Spreadsheet: dd5e491e-bdad-4064-ab7b-03f20bb0a14c
Sheet: Sheet1

CSCB NATURAL RESOURCES CONSERVATION MATCHING GRANTS PROGRAM | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12
Cost-Share Assistance Agreement, and Payment Claim
IN ACCOUNT WITH THE |  |  |  | Landowner district ID (optional) |  |  |  | Landowner
 |  |  |  |  |  |  |  | Address
CONSERVATION DISTRICT (CD) |  |  |  |  |  |  |  | City etc.
(We) the undersigned, request cost-share assistance for the cost of installing natural resource conservation practices as listed below.  It is agreed that:
1.  This application will not be effective until approved by the Conservation District (CD).
2. The authorizing techncian must make prior determination (through a site visit) that the requested practices are necessary and feasible on the site propose; they will be appropriately planned and installed; and the costs are reasonable. The landowner must sign in agreement to the request as stated below before work begins.
3. Engineering practices must be planned and installed in accordance with technical standards and specification of the Natural Resources Conservation Service (NRCS) or be authorized by a professional engineer.
4. The authorizing techncian must inspect completed work and certifty satisfactory completion to required standards as pre-requisite to cost-share payments being made.
5.  Before receiving any cost-share funds, the landowner(s) must sign the agreement below relating to the installation and maintenance of practices installed.
6.  Items  for which reimbursement is claimed are to be supported by documentation of payments made or due, or applicable in-kind records, and  reviewed by the conservation district prior to cost-share payment.
7.   Maximum reimbursement will be limited to the % of the costs as specified below, or the amount obligated by the Conservation District -  whichever is the least.
 | Location of Practice
 |  |  |  | 1/4 | SECTION |  | TOWNSHIP |  | RANGE |  | COUNTY
APPLICANT'S REQUEST FOR PRACTICES |  |  |  |  |  |  |  | PRACTICES  COMPLETED                                        (explain if different than planned)
Month and Year | PRACTICE [NAME]           (for weeds, descibe species,control method, chemicals) | UNIT (No/   Ac/Ft) | No. of UNITS (a) | $/ UNIT (b) | COST SHARE             a x b x c |  | Practice Lifespan (yrs) | Month and Year | No. of UNITS  (a) | $/UNIT   (b) | COST SHARE            a x b x c
 |  |  |  |  | %        ( c) | $ |  |  |  |  | %  (c ) | $
 |  |  |  |  |  | 0 |  |  |  |  |  | 0
 |  |  |  |  |  | 0 |  |  |  |  |  | 0
 |  |  |  |  |  | 0 |  |  |  |  |  | 0
 |  |  |  |  |  | 0 |  |  |  |  |  | 0
 |  |  |  |  |  | 0 |  |  |  |  |  | 0
 |  |  |  |  |  | 0 |  |  |  |  |  | 0
 |  |  |  |  |  | 0 |  |  |  |  |  | 0
 |  |  |  |  |  | 0 |  |  |  |  |  | 0
 |  |  |  |  |  | 0 |  |  |  |  |  | 0
If you need more space, please attach a separate sheet. |  |  |  | C/S TOTAL |  | 0 |  | C/S TOTAL |  |  |  | 0
 |  |  |  |  |  |  |  | LESS OTHER COST-SHARE ASSISTANCE
Request Signature: Landowner or Authorized Rep |  |  |  | Date |  |  |  | CSCB PAID TO LANDOWNER |  |  |  | 0
I have inspected the site and certify that practices and quantities requested are necessary and practical, and will be planned in accordance with applicable statutory rules and regulations and NRCS technical standards and specifications. |  |  |  |  |  | LANDOWNER(S) COMPLETION CERTIFICATION AND AGREEMENT:
 |  |  |  |  |  | I certify that the above practices are complete and all items for which payment is claimed relate to these practices and are reasonable, proper, and correct. I certify that I am the owner of the above described property and agree that if any of the above installed practices shall be removed, altered, or modified so as to lessen their effectiveness without consent of the Conservation District for the practice life span after the date of receiving payment, that portion of the claimed amount shall  be refunded to the Conservation District.    If title to this land is transferred to another party, it shall be my responsibility to advise the new owner of this agreement and obtain such new owner's acceptance of the responsibilities herein.
Request Signature: Authorizing Tech/Engineer |  |  |  | Date
CONSERVATION DISTRICT APPROVAL OF REQUEST:
The Conservation District Board of Supervisors approved this request
and hereby obligates a maximum of |  |  | $
District  Board Authorized Signature |  |  |  | Date |  | Signature of Landowner(s) |  |  |  |  | Date
WORK COMPLETION TECHNICAL CERTIFICATION: |  |  |  |  |  | CONSERVATION DISTRICT PAYMENT CLAIM CERTIFICATION:
I certify that the practices reported as completed above were inspected by me as completed and installed to required standards and specifications. |  |  |  |  |  | I hereby certify that the above claim cost documentation has been reviewed by me and is a legitimate claim
Signature of Authorizing Technician/Engineer |  |  |  | Date |  | District  Board Authorized Signature |  |  |  |  | Date
Print name of authorizing technician/Engineer |  |  |  |  |  | Print name of authorized signatory