[EXAMPLES FOR COMPLETING THIS FORM ARE IN BRACKETS. PLEASE
COMPLETE EVERY FIELD AND DELETE ALL INSTRUCTIONS AND BRACKETS.]
[Complete the applicable section either: Section A for a property conveyance or Section B for
an Alteration and Condemnation. Delete the section that is not applicable to your request.
Please submit copies to LSOHC and DNR Pass-through Administrator.]
Real Property Conveyance, Alteration, and Condemnation Form
Date: [April 28, 2011]
Contact information of requester: [Name, address, phone, e-mail]
Section A. Real Property Conveyance
I.
Land to be Conveyed to another Party
Expected date of conveyance: [April 28, 2011]
Program title: [title as it appears in legislation]
Current Project manager: [project manager name, organization, address, city, state, zip, phone
and e-mail]
Legislative citation/language: [ML2009, Chpt. 172, Art. 1, Sec. 2, Subd. X(x) / ML2010, Chpt.
361, Art. 1, Sec. 2, Subd. X(x), include legislative subdivision language under citation.]
Property identification (parcel name, TRDS, acres):
[Township,
Range – if the range is less than 10 a zero needs to be placed in from of the number,
Direction – the number is either 1 if in northeastern Cook County or 2 for the rest of the state
Section - if the section is less than 10 a zero needs to be placed in from of the number]
Property description (cover type, topographical, significant land/water features): [Prairie,
Wetland, Forest, Other Habitat / hilly, wetland, low lying, heavily covered / borders Lake
Vermillion, is centered in other WMA land]
Original purchase price: [$0.00]
OHF activity: [Restore, Protect, Enhance]
Location of local government office where notice of funding restriction is filed: [Enter the
County and City location]
Original intended use of land: [from appropriation and accomplishment plan]
II.
Party to which Land is being Conveyed
Recipient of conveyance and future contact/manager if different: [name, organization, address,
city, state, zip, phone and e-mail]
Terms of conveyance: [insert examples of choices here?]
Reason for exchange: [insert examples of choices here?]
OHF activity: [Restore, Protect, Enhance]
Location of local government office where notice of funding restriction will be filed: [Enter the
County and City location]
Future intended use of land: [conservation use]
III.
Replacement Land
Property identification (parcel name, TRDS, acres): [township, range, direction, section, the
direction is either 01 for east (northeastern Cook County or 02 for west – majority of state]
Property description (cover type, topographical, significant land/water features): [Prairie,
Wetland, Forest, Other Habitat / hilly, wetland, low lying, heavily covered / borders Lake
Vermillion, is centered in other WMA land]
Purchase price: [$0.00]
Appraised price: [$0.00]
Approval by commissioner of DNR: attach copy that includes date
Section B. Alteration of Use and Condemnations
I.
Land Use to be Converted
Date of expected alteration: [April 28, 2011]
Program title: [title as it appears in legislation]
Project manager: [project manager name, organization, address, city, state, zip, phone and email]
Legislative citation: [ML2009, Chpt. 172, Art. 1, Sec. 2, Subd. X(x) / ML2010, Chpt. 361, Art.
1, Sec. 2, Subd. X(x)]
Property identification (parcel name, TRDS, acres): [township, range, direction, section, the
direction is either 01 for east (northeastern Cook County or 02 for west – majority of state]
Property description (cover type, topographical, significant land/water features): [Prairie,
Wetland, Forest, Other Habitat / hilly, wetland, low lying, heavily covered / borders Lake
Vermillion, is centered in other WMA land]
Original purchase price: [$0.00]
Most recent appraised value: [$0.00]
OHF activity: [Restore, Protect, Enhance]
Nature of alteration and impact on habitat values: [e.g. powerline, road construction, cell tower]
II.
Land Interest to be Condemned
Property identification (parcel name, TRDS, acres): [township, range, direction, section, the
direction is either 01 for east (northeastern Cook County or 02 for west – majority of state]
Property description (cover type, topographical, significant land/water features)
Original purchase price: [$0.00]
Most recent appraised value: [$0.00]
Nature of condemnation: [insert examples of choices here?]
Suggested use of condemnation proceeds: [e.g. funds returned to OHF, funds used to purchase
land of equivalent conservation value]