TRANSMITTAL FORM

(Note:  A ".pdf" version of this document is available at this link.)

To Indicate the Number of Pine Barrens Credits to be Sold
(Originating From Central Pine Barrens Sending Area Land in the Town of Brookhaven)

Dated  ________, 2001

By Mail: By Facsimile Transmission: By Hand or Overnight Courier:
Pine Barrens Credit Clearinghouse (631) 224-7653 Pine Barrens Credit Clearinghouse
P.O. Box 587 To Confirm Receipt of Facsimile: 3525 Sunrise Highway, 2nd Floor
Great River, New York 11739-0587 (631) 563-0385 Great River, New York 11739

PLEASE CALL TO CONFIRM RECEIPT OF TRANSMITTAL FORM (631) 563-0352
 
DESCRIPTION OF CREDITS
Letter of Interpretation/ Pine Barrens Credits
(Attach additional list, if necessary)
Print Name(s) and Address(e's) of Credit Holder(s) (please print in box below exactly as name(s) appear on the Pine Barrens Credit Certificate(s) or Letter(s) of Interpretation as appropriate)
Certificate Number
(If you have a Certificate)
Suffolk County Tax Map Number on Letter of Interpretation
Total Number of Credits Represented by Certificates/ Letter of Interpretation
Number of Credits that may be sold at indicated price
Total Credits:

 
TOTAL PURCHASE PRICE OF CREDITS THAT MAY BE SOLD
___________ x $ 40,000.00 = $ ________________
total credits (price per credit) total purchase price 

(YOU MUST COMPLETE THE BACK OF THIS FORM)
SIGNATURE

The Credit Holder (LOI Holder) must sign this document in order to be considered for the purchase of Credits. The Credit Holder understands that there is no guarantee that his/her Credits will be purchased. The signature(s) below must match the name or names listed on either the Pine Barrens Credit Certificate and/or the Letter of Interpretation.
 


____________________________________
Credit Holder's Name

Dated: ______________________________

____________________________________
Credit Holder's Name

Dated: _____________________________

Capacity (full title)_______________________________________________________________


 


Address (to which documents and payments should be sent)

________________________________________________________________________

_________________________________________________________________________

Telephone Number(s): (____)_____________ (____)_____________

Email Address: ______________________________________________________