Fillable MDAR - Statement of Property Owner

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MDAR - Statement of Property Owner

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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T
HE
C
OMMONWEALTH
O
F
M
ASSACHUSETTS
EXECUTIVE OFFICE OF ENERGY AND ENVIRONMENTAL AFFAIRS
Department of Agricultural Resources
251 Causeway Street, Suite 500, Boston, MA 02114
617-626-1700 fax: 617-626-1850 www.mass.gov/agr
CHARLES D. BAKER
Governor
KARYN E. POLITO
Lt. Governor
MATTHEW A. BEATON
Secretary
JOHN LEBEAUX
Commissioner
Statement of Property Owner
Name(s) of Property Owner(s):
Property Address(es):
Name of License Applicant:
Relationship to Owner: ☐Property Manager ☐Lessee ☐Other (please explain)
The individual(s) signing hereby acknowledge that he/she is the legal property owner(s) of the above-
listed property(s), that she/she are consenting to the use of the property(s) for the growing and/or
processing of industrial hemp, and acknowledge the following:
• That the cultivation and possession of industrial hemp in Massachusetts in a violation of the
Controlled Substance Act, 21 U.S.C. 801 et. seq., unless done so in accordance with Section
7606 of the Agricultural Act of 2014, and M.G.L. c. 128, Sections 116 through 123.
• That federal prosecution for growing or possessing industrial hemp in violation of federal law
may include criminal penalties, forfeiture of property, and loss of access to federal agricultural
benefits, including but not limited to, services provided by the United States Department of
Agriculture Natural Resources Conservation Service, agricultural loans, and insurance programs.
• That state penalties for growing or possessing industrial hemp in violation of state law may
include civil administrative fines in accordance with M.G.L. c. 128, Section 123.
• If the growing and/or processing site(s) are subject to an Agricultural Preservation Restriction
(“APR”), the land may not be eligible for use in the Department’s Industrial Hemp Program and
that it is the owner and applicant’s responsibility to review and understand the terms and
conditions set forth in the APR and to obtain prior written approval before submitting this
application.
• That any individual/entity registered by the Department to grow or process industrial hemp shall
be subject to audit, inspection, and testing pursuant to M.G.L. c. 128, Section 122 by and at the
discretion of the Department.
Page 2 of 2
• That upon approval of the application, the Department may share the location of all growing
and/or processing sites with municipal officials and local law enforcement in the city or town
where hemp will be grown or processed. Any information obtained by the Department may be
disclosed to the public and/or to law enforcement agencies without further notice to me, the
Applicant, the owner of the property registered for cultivation and/or processing of industrial
hemp, or any Department representatives, unless otherwise prohibited by law.
(please initial): _____________I hereby give consent for the Department to conduct both scheduled and
random inspections of and around the premises on which industrial hemp is being sown, grown,
harvested, stored, and processed.
(Please attach a separate, notarized signature page for each property owner)
Signature Date
COMMONWEALTH OF MASSACHUSETTS
, ss. Date:
On this ____ day of , 20 before me, the undersigned Notary Public, personally
appeared, personally appeared the above-named who proved to me
through satisfactory evidence of identification, namely personal knowledge, to be the person whose
name is signed on this document, and acknowledged to me that he/she signed it voluntarily for its stated
purpose.
_________________________________
Notary Public:
Commission Expires:
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MDAR - Statement of Property Owner

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Completed 11 May 2020

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