Form
Application for a Land Preservation Credit
*VALPC1118888*
Donations recorded on or after July 1, 2015 must file a complete Form LPC-1 on or
LPC-1
before December 31 of the calendar year following the year the donation was recorded.
Acknowledgment of receipt by the Department of Taxation of this application form does NOT constitute
certification, approval, or validation of the donation or of the credit valuation.
Mail form, enclosures, and payment
Before completing Form LPC-1, please read the instructions.
(if applicable) to:
To avoid delays at the time of annual return processing, Form LPC-1 should be filed by the applicant within 90
Virginia Department of Taxation
days of the donation, but at least 90 days before filing your annual return. Applications for tax credits of $1 million
Tax Credit Unit
or more should be submitted at least 120 days before filing an annual return.
P.O. Box 715
For general assistance, call (804) 786-2992.
Richmond, VA 23218-0715
For assistance regarding Sections IV, V, and Schedules B & C, call (804) 371-5218.
Also send a copy of form and specified enclosures (see What To Enclose) to:
Department of Conservation & Recreation, Tax Credit Program, 600 East Main Street, 24th Floor, Richmond, VA 23219
Section I – Applicant Information
A) Applicant Type - Check One
Individual Taxpayer
Married Donors
Multiple Donors
Trust/Estate
Pass-Through Entities
Corporation
Non-Profit
Other Entity - Specify _________________________________________
B) Applicant Name (As Shown on Deed)
C) Applicant Identification Number (Check appropriate box and enter number.)
SSN
FEIN
D) Street Address or P.O. Box Number
City
State
ZIP Code
E) Contact Name, If Different from Above
F) Phone Number
G) Fax Number
H) Email Address
Section II – Donation Questions
II-A - Questions for a Donation Made on or After January 1, 2007
A) Are you a nonprofit holder of easements as defined in Va. Code § 10.1-1009?
Yes
No
IF YES, GO TO B; IF NO, GO TO C.
B) Do you hold one or more conservation easements excluding this donation that were acquired pursuant to the authority
Yes
No
conferred on a “holder” by Va. Code § 10.1-1010?
IF YES, STOP. YOU DO NOT QUALIFY.
C) Have you applied for a Historic Rehabilitation Credit in the last 5 years on this property/building?
Yes
No
IF YES, STOP. YOU DO NOT QUALIFY.
D) In the past 11 years, have you, a family member or an affiliate been issued a credit for a donation on any portion of this
Yes
No
parcel(s)? IF YES, LP# _______________________ . DONATION MAY REQUIRE DCR VERIFICATION. (See instructions).
II-B - Questions for a Donation Made on or After July 1, 2010
A) If your application is for a credit of $250,000 or more, has a credit been applied for and/or issued within the past 3 years for
Yes
No
real property that was formerly part of the same parcel of land as the property being donated?
IF YES, LP# _______________________ . DONATION MAY REQUIRE DCR VERIFICATION. (See instructions).
Section III – Property and Credit Information
A) Type of Donation - Check One
B) Bargain Sale - Check One
C) Number of Acres
D) Date Acquired
No
Fee Simple
Yes
(If Yes, Enter Amount Received)
Less-Than-Fee Simple
$
.00
Facade
E) Property Street Address (No P.O. Box)
City
State
ZIP Code
F)
Property Information - Enclose Additional Pages, if Needed
Zoning & Highest and Best Use
Tax Map or PIN
Recording Locality
Current Zoning:
Highest and Best Use Before Donation:
G) Name(s) of Eligible Conservation Agency(ies) Receiving Donation
H) Jurisdiction(s) Donation Was Recorded
I) Date Recorded
J) Appraisal Company Name
K) Company’s FEIN or SSN L) Appraisal Evaluation Date M) Appraisal Report Date
N) Appraised Value of Donation
O) Credit Amount Requested
P) Assessed Value of Land per Acre
Q) Appraised Value Per Acre
Form
Application for a Land Preservation Credit
*VALPC1118888*
Donations recorded on or after July 1, 2015 must file a complete Form LPC-1 on or
LPC-1
before December 31 of the calendar year following the year the donation was recorded.
Acknowledgment of receipt by the Department of Taxation of this application form does NOT constitute
certification, approval, or validation of the donation or of the credit valuation.
Mail form, enclosures, and payment
Before completing Form LPC-1, please read the instructions.
