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| JONAH INTERAGENCY MITIGATION & RECLAMATION OFFICE                     |
|                                                                       |
| 1625 West Pine                                                        |
|                                                                       |
| PO Box 768                                                            |
|                                                                       |
| Pinedale, Wyoming 82941                                               |
|                                                                       |
| \(307\) 367-5363                                                      |
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| APPLICATION FOR FUNDING                                               |
|                                                                       |
| (use additional sheets if necessary)                                  |
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| **1. GENERAL PROJECT INFORMATION**                                    |
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| P*roject Name*:                                                       |
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| *General Location* (distance and direction from nearest city/town,    |
| attach map at a scale not less than ½" = 1 mile):                     |
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| *Legal Location of Project* (attach map at a scale not less than 1" = |
| 2,000').\                                                             |
| Township: [T N]{.underline}\                                          |
| Range: [R W]{.underline}\                                             |
| Section(s): [\_]{.underline}\                                         |
| County: [\_]{.underline}                                              |
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| *Surface Ownership* (check all that apply): Federal State Private     |
| [\_]{.underline}                                                      |
|                                                                       |
| \*\*If project includes a mosaic of land ownerships (e.g., mix of     |
| federal, state and/or fee lands), provide a breakdown for each        |
| specific owner by acres and percent of total project area.            |
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| *Contact Information* *for Affected Parties or Agencies*:             |
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| **2. APPLICANT INFORMATION**                                          |
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| *Name/Organization:*                                                  |
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| *Mailing Address:*                                                    |
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| *City:* *State:* *Zip Code* :                                         |
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| *Daytime Phone \#* *Fax \#*                                           |
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| *Email Address:*                                                      |
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| *Point of Contact* (if different from above)                          |
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| **3. PROJECT DESCRIPTION**                                            |
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| *General Project Type* (check all that apply): Wildlife               |
|                                                                       |
| > Land Use/Livestock Land Use/Recreation                              |
| >                                                                     |
| > Cultural [\_\_\_\_\_\_\_]{.underline} Other                         |
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| *Describe Project Proposal* (e.g., mechanical treatment, water        |
| improvement, etc.)                                                    |
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| *Total Project Acres* (if applicable)                                 |
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| *Acres Indirectly Affected* (if applicable, explain)                  |
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| **4. OBJECTIVES OF PROJECT, AND BENEFITS TO JIO Off-Site Mitigation   |
| Strategic Goals.**                                                    |
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| **5. DIRECT/INDIRECT EFFECTS ON OTHER RESOURCES.** (if applicable)    |
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| **6. POTENTIAL FOR FUTURE EXPANSION OF PROJECT. Explain**             |
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| **7. LIST ALL PROJECT PARTNERS/COOPERATORS, THEIR ROLES AND/OR        |
| CONTRIBUTIONS**                                                       |
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| **8. PROJECT MONITORING AND REPORTING** (Describe how monitoring and  |
| reporting will be done, and how it relates to the objectives)         |
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| **9. RESEARCH POTENTIAL**                                             |
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| **10. PERMITS AND AUTHORIZATIONS REQUIRED PRIOR TO PROJECT            |
| IMPLEMENTATION** (including but not necessarily limited to the        |
| following):                                                           |
|                                                                       |
| **11. TOTAL PROJECT COST (Attach detailed budget)**                   |
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| > Project Planning and Design \$                                      |
|                                                                       |
| Project Implementation \$                                             |
|                                                                       |
| > Project Operation and Maintenance \$                                |
| >                                                                     |
| > Total Required \$                                                   |
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| **12. MATCHING FUNDS ANTICIPATED IN CASH** (list source and amount)   |
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| **13. ANTICIPATED "IN KIND" MATCHING FUNDS** (list source, valuation, |
| and valuation method)                                                 |
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| **14. PERCENTAGE OF FUNDING ON HAND OR COMMITTED**                    |
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| **15. TOTAL JIO FUNDING REQUESTED:** \$                               |
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| **16. EXPECTED/ANTICIPATED LIFE OF PROJECT (LOP)**                    |
|                                                                       |
| Perpetual \> 50 Years 25-50 Years \< 25                               |
| Years\_\_\_\_\_\_\_\_\_\_\_\_\_                                       |
|                                                                       |
| Explain Basis for Projected LOP:                                      |
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| **17. PROJECT TIMELINE AND ESTIMATED COMPLETION DATE. Explain**       |
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| **18. ATTACHMENTS AND SUPPORTING DOCUMENTATION**                      |
|                                                                       |
| > Project Design                                                      |
| >                                                                     |
| > Letters of Support                                                  |
| >                                                                     |
| > Management Plan Long Term Short Term ^1^                            |
| >                                                                     |
| > Monitoring Plan Long Term Short Term ^1^                            |
| >                                                                     |
| > Relevant Past Experience Other Explain:                             |
| >                                                                     |
| > ^1^ Long term is defined as greater than (\>) 5 years; short term   |
| > is less than (\<) 5 years.                                          |
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| **19. ADDITIONAL INFORMATION FOR JIO CONSIDERATION**                  |
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| **20. ACKNOWLEDGEMENT**                                               |
|                                                                       |
| > Signed                                                              |
| >                                                                     |
| > Printed Name                                                        |
| >                                                                     |
| > Title                                                               |
| >                                                                     |
| > Date                                                                |
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