Number range CHAPTER

**1. Project Number (Assigned by federal unit):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**2. AMOUNT REQUESTED (Marking both years = 2 separate projects)**

**FY 2009\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**FY2010 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**3. Project Name:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**4**. **County:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**5. Project Applicant:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**6. Applicant's Phone #:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**7. Applicant's
E-mail:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**8. BLM Point of Contact (POC):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**9. BLM POC's Phone #:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**10. BLM POC's E-mail:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**11. Project Description:** *(Provide concise description of project
and attach map. Include an electronic copy of each map.)*

12\. Statement of Project Goals and Objectives:

13\. Project Location : *(Attach project area maps showing general and
specific locations of project. Include a legal description such as
Township(s), Range(s), and Section(s), if possible, and the 4^th^ and
5^th^ Field Watersheds and HUC #s (if known). )*

BLM District \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ BLM
Resource Area
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

State / Private / other lands involved? Yes \_\_ No

14\. Coordination of this project with other related project(s) on
adjacent lands?

Yes \_\_\_\_ No

**15. How does proposed project meet purposes of the Legislation?**

A\) \_\_\_\_ Improves maintenance of existing infrastructure.

B\) \_\_\_ Implements stewardship objectives that enhance forest
ecosystems.

C\) Restore and improve land health and water quality

\_\_\_ Restores and improves land health.

\_\_\_ Restores water quality.

**16. Project Type** ***(check one)***

A\) Roads, trails, and infrastructure maintenance or obliteration:

\_\_ Road Maintenance  Trail Maintenance

\_\_ Road Decommission/Obliteration  Trail Obliteration

 Other Infrastructure Maintenance (specify):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> B\) Restore and improve land health and water quality, or implement
> stewardship objectives that enhance forest ecosystems:

 Soil Productivity Improvement \_\_\_ Forest Health Improvement

 Watershed Restoration & Mntc.  Wildlife Habitat Restoration

 Fish Habitat Restoration  Control of Noxious Weeds

 Reestablish Native Species \_\_\_Fuels Reduction/Restoration of Fire
Processes

 Other Project Type
(specify)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**17. Measure of Project Accomplishments/Expected Outcomes**

(For BLM: Use workload measures associated with the budget process)

a\. Total Acres:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ b. Total Miles:

> c\. No. Structures: d. Estimated People Reached *(for environmental
> education projects)*: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

e\. No. Of Laborer Days:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

f\. Other (specify):

**18. Duration of Project:** Estimated Start Date
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Estimated Completion Date
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Total Duration (days)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**19. Describe benefits of the projects. Include benefits from any
cooperative/ collaborative relationships among public land users,
communities, and benefits to target species** *(if applicable).*

**20. How does project benefit federal lands and/or resources?**
*(Please be specific.)*

**21. Status of Project Planning**

a\. NEPA Complete: \_\_ Yes  No

b\. If No, give est. date of completion: \_\_\_\_\_\_\_\_

c\. NOAA Fisheries ESA/EFH Consultation Complete: \_\_ Yes  No  Not
Applicable

d\. USFWS Sec. 7 ESA Consultation Complete: \_\_ Yes  No  Not
Applicable

e\. SSS Program requirements Complete: \_\_ Yes  No  Not Applicable

f\. DSL/ODFW\* Permits Obtained: \_\_ Yes  No  Not Applicable

g\. DSL/COE\* 404 Fill/Removal Permit Obtained: \_\_ Yes  No  Not
Applicable

h\. SHPO\* Concurrence Received: \_\_ Yes  No  Not Applicable

i\. Project Design(s) Completed: \_\_ Yes  No  Not Applicable

***\*** DSL = Dept. of State Lands, ODFW = Oregon Dept. of Fish and
Wildlife, COE = Army Corps of Engineers, SHPO = State Historic
Preservation Officer*

**22. Proposed Method(s) of Accomplishment** *(Mark several if a
combination will be used)*

 Contract  Federal Workforce

\_\_ County Workforce  Volunteers

 Other (specify):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**23. Will the Project Generate Merchantable Materials?**

