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• Attach to Wisconsin Income Tax Schedule FC ALSO: Deerfield • • ZONING CERTIFICATE — FARMLAND PRESERVATION ACT — STATE OF WISCONSIN (1) Name of Owner(s) — Kelly .LeRoy (Last) (First) (Middle Initial) (2) Address 1186 Liberty Road, Deerfield, WI 53531 (3) Phone 764-5373 (4) Location of the land Town of Christiana Secs 4, 5 & 9 6-N 12-E ' Dane Town, Village,or City Section,Township, Range County (If part of the owner's farmland is located in another town, village, or city,please submit information about that farmland on a separate Jonn.) EXCLUSIVE AGRICULTURAL ZONING (5) Dane County has an exclusive agricultural zoning ordinance which has been certified (County, Town, Village or City) by the State Agricultural Lands Preservation Board. (6) If the land is located in a town, has the town adopted the county exclusive agricultural zoning ordinance? Yes X No Date of Town Approval July 19, 1979 (7) Does each structure or improvement on the land conform to the requirements of the exclusive agricultural zoning ordinance? Yes No X Land on which tax credit is claimed: (8)• Parcel No. (from tax rolls) (9) Total Acres in parcel (10) Acres in Exclusive Ag. District • 8-04-81 40.0 40.0 8-05-107 20.5 20.5 -- 8-05-108 40.2 40.2 8-09-178 39.6 39.6 • • • Total 140.3 Total 140.3 AGRICULTURAL PRESERVATION PLAN (11) _ Dane • County has adopted an agricultural preservation plan which was certified (date) 12/4/81 by the State Agricultural Lands Preservation Board. Is all of the owner/applicant farmland located in an agricultural preservation district under the certified county preservation plan? Yes • . No If NO, how many acres are in the preservation district? • CERTIFICATION Signature of Zoning Authority: _ Program Year - Title: ZONING ADMINISTRATOR Date:.__—_—___—__ --- • RE-CERTIFICATION (Note:If any of the above information has changed,please submit a new zoning certificate.) The undersigned hereby certifies that the information contained on this form is true and correct on the most recent date shown below. • Signature of Zoning Authority Title Date Program Year 2. - . _ .. - -- -- _• -- • Signature of Zoning Authority Title Date Program Year 3. --- - -- _— Signature of Zoning Authority Title Date Program Year Signature of Zoning Authority Title Date Program Year (The land must be in an exclusive agricultural zone on Dec. .i I of the year Ji)r which credit is being claimed. This certificate, along with property tax bills, must be included with the Schedule 1•C'when credit claim is filed with the Wisconsin Department of•Revcnue.) .