Free 51422.pdf - Indiana

INDIANA'S FOREST RESTORATION GRANT APPLICATION Forestland Enhancement Program (FLEP)
Department of Natural Resources/Division of Forestry
State Form 51422 (7-03)

STEP 1- Forest Stewardship Request: Owner please, complete step #1 and return application, a signed grant agreement and W-9 (taxpayer
identification form) to the District Forester. He/she will determine project eligibility and complete step #2. I, _____________________________, hereby apply for cost-share funds to install the forest conservation practice(s) listed below on my land. I understand the practice(s) installed must adhere to the forestry plan developed or approved by the IDNR District Forester and follow applicable IDNR or USDA Natural Resource Conservation Service standards. If approved for funding, I agree to maintain the practice(s) and provide access to such areas for inspection purposes for 10 years from the date of completion. I also understand that failure to maintain the practice(s), or to notify future owners of such terms may require re-payment of the grant. If the practice(s) are approved for funding, the landowner will be notified by Central Office and will be given permission to incur cost. The terms and conditions of this contract are contained in this Grant Application and in the Grant Appendix and any addendum thereto. BY SIGNING THIS CONTRACT LANDOWNER ACKNOWLEDGES RECEIPT OF THE FOLLOWING: Indiana's Forest Restoration Grant Application and Grant Appendix and any addendum thereto.

Forestry Practices requested: 1) _____________________________________________________________ 2) _____________________________________________________________ 3) _____________________________________________________________

Acres: _____________ Acres: _____________ Acres: _____________

Property Location: County ________________, Civil Township _________________, Section _______, Twp _______, Range _______ Address: ___________________________________ City:_____________________, State: _________ Zip Code: ________________ Phone number: _____________________________ Owner signature: _______________________________ Date: _______________ E-mail address: _____________________________ STEP 2 - Forester's Determination: The District Forester completes and sends to Central Office a signed application and W-9 form. All projects
over $6,000 must also include a signed grant agreement and EDS form in order to be considered for funding.

Practice

Quantity

Estimated Cost

Cost Share (%)

Cost-Share Needed ($)

Practice Priority

Quantity Completed

Documented Costs

Cost Share Earned

I certify that the above practices are practical and needed for the above described property and the owner has the required a forest management plan or said plan is part of this application for cost share assistance. Management Plan on file: Yes ______ No ______

District Forester's signature: ____________________________________ Date: _______________________ FLEP Hours: ___________ FOR CENTRAL OFFICE USE: Division of Forestry Approval By: ________________________________ Date: __________________ Project #'s ____________, ____________ and _____________ Funding code: ______________ Expiration date ___________________ STOP!! AFTER THE PROJECT HAS BEEN COMPLETED, FILL IN STEPS 3 AND 4!! STEP 3- Owner Certifies Completion: Owner completes step #3 after project(s) has been completed and sends this form with the original bills and
expense documentation to the District Forester. To the best of my knowledge, the project(s) described above has been completed and the attached expenses were spent on the project(s).

Owner:__________________________________Date:________________________ SS#(for payment purposes): ___________________ STEP 4- Forester Certifies Completion: District Forester, upon certifying project(s) completion and payment due, please submit
1) this form, 2) expense documentation and 3) claim voucher to Central Office. The State will send payment directly to the landowner. The undersigned hereby certifies that the above forestry project(s) have been inspected for completion, meet all program standards and (according to the bills and documentation submitted here of) the following total dollar amount has been earned by the owner: $_____________.

District Forester _____________________________________ Date: ____________________ Additional FLEP hours:_____________ Cancellation: Owner or Forester may cancel the project. This project will not be completed for the following reasons: ______________ __________________________________________________________________________________________________ Please cancel. Signature of Forester or Owner (circle one) ______________________________________ Date:________________
The DNR prohibits discrimination on the basis of race, national origin, sex, or disability. If you believe you have been discriminated against in any program, activity, or facility as described above, or if you desire further information, please write to: Department of Natural Resources, Executive Office 402 West Washington St., RM W256 Indianapolis, IN 46204 or call at 317-232-4020.