Land Disclosure Document

Land Disclosure Document

Instructions:

Thank you for completing this questionnaire. Please answer the questions based on your knowledge. You are not expected to find answers. If you answer “yes” to any of the questions, please provide additional information, or an ENGIE representative will contact you to go over the information. Feel free to attach any information you think might be helpful with your answers. Your information is important to us in assessing the property for this project, so please complete and submit the form as soon as possible.

Project Name or County, State

Name of Your Land Agent

Landowner Information

Last Name

First Name

Phone Number

How are you feeling about this opportunity?

RED - I am unhappy

YELLOW - I have reservations

GREEN - I am happy

BLUE - I am an ENGIE Advocate in my community

Select

Property Information

Property Address

City

State

Zip Code

Do you currently occupy the property?

Select

Tenant Name (if applicable)

Tenant Phone # (if applicable)

Permitted Encumbrances

Please indicate if the following agreements affect the Premises. Please choose one and explain if, Yes.

Mortgage(s)

Select

If yes, is it FSA?

Oil & Gas Lease (s)

Select

Oil & Gas Explanation

If YES, identify lessee(s) and how long is the term:

Pipeline Easement(s)

Select

Pipeline Easement Explanation

If YES, identify easement holder(s):

Electric Line Easement(s)

Select

Electric Line Easement Explanation

Private or Public Access Easement(s)

Select

Hunting Lease(s)

Select

Hunting Lease Explanation

If YES, please provide a copy of the lease and all amendments.

Grazing Lease(s)

Select

Grazing Lease(s) Explanation

If YES, please provide a copy of the lease and all amendments.

CRP Acreage

Select

CRP Acreage Explanation

If any portion of the Premises under contract with or included in the Conservation Reserve Program (CRP) or other related program, please provide a copy of the contract and all amendments. What is the length of contract?

Other encumbrances or third-party rights

Select

If yes, please list:

Does anyone other than yourself have a lease, easement, claim or any other right to use or occupy any part of your property surface or subsurface, other than those stated in documents available in the public record?

Select

If Yes, please explain:

Are there Severed Minerals?

Select

If yes, please let us know:

Land Information

Please indicate if the following affect the Premises. Provide any maps or documentation to support the land information.

Are there trees we should not clear?

Select

If yes, what kind of tree and location:

Are there crops on the land?

Select

If yes, what kind:

Above ground wells

Select

If yes, please provide location:

Capped Wells

Select

If yes, please provide location:

Abandoned Oil & Gas Wells

Select

If yes, please provide location:

Above ground pipe

Select

If yes, please provide location:

Below ground pipe

Select

If yes, please provide location:

Structures / Buildings to Avoid

Select

If yes, please provide location:

Structures / Buildings to Remove

Select

Other Special Considerations of the Land

Select

If yes, please provide explanation and location:

Current Use of the Land Subject to the Lease

Please provide an approximate percentage of how the land is currently being used between the six options below. For idle land, please select Other Agriculture:

Irrigated Crop

Non-irrigated Crop

Pasture

Forest or Timber

Other Agriculture

Non-Agriculture

Has the current use of the land changed during the last 5 years?

Select or enter value

If yes, please provide explanation:

Other

Please indicate if the following affect the Premises. Provide any maps, images or documentation to support the land information.

Cattle or Livestock on Property

Select

If yes, what kind:

Free-roaming dogs or potentially dangerous animals

Select

If yes, what kind:

Irrigation or Pivot System

Select

Any drain tile on site

Select

Existing fences

Select

If yes, please provide location:

Transmission/Power Lines, Substations on Property

Select

If yes, please provide location:

Existing access drives

Select

If yes, please provide location:

Contaminated Soil

Select

If yes, please provide explanation and location:

Other special considerations of the land?

Acknowledgement

Please add your initials acknowledging that this form has been filled to the best of your knowledge of the land.

Date

Initials

File Upload

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse