Sample Form 6A CERTIFICATION FORM for STATE LAND ACQUISITION

Sample Form 6A – CERTIFICATION FORM FOR STATE LAND ACQUISITION

The sample form on the following page contains the template for the certification form used when the survey is prepared for the purpose of acquisition by the State of New Jersey. This form can be substituted by a document that contains the same information in substantially the same form. Please print on a single sheet of paper if possible; legal size (8-1/2” by 14”) may be used if necessary. For Certification Forms that do not fit onto a single legal sized page, multiple letter size pages may be used.

If the acquisition project is a joint undertaking by multiple agencies or entities, then the following information is to be added at the end of the “Project Information” section:

ACQUISITION PARTNER:______

PROJECT NAME:______

GREEN ACRES SOURCE OF FUNDING/ PROJECT NUMBER:______

GREEN ACRES PARTICIPATION ACRES THIS FUNDING SOURCE:______

If the acquisition project entails more than one tax lot, create a separate entry under “Acquisition Parcel Information” for each individual tax lot, using the following format. The necessary information for each separate tax lot is as follows:

BLOCK:_____ LOT:_____ MUNICIPALITY:______COUNTY:______

ENTIRE__ or PART__ (OF LOT)FEE___ PERCENT of LOT:___ ACRES:______

EASEMENT___TYPE OF EASEMENT______

Identify the deed used as reference for the property or properties in question in the “Acquisition Title Information” whether or not title commitment information is available.

NEW JERSEY DEPARTMENT OF ENVIRONMENTAL PROTECTION

GREEN ACRES PROGRAM

STATE LAND ACQUISITION PROGRAM

SURVEYOR’S CERTIFICATION AND SUMMARY FORM

PROJECT INFORMATION

PROJECT NAME:______

GREEN ACRES SOURCE OF FUNDING/ PROJECT NUMBER: SA-______-______

SELLER’S NAME:______

MANAGING AGENCY/ENTITY:______

ACQUISITION PARCEL INFORMATION

BLOCK:_____ LOT:_____ MUNICIPALITY:______COUNTY:______

ENTIRE__ or PART__ (OF LOT) FEE___ PERCENT of LOT:___ ACRES:______

EASEMENT___TYPE OF EASEMENT______

ACQUISITION SURVEY INFORMATION

PREPARED FOR :___NJDEP GREEN ACRES PROGRAM______

SURVEY FIRM:______CONTRACT No._S-______

SURVEYOR:______NJPLS No.______

DATE ON SURVEY PLAN:______DATE SIGNED:______DATE LAST REVISED:______

ACQUISITION TITLE INFORMATION

TITLE COMPANY______

COMMITMENT No.______DATE OF COMMITMENT______

DEED(S) USED FOR REFERENCE:______

CERTIFICATION

I hereby certify that I have completed the above survey(s) in accordance with the Green Acres Survey Guidelines contained in a written contract as indicated. Based upon an actual field survey and my examination of evidence, the above parcels consist of a total surveyed area of ______acres subject to the following:

EASEMENTS______

RESTRICTIONS______

CONDITIONS______

PUBLIC ROAD______AC. CLAIMED NJ TIDELANDS ____AC. CLOUDED TITLE ____AC.

UNDERWATER_____AC. ENCROACHMENTS: YES___NO___ # OF DESCRIPTIONS:___

______

SURVEYOR’S SIGNATURE, DATE & SEAL REVIEW BY GREEN ACRES, NJDEP