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Attach to Wisconsin Income Tax Schedule FC i ZONING CERTIFICATE — FARMLAND PRESERVATION ACT — STATE OF WISCONSIN • (1) Name of Owners) Keller • Roman J. (Last) (First) (Middle Initial) (2) Address R#2, CTH I, Waunakee, WI 53597 849-4475 (3) Phone - (4) Location of the land Town of Westport Sec 3 8-N 9-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 form.) 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 December 7, 1979 (7) Does each structure or improvement on the land conform to the requirements of the exclusive agricultural zoning ordinance? Yes X No Land on which tax credit is claimed: (81 Parcel No. (from tax rolls) (9) Total Acres in parcel (10) Acres in Exclusive Ag. District 0809-034-8500-5 40.0000 40.0000 0809-031-8500-8 42.1000 42.1000 0809-031-9000-1 4 0.40 00 40.4000 Total 122.5 Total 122.5 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 Veal 2. _ ..__.. - _ -- -- Signature of Zoning Authority Title Date Program Year 3. _.— --- — -- -- Signature of Zoning Authority Title Date Program Year 4. --- - ------------ - - - - - ----------- _ _-_--_.._ ---------- Signature of Zoning Authority Title Date Program Year (The laud must be in an exclusive agricultural zone on Dec. .1/ of the year jr ii which credit is being claimed. This certificate, along with property tax bills, must be included with the Schedule a'when credit claim is filed with the Wisconsin Department of Revenue.)