(if applicable) to:
To avoid delays at the time of annual return processing, Form LPC-1 should be filed by the applicant within 90
Virginia Department of Taxation
days of the donation, but at least 90 days before filing your annual return. Applications for tax credits of $1 million
Tax Credit Unit
or more should be submitted at least 120 days before filing an annual return.
P.O. Box 715
For general assistance, call (804) 786-2992.
Richmond, VA 23218-0715
For assistance regarding Sections IV, V, and Schedules B & C, call (804) 371-5218.
Also send a copy of form and specified enclosures (see What To Enclose) to:
Department of Conservation & Recreation, Tax Credit Program, 600 East Main Street, 24th Floor, Richmond, VA 23219
Section I – Applicant Information
A) Applicant Type - Check One
Individual Taxpayer
Married Donors
Multiple Donors
Trust/Estate
Pass-Through Entities
Corporation
Non-Profit
Other Entity - Specify _________________________________________
B) Applicant Name (As Shown on Deed)
C) Applicant Identification Number (Check appropriate box and enter number.)
SSN
FEIN
D) Street Address or P.O. Box Number
City
State
ZIP Code
E) Contact Name, If Different from Above
F) Phone Number
G) Fax Number
H) Email Address
Section II – Donation Questions
II-A - Questions for a Donation Made on or After January 1, 2007
A) Are you a nonprofit holder of easements as defined in Va. Code § 10.1-1009?
Yes
No
IF YES, GO TO B; IF NO, GO TO C.
B) Do you hold one or more conservation easements excluding this donation that were acquired pursuant to the authority
Yes
No
conferred on a “holder” by Va. Code § 10.1-1010?
IF YES, STOP. YOU DO NOT QUALIFY.
C) Have you applied for a Historic Rehabilitation Credit in the last 5 years on this property/building?
Yes
No
IF YES, STOP. YOU DO NOT QUALIFY.
D) In the past 11 years, have you, a family member or an affiliate been issued a credit for a donation on any portion of this
Yes
No
parcel(s)? IF YES, LP# _______________________ . DONATION MAY REQUIRE DCR VERIFICATION. (See instructions).
II-B - Questions for a Donation Made on or After July 1, 2010
A) If your application is for a credit of $250,000 or more, has a credit been applied for and/or issued within the past 3 years for
Yes
No
real property that was formerly part of the same parcel of land as the property being donated?
IF YES, LP# _______________________ . DONATION MAY REQUIRE DCR VERIFICATION. (See instructions).
Section III – Property and Credit Information
A) Type of Donation - Check One
B) Bargain Sale - Check One
C) Number of Acres
D) Date Acquired
No
Fee Simple
Yes
(If Yes, Enter Amount Received)
Less-Than-Fee Simple
$
.00
Facade
E) Property Street Address (No P.O. Box)
City
State
ZIP Code
F)
Property Information - Enclose Additional Pages, if Needed
Zoning & Highest and Best Use
Tax Map or PIN
Recording Locality
Current Zoning:
Highest and Best Use Before Donation:
G) Name(s) of Eligible Conservation Agency(ies) Receiving Donation
H) Jurisdiction(s) Donation Was Recorded
I) Date Recorded
J) Appraisal Company Name
K) Company’s FEIN or SSN L) Appraisal Evaluation Date M) Appraisal Report Date
N) Appraised Value of Donation
O) Credit Amount Requested
P) Assessed Value of Land per Acre
Q) Appraised Value Per Acre
Application for a Land Preservation Credit
Form LPC-1
*VALPC1218888*
Page 2
Section IV – Conservation Information for Reporting Purposes
A) Conservation Purpose: Identify the conservation purpose(s) protected by the donation by checking the applicable box(es). Also, specify the acreage
of each use indicated. See Instructions for definitions of these conservation purpose categories.
Conservation Purpose
Check Applicable Boxes
Acres
1. Agricultural Use
2. Forestal Use
3. Natural Habitat and Biological Diversity
4. Historic Preservation
5. Natural Resource Based Outdoor Recreation and Education
6. Watershed Preservation
7. Preservation of Scenic Open Space
8. Conservation and Open Space Lands Designated by Local Governments
B) Public Benefit: Indicate how the donation will protect the conservation purpose(s) identified above and benefit the public.
Indicate which of the following restrictions are included in the deed of donation:
4. Restrictions on the location of permitted
1. Limitations on the number of property divisions.
Yes
No
Yes
No
new roads or access ways.
