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• Acknowledgment of receipt by the Department of Taxation of this application form does NOT Before completing Form LPC-1, please read the instructions. return. Form LPC-1 $SSOLFDQW7\SH&KHFN2QH Individual Taxpayer Married Donors Multiple Donors Trust/Estate Pass-Through Entities

Corporation Non-Profit

SSN FEIN

CityState

ZIP

Code)3KRQH1XPEHU*)$;1XPEHU+(PDLO

Section II - Donation Questions

Va. Code § 10.1-1009?

conferred on a "holder" by Va. Code § 10.1-1010?

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Yes No

Yes No

Yes No

Yes No

real property that was formerly part of the same parcel of land as the p roperty being donated?

Yes No

Section III - Property and Credit Information

Fee Simple

Less-Than-Fee Simple

Facade

No Yes ''DWH$FTXLUHG (3URSHUW\6WUHHW$GGUHVV1R32%R[CityStateZIP Code

Tax Map or PINLocality

Current Zoning:

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32%R[

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For general assistance, call

)RUDVVLVWDQFHUHJDUGLQJ6HFWLRQV,99 and Schedules B & C, call 5HY LPC-1 on or before of the calendar year following the year the donation was recorded.

Form LPC-1

Conservation Purpose$FUHV

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4.

Historic Preservation

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1.

Limitations on the number of property divisions.

Yes No

permitted new roads or access ways.

Yes No

2.

Limitations on the amount of new buildings and

structures.

Yes No

and ground disturbing activity that may impact historic, cultural, or natural heritage resources.

Yes No

buildings and structures.

Yes No

Yes No

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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

$JULFXOWXUH%HVW0DQDJHPHQW3UDFWLFHCurrently Practiced 2.

Cover Crop Practices

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Silviculture Best Management Practice

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Stream Crossings

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)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

Yes No

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