ACT 250 DISCLOSURE STATEMENT
                           VERMONT NATURAL RESOURCES BOARD
                           MONTPELIER, VERMONT  05602

NOTE:  IF THIS TRANSACTION DOES NOT INVOLVE THE PARTITION OR DIVISION OF LAND BY A PERSON, THIS ACT 250 
DISCLOSURE STATEMENT IS NOT REQUIRED.  REFER TO 10 V.S.A. § 6001(14)(a) and (b) FOR THE DEFINITION OF “PERSON”.
1.  SUBDIVIDER’S (TRANSFEROR) FULL NAME(S)           MAILING ADDRESS 

 NAME OF CONTACT PERSON FOR SUBDIVIDER               MAILING ADDRESS                                TELEPHONE NO.

2.  BUYER’S (TRANSFEREE) FULL NAME(S)                MAILING ADDRESS 

3.  DESCRIPTION OF PROPERTY

 TOWN                                                ROAD                                           NUMBER OF ACRES
4.  State the total number of lots or parcels the Subdivider intends to create as part of this partition or division of land.            
 NUMBER OF LOTS
5.  Has the Subdivider divided or partitioned any other land within the past five years which is located within the same town 
 or district or is located within five miles (if in a different district)?
 See map.      Lots within the same town?                                                NO   YES NUMBER OF LOTS  ___________
               Lots within the same district?                                            NO   YES NUMBER OF LOTS  ___________
               Lots within five miles?                                                   NO   YES NUMBER OF LOTS  ___________ 
6.  Have the Subdivider’s parents or children (natural or adoptive) or spouse or any trust, corporation, or other entity affiliated 
 with the Subdivider, divided or partitioned any other land within the past five years which is located within the same town 
 or district or is located within five miles (if in a different district) of the land being partitioned?
   NO      YES  IF “YES,” COMPLETE THE FOLLOWING ABOUT THE FAMILY MEMBER
 NAME                                           ADDRESS                                                  RELATIONSHIP

7.  Did the Subdivider profit or derive any consideration or financial benefit from the partition or division of the land of that 
 family member or other entity as listed in #6 above.
   NO      YES  IF “YES,” COMPLETE THE FOLLOWING ABOUT THE FAMILY MEMBER
 NAME                                           ADDRESS                                                  RELATIONSHIP                   

                                                                                                                 FORM 250
                                                                                                                     (Rev. 06/15)

8.  Will any family member or entity 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 Commission 
 (see 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.  Failure to obtain an Act 250 permit in violation of 10 V.S.A. § 6081 may result in prosecution 
 under the Environmental Enforcement Act, 10 V.S.A. Chapter 200.
 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)

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                       ACT 250 DISCLOSURE STATEMENT
                                          GENERAL INSTRUCTIONS
Prior to the division or partition of land, the seller or other person dividing or partitioning the land shall prepare an “Act 250 
Disclosure Statement.”  A person who is dividing or partitioning land, but is not selling it, shall file a copy of the statement with the 
town clerk, who shall record it in the land records.  The seller who is dividing or partitioning land as part of the sale shall provide 
the buyer with the statement within ten days of entering into a purchase and sale agreement  for the sale or exchange of land, or at 
the time of transfer of title, if no purchase and sale agreement was executed, and shall file a copy of the statement with the town 
clerk, who shall record it in the land records.  Failure to provide the statement as required shall, at the buyer’s option, render the 
purchase and sales agreement unenforceable.  Do not send Act 250 Disclosure Statement to the Natural Resources Board.

                                          LINE-BY-LINE INSTRUCTIONS
1. - 7.  Subdivider(s) Be sure to enter the full names and mailing addresses of all Subdivider(s) and Buyer(s).  Be certain to 
    and Buyer(s)       complete all items.

8.  Benefit            Indicate by checking “yes” or “no” whether any family member listed in #6 will derive any profit or 
    to Family          consideration, or acquire any other beneficial interest from the partition or division of the land which 
    Members from       is the subject of this Disclosure Statement.  If the family member receives financial support from the 
    Subdivider’s       subdivider(s),  or  if  the  subdivider(s)  receive  financial  support  from  the  family  member,  there  is  a 
    Transactions       presumption of financial benefit and that person should be listed.  If, however, a child is emancipated 
                       and is not receiving financial support from the parent, there is no presumption of benefit and that family 
                       member should not be listed.

9.  Affiliated         This includes all persons who are affiliated with the Subdivider in the partition or division of the land in 
    Persons            question (i.e. derive a profit, consideration or other beneficial interest from the subdivision).  However, 
                       some individuals and entities are presumed not to be affiliated with the Subdivider in the subdivision, 
                       unless there is substantial evidence of an intent to evade the purposes of Act 250.  These include:

                       (i)   A stockholder in a corporation subdividing land, where the stockholder and the stockholder’s 
                       spouse, children, parents and siblings own less than 5% of the outstanding shares of the 
                       corporation.

                       (ii)  A court-appointed guardian, licensed attorney, real estate broker or salesperson, engineer 
                       or land surveyor, unless the compensation or benefit which they receive for their duties 
                       indicates more than an agency relationship with the Subdivider. 

                       (iii) A chartered lending institution which financed the Subdivider’s purchase or ownership of 
                       the land, provided the financing rate is not substantially higher than the prevailing lending 
                       rates in the community.

10. Affiliated Land    List all lots or parcels of land partitioned or divided for the purpose of resale by the persons identified 
    Transactions       in item #9 above within the preceding five years and within the same jurisdictional area of the District 
                       Environmental Commission or within five miles of the land being divided if the previously divided land 
                       is in another district (see map on our website).  Subdivided lots or parcels which were conveyed by these 
                       persons prior to July 1, 1987, and which are more than five miles away from the land being partitioned 
                       or divided, need not be listed.  List the full name of the person, the town in which the land is located, a 
                       brief description of the land (i.e. undeveloped land, residential subdivision, lot number, etc.), the number 
                       of acres, and the date the lot or parcel was created.  Dates for creation of lots or parcels can include 
                       the date a plot plan is filed in the town land records, the date a subdivision permit or wastewater and 
                       potable water supply permit by the state or delegated municipality is issued, the date a local subdivision 
                       or zoning permit is issued, or in the absence of any of the above, the date of the legal conveyance of the 
                       lot, whichever is first.

11. Notice That        With this statement buyers are on notice that the partition or division of land which is the subject of this 
    An Act 250         Disclosure Statement may be subject to the permit requirements of Act 250. The buyer should request 
    Permit May be      a jurisdictional opinion from the District Coordinator serving the district in which the land is located 
    Required           regarding the applicability of Act 250 to this transaction by submitting the Disclosure Statement to the 
                       coordinator at the appropriate Regional Office (see map on our website).

12. Act 250 Permit     Enter the Act 250 Land Use Permit Number for this land, if one has been issued. 
    Number