2. Limitations on the amount of new buildings and
5. Limitations on alterations, demolition,
and ground disturbing activity that
structures.
Yes
No
Yes
No
may impact historic, cultural, or natural
heritage resources.
3. Restrictions on the location of permitted new
6. Limitations on utility placement.
Yes
No
Yes
No
buildings and structures.
7. Please list any other restrictions specifically donated to protect the conservation purposes and to benefit the public.
C) Riparian Buffers: If riparian buffers are required in the deed of easement, then indicate the total length (in linear
Forested/Vegetated: ______ feet
feet) of those that provide at least a 35-foot wide buffer (See instructions for definitions).
No-plow: _______________ feet
D) Land Currently Being Used for Production Agriculture and Silviculture.
Acres
1. Provide an estimate of the number of acres of the land currently being used in production agriculture (See instructions
for definition):
2. Provide an estimate of the number of acres of the land currently being used in production silviculture (See instructions
for definition):
E) Onsite Operational Water Quality Best Management Practices.
Does the land have onsite operational best management practices that are designed to reduce the amount of nutrients
Yes
No
and sediment entering public waters?
If Yes, indicate which of the following BMPs are being practiced, and whether the terms of the deed of easement require their continued practice.
Agriculture Best Management Practice
Currently Practiced
Deed Requires Continued Practice
1. Nutrient Management Plan Writing and Implementation
2. Cover Crop Practices
3. Livestock Exclusion Practices
4. Riparian Buffer Practices
Silviculture Best Management Practice
Currently Practiced
Deed Requires Continued Practice
5. Streamside Management Zones
6. Forest Roads
7. Stream Crossings
8. Harvest Planning
9. Other Agriculture or Silviculture BMPs (See instructions for Section D).
Provide appropriate practice number(s):
F) Forest Management: Is the property fully or partially forested?
Yes
No
If Yes, is a forest management plan included in the terms of the donation?
Yes
No
Form LPC-1
*VALPC1318888*
Application for a Land Preservation Credit
Page 3
Section V – Fee Simple Donation
Check Applicable Boxes
A) The donation is a full or partial gift in fee simple to a public or private conservation agency. (If the application
is for $1 million or more, also complete Schedule C.)
Conservation Agency Name: __________________________________________________
B) The donation is a full or partial gift to a “holder” as defined in Va. Code § 10.1-1009, and documentation is
included that the agency agrees that subsequent conveyances of the fee interest in the property will be made subject
to a conservation easement or will be made to the Commonwealth of Virginia or a federal conservation agency.
Conservation Agency Name: __________________________________________________
Section VI – Less-Than-Fee Simple Donation
Explain how this donation meets the requirements of § 170(h) of the United States Internal Revenue Code of 1986, as amended.
Enclose additional pages if needed.
Section VII – Declaration, Signature, and Notarization
Enclosure Checklist
DCR - All Donations (2007 & After)
TAX - All Donations
A Copy of LPC Application
Original LPC Application
IRS Form 8283
Recorded Deed
Recorded Deed
A Copy or CD of Full Appraisal
DCR - Donations of $1 Million or More (2007 & After)
IRS Form 8283
Baseline Documentation
Signed Statement or Affidavit from Appraiser
I (we) the undersigned declare, under the penalties provided by law, that this form (including any accompanying schedules, statements, and
enclosures) has been examined by me (us) and is, to the best of my (our) knowledge and belief, a true, correct, and complete application, made
in good faith pursuant to the income tax laws of the Commonwealth of Virginia. I (we) understand that the Department of Taxation will record the
information submitted on this application; however, acceptance of this application does not constitute certification, approval, or validation of the
donation or valuation of the credit by the Department of Taxation. If a person other than the taxpayer prepares this application, their declaration is
based on all information of which they have knowledge.
I authorize the Department of Taxation to discuss my application with the contact person listed in Section I of Schedule A, my broker,
and share and/or discuss this application with DCR, if applicable. Further, I authorize the Department of Conservation and Recreation to
discuss my application with the contact person, the holder of the conservation easement, or the holder’s representative, if applicable.
Signature of Applicant
Signature of Applicant
Must Be
Print Name
Print Name
Signed in
Presence
of Notary
Title
Date
Title
Date
Notary Information
Subscribed and sworn before me this ___________day of ____________________________,
20 _____ , in the (City/County) ____________________________, of _________________________.
Notary Public Signature
Date
Notary Public Name Printed
My Commission Expires