Impact Fee Form

Developer Information

Development Company

State of Incorporation

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Telephone

Fax

Contact Person

Name

Title

Office Phone

Cell Phone

Email Address

Development Information

Name of Development

Location (Address or Cross Streets)

Residential Units: Single- or Two-Family, or Townhomes ($1,372.96 per unit)

Residential Units: Multi-Family or Townhomes ($1,264.46 per unit)

Non-Residential Uses ($1.55 per square foot)

Non-Residential: Total Square Feet

Impact Fee Determination

Enter Amount Here

The Applicant desires to make an in-kind contribution in lieu of paying all or a portion of the impact fee owed.

Description of the in-kind contribution (attach additional information if necessary) and amount of impact fee off-set:

By checking this box, the developer is electronically signing this Impact Fee Form with the other documentation required by the Town as part of its development permit application process. If the Town denies the application, the developer is not required to pay the Impact fee or make an In-Kind Contribution to the District. If the Town grants the application and issues a development permit, the developer must pay the Impact Fee and/or make the In-Kind Contribution, or enter into a written agreement with the District to make the In-Kind Contribution before the Town will issue a Certificate of Occupancy in connection with the development.

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