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ADFP-2 (Rev. 2-1-79) Attach to Wisconsin Income Tax Schedule FC ZONING CERTIFICATE — FARMLAND PRESERVATION ACT — STATE OF WISCONSIN • (1) Name of Owner(s) Gilbertson Robert J. (Last) (First) (Middle Initial) (2) Address 1088 r m H "H", P#7, Mount Horeb, WI 53572 (3) Phone 437-5120 (4) Location of the land Town of Perry Secs 10, 15 & 16 5-N 6-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) Wane 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 August 22, 1 979 (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: (8) Parcel No. (from tax rolls) (9) Total Acres in parcel (10) Acres in Exclusive Ag. District 22-16-307 39.7 39.7 22-15-294 39.9 39.9 22-15-293 39.7 39.7 22-10-206 40.0 41 0 --- --_ 22-15-288 39.6 39.6 V� Total 198.9 Total 198.9 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 inj'onnation 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 Yeas 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 ram Year (The land must be in an exclusive agricultural zone on Dec. 31 of the year Pr which credit is being claimed. This certificate, along with property tax bills, must be included with the Schedule PC'when credit claim is filed with the Wisconsin Department of Revenue.)