Attachment III
DOA-712

Notice of Record - Senior Center Reversionary Interest
Private Non-Profit Corporations

This is to serve as notice to all potential sellers, purchasers, transferors and recipients of a transfer of the real property described below as to the Federal Government's reversionary interest as set forth in Section 312 of the Older Americans Act of 1965, as amended, 42 U.S.C. 303b, which have arisen as a result of 

(Senior Center Sponsoring Agency)

receipt and use of Department of Health and Human Service's grant funds in connection with the purchase or construction of said property.  The property to which this notice is applicable is

(Address)

and identified as Parcel 										
(Insert Appropriate Number(s)

in the books and records of the Register of Deeds for 

 						County, North Carolina.  Said
	(County Name)

real property is also described as:									

		(Insert Description Provided in Survey)

Further information as to the Federal Government's interest referred to above can be obtained from 											

(Name of Agency)

			(Address of Area Agency on Aging)

Attachment III
DOA-712

											
					Name of Corporation

				By							 (Signature)
					Executive Director

Attest: 					 (Signature)
	Secretary of Governing Body

					(Notary Seal)