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I COLC no RIVER BASIN SALINITY CONTROL PROGRAh. Cost-Share Assistance Application, Agreement, and Payment Claim 2. / () _ 2./ 0 ~ ~ rrt...( u> -3 Date '1- ~ 1'6' SSN or Tax 10# Landowner ACCOUNT WITH THE MESA CD ,( '" G; PI;<.u ~~c? 'YS~? Zip I (we) the undersigned do hereby request cost-share assistance to help defray the cost of installing the soil and water conservation practices as listed below. It is understood and agreed that: I Before receiving any cost-share funds, It will be necessary for the landowner(s) to sign the agreement below relating to the maintenance of practices Installed. Practices must be planned and installed in accordance with technical specifications of the Natural Resources Conservation Service (NRCS). The responsible technician must make prior determination that the practices are feasible on the site where they are to be installed, that they are properly planned and installed, and that estimates of quantities are proper and reasonable, , Items of cost for which reimbursement Is later claimed are to be supported by documentation of payments made or due to contractors or other workers. I This application will not be effective until approved by the Conservation District (CD). Claims for payment will not be accepted more than nine (9) months from the date this application is approved, unless an extension is granted by the CD. Maximum reimbursement will be limited to the amount agreed upon In this document, not to exceed 100% of the actual project cost. OCATION OF PRACTICE: 1/4, SEC ,TWP ,RNG COUNTY APPLICANT'S REQUEST PRACTICE UNITS PERFORMED AVG MAXIMUM COST.SHARE: COSTI ASSISTANCE SHARE RATE EXTENT X PRACTICE UNIT EXTENT UNIT % $ YEAR EXTENT AVG _% SMALLEST ACT RATE Refer to attached Contract Support Document for Planned Practices, extents, cost share estimates and application schedule. If you need more space, please attach aseparate sheet TOTAL Date Practices and quantities requested are needed and practical, and will I be:t 'oa"","", '" NReS ~.'''.':;oal'PdoallO~! ~!a .,{lteY -* Signature of Technician , ~ .APPLlCATION APPROVAL: The CD Board of Supervisors approved the applicant's e uest and ~reby obligates $ 64,102.00 . " ~< \N ~.. /'(i! Signature of CD Representative 6:t / Datp 69 COMPLETION AND DOCUMENTATION CERTIFICATION: Signature of Technician Date nature of CD Re resentative Date ~v. 3/07 I $64102 TOTAL $ LESS OTHER COST -SHARE ASSISTANCE $ TOTAL AMOUNT LANDOWNER CLAIM $ LANDOWNER'S CERTIFICATION AND AGREEMENT: I certify that the items for which payment is claimed were furnished and that the charges are reasonable, proper, and correct, and no part of the claim has been paid. I further certify that I am the owner of the above described property and agree that if any or all of above installed practices shall be removed, altered, or modified so as to lessen their effectiveness without consent of the CD for the "lifespan of the practice(s)" after the date of receiving payment, that portion of the claimed amount shall be refunded to the CD. If title to this land is transferred to another party, it shall be my responsibility to advise the new owner that this agreement is in force and to obtain such new owner's acceptance of the responsibilities herein. The attached plan/schedule of operations prepared by the NRCS is hereby made a part of this agreement. Si nature of Landowner Date CONSERVATION DISTRICT CERTIFICATION: I hereby certify that the above claim has been reviewed by me and I find it a proper claim against the Mesa CD Salinity Control Cost Share Program fund. Authorized Signature Date