Free 51338.pdf - Indiana

INDIANA ORGANIC CERTIFICATION COST SHARE PROGRAM APPLICATION
State Form 51338 (5-03) Form approved by State Board of Accounts, 2003

Contact Name: ___________________________________________________________________________________ Business/Farm Name: _____________________________________________________________________________ Address: ________________________________________________________________________________________ City: Phone: ( ) Fax: ( ) State: Zip Code: _____________________ Email: ______________________________

Date of Certification/Continuance of Certification: ______________________________________________________ Name of Certifier: ________________________________________________________________________________ Total Amount Paid for Certification (do not include membership fees) $ _____________________________________

The following documents must be included with your application in order for your cost share to be processed. If you do not have these documents, contact your certifier and request them. · · · A copy of your certificate, or other proof of certification or continuance, that shows the effective date; A copy of your invoice and/or receipt that itemized your certification costs; and Proof of payment {front and back of cancelled check(s) or copies of money orders}.

Return this form with the appropriate documents to:

Pam Robinson Office of the Commissioner of Agriculture ISTA Center - Suite 414 150 West Market Street Indianapolis, Indiana 46204-2810 (317) 232-8773 [email protected]

OCA OFFICE USE ONLY
Received: Processed: Paid: