2. Clean and Green Conveyance Form

   ACT 319

   NOTIFICATION OF CONVEYANCE FOR PROPERTIES ENROLLED UNDER THE PENNSYLVANIA FARMLANDS AND FOREST LAND ASSSESSMENT ACT OF 1974

   The following information must be provided by the current landowner to the County Assessor 30 days prior to any proposed transfer, split-off or separation of land enrolled under the act.

6. Phone Number:*
7. Email:*
9. County Parcel Number:*
11. Name(s) address(es) and phone numbers (daytime and evening) of landowner(s):
13. Current
14. Proposed
16. Year of enrollment under the act:
18. To the best of your knowledge, has any land been previously conveyed from the original tract enrolled under the act?

    1. Yes
    2. No
20. Complete the appropriate sections by showing the number of acres proposed for conveyance:
22. Agricultural Use:
23. Transfer
24. Split-Off
25. Separation
27. Forest Reserve:
28. Transfer
29. Split-Off
30. Separation
32. Agricultural Reserve:
33. Transfer
34. Split-Off
35. Separation
37. Check the proposed use for the land to be conveyed under this notification:

    1. Agriculture
    2. Forest Land
    3. Agriculture Reserve

    1. Urban
    2. Public (roads, parks)
38. Other (Specify)
42. By checking this box, I hereby certify that all the above information is true and correct.*

    1. I hereby certify the above to be true and correct.
44. First Name*
45. Last Name*
49. NOTE

    Upon submission of this application, I am asserting that I am the owner of the property listed above. If, for any reason, your proposal changes, please submit a revised Notice of Conveyance to our department for review.

Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field