NOTIFICATION OF CONVEYANCE FOR PROPERTIES
ENROLLED UNDER THE PENNSYLVANIA FARMLAND
AND FOREST LAND ASSESSMENT 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.
1) County Index Number: I.D.__________ Map ____________ Block ____________ Parcel ______________
2) Name(s), address(es) and phone numbers (daytime and evening) of landowner(s):
3) Year of enrollment under the act: _______________________________________
4) To the best of your knowledge, has any land been previously conveyed from the original tract enrolled under the act?
5) Complete the appropriate sections of the following table by showing the number of acres proposed for conveyance:
TRANSFER SPLIT-OFF SEPARATION
6) Check the proposed use for the land to be conveyed under this notification:
Forest Land Public (roads, parks)
Agriculture Reserve Other (Specify)
7) Signature of current landowner(s): __________________________ Date: _____________
__________________________ Date: _____________
Return this form to: ERIE COUNTY BUREAU OF ASSESSMENT
ERIE COUNTY COURT HOUSE ROOM 104
140 W 6
ERIE PA 16501-1097
NOTE: Landowners of properties enrolled under the Act are also required to notify the County Assessor 30 days prior to any proposed change
of use. Change of use notification can be done with a letter giving the name and address of the owner, the proposed new use and the
acreage involved. Failure to file this notification 30 days prior to conveyance is subject to a $100.00 civil penalty.
CLEAN AND GREEN CONVEYANCE – REV. 9/2001