STATE OF NEW MEXICO
ENERGY, MINERALS AND NATURAL RESOURCES DEPARTMENT
LAND CONSERVATION INCENTIVES TAX CREDIT
APPLICATION FORM
Submit to: Bob Sivinski, Forestry Division, 1220 So. St. Francis Dr., Santa Fe, New Mexico 87505
Date:
Applicant Name:
Address:
Telephone:
Fax Number:
E-mail Address:
Social Security Number (or Federal Tax Identification Number):
New Mexico CRS Number:
Documents that must be submitted with this application:
1. Copy of conservation easement or deed recorded with the county clerk of the county or county
where the donated land is located.
2. Qualified appraisal of land or interest in land donated prepared by a qualified appraiser showing
the fair market value of the land or interest in land.
3. Statement from the public or private conservation agency to whom you donated the land or a copy
of Internal Revenue Service Form 8283 signed by the public or private conservation agency.
4. If the donation is to a private conservation agency, a copy of that agency's 501(c)(3) certification
from the Internal Revenue Service.
5. If the donation is an interest in land rather than in fee, a title opinion or other documentation
showing that you own the mineral interests or a report from a professional geologist that the
probability of surface mining occurring on such property is so remote as to be negligible.
For donations of interests in land you may need to submit the following documents with this
application:
1. Is the interest in land subject to a mortgage?  Yes,  No. If yes, attach the subordination
agreement from the mortgage holder that subordinates its rights in the interest in land to the public
or private conservation agency.
2. If the conservation or preservation purpose is for the preservation of a certified historic structure,
documentation that the structure is listed in the National Register of Historic Places or is located in
a registered historic district and certified by the United States Secretary of the Interior to the
United States Secretary of the Treasury as being of historic significance to the district.
3. If the conservation or preservation purpose is for the preservation of a historically important land
area, documentation in the form of the nomination or determination of eligibility for the National
Register of Historic Places.
4. If the conservation or preservation purpose is for the preservation of open space that is not
pursuant to a clearly delineated federal, state, or local policy, a description of how the
conservation easement or deed will provide for the general public's scenic enjoyment and
identifying the significant public benefit unless there are provisions in the conservation easement
or deed that address this.
5. If the conservation or preservation purpose is for the protection of a relatively natural habitat, a
description of the habitat and how the conservation easement or deed protects such habitat
unless the baseline documentation or a provision in the conservation easement or deed
addresses this.
I certify the information above and attached to be true and certify that I did not donate the land or
interest in land for open space for the purpose of fulfilling density requirements to obtain subdivision
or building permits.
Signature of Applicant
or Authorized Representative:
Date: