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									                    Wisconsin Farmland Preservation Program (ch. 91, Wis. Stats.)

                                        REZONE RECORD
                                         (OPTIONAL FORM)

Location and Description of Rezoned Land (attach map and legal description)

County                                             Parcel Number                    Acres

                                                                ……………………
Town/Village/City
                                                                ……………………

                                                                ……………………

                                                                ……………………

                                                                ……………………
                                                                                    _____
                                                                     Total Acres

Owner(s) of Rezoned Land
Name:

Address:

Person Requesting Rezoning (if different from landowner):
Name:

Address:

Rezoned from (identify certified farmland preservation district)

District Identification Number

District Name

Rezoned to (identify zoning district)

District Identification Number

District Name:

Public Hearing

Presiding Officer or Body:

Hearing Location:

Hearing Date and Time:

Comments Received?               (If yes, attach record of persons and comments.)
Required Findings

Has the zoning authority made all of the following findings after public hearing, as required by s.
91.48(1)(a), Wis. Stats.?         (If yes, attach resolution, minutes, or other record of findings by
approving body.)

   The rezoned land is better suited for a use not allowed in the farmland preservation zoning district.
   The rezoning is consistent with any applicable comprehensive plan.
   The rezoning is substantially consistent with the county certified farmland preservation plan.
   The rezoning will not substantially impair or limit current or future agricultural use of surrounding
    parcels of land that are zoned for or legally restricted to agricultural use.

State “Conversion Fee”
The person requesting the rezoning paid the following state “conversion fee,” as required by s.
91.48(1)(b), Wis. Stats.:

($______________________) X 3 X (________________ ) = $_____________________
Grade 1 per-acre Ag Land Assessment     Number of Acres Rezoned       Total State-Mandated Conversion Fee
    Value In Town or Municipality        (Round Up to Next Whole #)


Local “Conversion Fee” If Any
The person requesting the rezoning paid the following supplementary local “conversion fee:”

                    [Enter Required Local “Conversion Fee” Amount Paid, if Any]


Fee Payment
    State “conversion fee” (see above):                                  $
    Local “conversion fee,” if any (see above):                          $
    Other rezoning fees:                                                 $
                                                                             ______

                                      TOTAL REZONING FEES                $

    Fee payment received on (date of receipt):

    Form of payment:

Rezoning Approval
Approving Body:            Approval Date:
Attach approval documentation (resolution, minutes or other record documenting action by
approving body)

Signature

This rezone record signed this             day of            ,

Zoning Authority (enter name of county, town, city or village):

Title of Authorized Signing Official:


Authorized Signature: _____________________________

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