Spreadsheet: 20ea4aa3-2ee0-4326-acf3-e0cb8428cfe9
Sheet: AD1156

1. To be completed by NRCS; check appropriate box: |  |  | This transaction is for CCC. |  |  |  | This transaction is for NRCS. |  |  |  |  |  |  | OMB No. 0578-0013
U.S. DEPARTMENT OF AGRICULTURE |  |  |  | REVISION OF PLAN OR SCHEDULE OF OPERATIONS |  |  |  |  |  |  |  |  | 2. | Page |  | of
 |  |  |  |  | OR MODIFICATION OF CONTRACT
The above statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 522a).  Furnishing this information is voluntary; however, failure to furnish correct, complete information will result in the withholding or withdrawal of such technical or financial assistance.  The information may be furnished to other USDA agencies, the Internal Revenue Service, the Department of Justice, or other State or Federal law enforcement agencies, or in response to orders of a court, magistrate, or administrative tribunal.
3. NAME |  |  | 4. COUNTY |  |  | 5. STATE | 6. CONTRACT OR |  |  |  |  | 7. REVISION OR
 |  |  |  |  |  | WI | AGREEMENT NO. |  |  |  |  | MODIFICATION NO.
 |  |  |  |  |  |  | COMPLETION SCHEDULE AND ESTIMATED
ITEM | FIELD | PLANNED  CONSERVATION |  | ESTIMATED | COST | COST SHARE | COST-SHARE OR PAYMENT BY YEAR
NO. |  | TREATMENT |  | AMOUNT | BASIS | OR PAYMENT | (For Non-Cost Share Items Show Units)
 |  | (Record of Decisions) |  | (UNITS) | $ | RATE
 |  |  |  |  |  | % | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | REF. NO.
 |  |  |  |  |  |  | Year | Year | Year | Year | Year | Year | Year | Year | Year | Year
8 | 9 | 10 |  | 11 | 12 | 13 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34
35. CERTIFICATION OF PARTICIPANTS
A. SIGNATURE |  |  | B. Date | C. SIGNATURE |  |  |  | D. Date |  | E. SIGNATURE |  |  |  |  | F. Date
36. REVIEWING OFFICIALS SIGNATURE
A. District Conservationist - Technical Adequacy Certification |  |  |  |  |  |  | B. Date | [NAME] BY (Conservation District Representative) |  |  |  |  |  | D. Date
SIGNATURE |  |  |  |  |  |  |  | SIGNATURE
OMB DISCLOSURE STATEMENT
Federal Agencies may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Public reporting burden for this collection is estimated to average 37.5 mins. per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Department of Agriculture, OIRM, [NAME], Wash. DC
NONDISCRIMINATION STATEMENT
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal or because all or part of an individuals income is derived from any public assistance program..  (Not all prohibited bases apply to all programs).  Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD).  To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW., Washington D.C. 20250-9410, or call (800) 795-3272 (voice) or (202)720-6382 (TDD).