8. Will any family member listed in #6 above derive any profit or consideration, or acquire any other beneficial interest from the
partition or division of the land subject to this statement? (Read instructions before answering.)
NO
YES
IF “YES,” LIST THE FAMILY MEMBER BELOW.
NAME OF FAMILY MEMBER
RELATIONSHIP TO SUBDIVIDER
9. List below in the space provided the name of all individuals and entities affiliated with the subdivider(s) in the partition or
division of the subject land, as that affiliation is conditioned and limited according to the definition of “person” in 10 V.S.A.
§6001(14).
NAME
NATURE OF AFFILIATION
10. List below any partition or division of land by any individuals or entities now or previously affiliated with the Subdivider(s)
for benefit or profit which has occurred within the preceding five years (including this transaction) and which is located
within five miles of the land being divided or partitioned, within the jurisdictional area of the District Environmental Commis-
sion (see attached District Map), or within the same town.
NAME
LOCATION (TOWN)
DESCRIPTION OF LAND
NO. OF LOTS
DATE CREATED
11. NOTICE THAT AN ACT 250 PERMIT MAY BE REQUIRED
As the Subdivider(s) of this property, I/we hereby notify the buyer that an Act 250 permit may be required prior to this
partition or division of the property.
Prior to the partition or division of the land in question, the buyer may submit to the District Coordinator this Disclosure
Statement and other relevant information and should request a jurisdictional opinion from the District Coordinator as to the
applicability of Act 250 to this proposed partition or division of land.
12. If an Act 250 permit has been issued for the land being partitioned, enter the Land Use Permit Number.
I/we the Subdivider(s) hereby swear and affirm that this Disclosure Statement is true and complete to the best of my/our
knowledge. Knowing falsification of any statement contained herein is punishable pursuant to the provisions of 10 V.S.A.
§6003; 10 V.S.A. Chapters 201 and 211; and 13 V.S.A. §3016.
DATE: _____________________________________
__________________________________________
__________________________________________
Signature(s) of Subdivider(s)