 Yes \_\_ No

**Table**

> ***Note: If you have a complex budget, add it as an appendix (with
> narrative). The Resource Advisory Committee will want to know
> specifically how the funds will be spent.***
>
> ***Fill table with the specific details of each [funding
> year]{.underline} request (i.e. use two separate tables, one for each
> year, if applying for two funding years).***

**Table 1:**

+-------------------------+-----------+-----------+-----------+-------+
| **Item**                | **A:**    | **B:**    | **C:**    | *     |
|                         |           |           |           | *D:** |
|                         | **Fed.    | **Re      | **Other** |       |
|                         | Agency**  | quested** |           | **To  |
|                         |           |           | **Contri  | tal** |
|                         | **Appro   | **Title   | butions** |       |
|                         | priated** | II**      |           | **A   |
|                         |           |           |           | vaila |
|                         | **Contr   | **Contr   |           | ble** |
|                         | ibution** | ibution** |           |       |
|                         | *         |           |           | **Fu  |
|                         | (identify | *(this    |           | nds** |
|                         | the       | appl      |           |       |
|                         | Federal   | ication)* |           |       |
|                         | agency)*  |           |           |       |
+=========================+===========+===========+===========+=======+
| 24\. Field Work & Site  |           |           |           |       |
| Surveys                 |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+
| 25\. NEPA & Sec.7 ESA   |           |           |           |       |
| Consultation            |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+
| 26\. Permit Acquisition |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+
| 27\. Project Design &   |           |           |           |       |
| Engineering             |           |           |           |       |
|                         |           |           |           |       |
| *(layout, mark and      |           |           |           |       |
| cruise, engineering     |           |           |           |       |
| plans, etc.)*           |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+
| 28\. Contract           |           |           |           |       |
| Preparation             |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+
| 29\. Contract           |           |           |           |       |
| Administration          |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+
| 30\. Contract Cost      |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+
| 31\. Workforce          |           |           |           |       |
| *(labor)* Cost          |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+
| 32\. Materials &        |           |           |           |       |
| Supplies                |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+
| 33\. Monitoring         |           |           |           |       |
| *(post-project          |           |           |           |       |
| completion)*            |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+
| 34\. Other or Applicant |           |           |           |       |
| *(Non-BLM)*             |           |           |           |       |
| Administrative/         |           |           |           |       |
| Overhead Costs          |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+
| 35\. Project Subtotal   |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+
| 36\. Indirect BLM       |           |           |           |       |
| Administrative/         |           |           |           |       |
| Overhead Costs *(10% -  |           |           |           |       |
| will be allocated from  |           |           |           |       |
| the Total Cost          |           |           |           |       |
| Estimate)*              |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+
| 37\. Total Cost         |           |           |           |       |
| Estimate                |           |           |           |       |
+-------------------------+-----------+-----------+-----------+-------+

**38. Identify Source(s) of Any Funding in Table 1, Column C. *(****List
source of funding if applicable (applied for and/or received)*

**39. Contributions to Past Year or Future Funding:**

**Is this a multi-year project? \_\_\_ Yes \_\_\_ No** *(if yes, then
display by year)*

  -------------- -------------- -------------- -------------- --------------
                 **Agencies (in **Partners (in **Partners     **Total**
                 kind)**        kind)**        (\$\$\$)**     

  **200\_**                                                   

  **200\_**                                                   

  **200\_**                                                   

  **20\_\_**                                                  

  **20\_\_**                                                  
  -------------- -------------- -------------- -------------- --------------

**40. Monitoring Plan** *(a monitoring plan is required).* Describe your
monitoring plan. Include the measures or assessments that will be made,
the costs, and who will be responsible for the monitoring. Include the
monitoring of ecological conditions, contributions towards local
employment, improvements that enhance forest ecosystems, and/ or the
quantity of forest products removed from public lands. *(Include all
timeframes -- when, where, and who will do this monitoring, and describe
what reports will be given to BLM on the progress of the project)*.