 – Legal Ownership Information
Legal Ownership Type:	Individual	Joint	Trust	LLC	Corp
Legal Landowner Name:
Mailing Address:
City:	State:	Zip:
Home Phone:	Work Phone:
E-mail:	Cell Phone:
SECTION 2 – Contact Information (if different than owner)
Contact Name:	Mr.	Mrs.	Ms.
Mailing Address:
City:	State:	Zip:
Home Phone:	Work Phone:
E-mail:	Cell Phone:
Relationship to Legal Landowner:
SECTION 3 – Property Information
County:
Property Location: (include 911 address, if possible)
Tax Map Parcel(s):
Total Acres to be Put Under Easement:
Acres of Forested Land:	Acres of Open Land:
Does the property have a survey and/or recorded plat?	Yes	No
If yes, provide copies with this application.
Are the boundaries marked?	Yes	No
Does the property have frontage on a public road or a deeded access easement?	Yes	No
Are there utility or access easements through the property?	Yes	No
Are there any known encroachments or boundary line disputes from neighboring properties?	Yes	No
Is this property covered by a written Forest Stewardship Management Plan?	Yes	No
If yes, provide a copy with this application.
Is there an active or pending timber sale contract?	Yes	No
Is there a nutrient or wetland mitigation bank or are there plans for one?	Yes	No
Is the property, or any portion of it, subject to a deed of trust, lien, mortgage or other third-party financial interest?	Yes	No

SECTION 4 – Additional Information
Briefly describe your reasons for conserving this property. If you are planning to pursue grant funding, please list all the grants you’re planning to pursue (for example, the Virginia Land Conservation Foundation, Enviva Forest Conservation Fund, etc.):
How did you learn about VDOF’s open space easement program and why did you choose VDOF’s program for your easement?
Has the property been in your family for more than 100 years?	Yes	No
If yes, would you like more information about VDOFs Century Forest Recognition?	Yes	No
Provide any additional information that you’d like to share:
SECTION 5 – Signature
Landowner Name (Print)	Landowner Signature	Date
VDOF Headquarters Office Use Only
Date Received:	Reviewed By:	Date Landowner Contacted: