PECONIC BAY REGION COMMUNITY PRESERVATION FUND TOWN OF SOUTHAMPTON FIRST-TIME HOMEBUYER'S EXEMPTION APPLICATION __________________________________________________________________________________ Schedule A Information Relating to Conveyance Name (individual: last, first, middle initial) Seller o o o o Individual Corporation Partnership Other Mailing Address City State Zip Code Please print or type Social Security Number Social Security Number Federal Employer ID Number Social Security Number Social Security Number - Purchaser o o o o Individual Corporation Partnership Other Name (individual: last, first, middle initial) Mailing Address City State Zip Code Federal Employer ID Number Village/ Hamlet Town Location and description of property conveyed Tax Map Designation Dist Section Address Block Lot Date of Contract Month Day Year Date of Closing Month Day Year Schedule B: Income and Purchase Price 1. Income................................................................................ (Verified by latest available Federal or State Income Tax Return) $______________________ 2. Purchase Price....................................................................... $______________________ (Verified by executed contract of sale) The undersigned Applicant(s)/Grantee(s) hereby certifies/certify that the property which is the subject of the application will be the primary residence of the Applicant(s) and that the Applicant(s) is/are a "first time homebuyer(s)" as defined by Section 1449-aa(18) of the New York State Tax Law. A first time homebuyer is a person who has not owned a primary residence and is not married to a person who has owned a residential property, including a manufactured home, town house or condominium at any time during the three-year period immediately prior to the date of the conveyance and does not own a vacation or investment home as of such date. This application, including any certification, schedule or attachment is, to the best of his/her/their knowledge, true and complete. FALSE STATEMENTS MADE PURSUANT TO THIS APPLICATION ARE PUNISHABLE BY CLASS-A MISDEMEANOR. _______________________________________ Applicant (Purchaser) ___________________________________________ Applicant (Purchaser) ACKNOWLEDGEMENT State of New York ) County of Suffolk ) ss. On the ____day of ______________, 201__, before me, the undersigned, a notary public in and for said state, personally appeared_______________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that (s)he executed the same in his capacity, and that by his/her signature on the instrument, the individual, or the persons on behalf of which the individual acted, executed the instrument. __________________________________ Notary Public ACKNOWLEDGMENT State of New York ) County of Suffolk ) ss. On the ____day of ______________, 201__, before me, the undersigned, a notary public in and for said state, personally appeared_______________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that (s)he executed the same in his capacity, and that by his/her signature on the instrument, the individual, or the persons on behalf of which the individual acted, executed the instrument. __________________________________ Notary Public Approved: _______________________________________ CPF Manager - Town of Southampton _________________________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com