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- -.- - - - - - - . - - - - - - - -- .E 3 OF 3 . PARTICIPANT HEAD GATE 135 LATERAL INC MESA, COLORADO LAND UNITS OR LEGAL DESCRIPTION No Tract Fields: UN PROGRAM AND CONTRACT NUMBER BSPP 2008 WATERSHED ACRES 400 EXPIRATION DATE NOTES: A. All items numbers on form NRCS-CPA-1155 must be carried out as part of this contract to prevent violation. B. When established, the conservation practices identified by the numbered items must be maintained by the participant at no cost to the government. C. All cost share rates are based on average cost (AC) with the following exceptions: AA = Actual costs not to exceed average cost. FR = Flat rate. NC = Non cost-shared. AM = Actual cost not to exceed the specified maximum. D. B si nin ,the partici ant acknowled es receipt of this conservation plan includin this form NRCS-CPA-1155 and a rees to campi with the terms and conditions here of. NRCS Approving Offici Signature Z . Date PUBLIC BURDEN STATEMENT According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collections is 0578-0013. The time required to complete this information .collection is estimated to average 45/0.75 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection information. PRIVACY ACT 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. USDA NON-DISCRIMINATION STATEMENT "The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, family status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or a part of an individual's 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 TOO). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.w., Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TOO). USDA is an equal opportunity provider and employer."