Pine Barrens Credit Clearinghouse
James T.B. Tripp, Esq., Chairman
Andrew P. Freleng, AICP, Vice Chairman
Richard W. Hanley, Member
Mitchell H. Pally, Esq., Member
Herbert Phillips, Member

TRANSMITTAL FORM

To Indicate a Price for Pine Barrens Credits
(Originating From Central Pine Barrens Core Area Land in the Town of Southampton,
in the Westhampton Beach and the Remsenburg-Speonk School District)

Dated ____________________, 2003

THE TRANSMITTAL FORM MUST BE RECEIVED AT THE CLEARINGHOUSE BY
5:00 P.M., NEW YORK CITY TIME, ON FRIDAY FEBRUARY 28, 2003.

By Mail:
Pine Barrens Credit Clearinghouse
P.O. Box 587
Great River, NY 11739-0587

By Facsimile Transmission
(631) 224-7653
To Confirm Receipt of Facsimile: (631) 224-2604

By Hand or Overnight Courier
Pine Barrens Credit Clearinghouse
3525 Sunrise Highway, 2nd Floor
Great River, NY 11739
 
 
DESCRIPTIONS OF CREDITS
Letter of Interpretation / Pine Barrens Credits
(Attach additional list, if necessary)
Print Name(s) and Address(es)
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
Certificate
Number
Suffolk County Tax Map
Number on Letter of Interpretation
Total Number of
Credits
Represented by
Certificate(s) /
Letter(s) of Interpretation
Number of
Credits
that may
be sold at
indicated price
         
       
       
       
Total Credits:
   

 
Please check the appropriate box below

[ ] Letter of Interpretation Holder   [ ] Credit Certificate Holder   [ ] Never Applied for a Letter of Interpretation

SIGNATURE

The Credit Holder must sign this document for it to be considered in this credit purchase. 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: _____________________________ __________________________________
 

Capacity (full title): __ _____________________________________________________
 

Address ( to which documents and payments should be sent):

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________
 

Telephone Number(s) (_____)_______________   (_____)_______________