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319-A, AGRICULTURE COST-SHARE CLEAN WATER ACT SECTION 319 COST-SHARE PROGRAM
State Form 50065 (R4 / 3-09) INSTRUCTIONS: See page 2 of this form.

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGAMENT

SECTION A
Applicant name Indiana county IDEM Contract/Agreement number

Name of sponsoring organization


Location information farm number Tract number Civil township Field(s) number USGS quad name Section number 12-digit HUC


Township Range

Latitude and longitude or universal transverse mercatur (UTM) coordinates

I hereby agree and certify that a conservation plan has been developed and will be followed in all fields that receive cost-share funds. All best management practices (BMPs) implemented with these grant funds will be operated and maintained in accordance with United States Department of Agriculture Natural Resources Conservation Service (NRCS) standards and specifications (or other specifications cited below). Practices shall be maintained as follows: vegetative and land management practices, five (5) years; structural practices, ten (10) years.
Applicant signature Printed Name Address (full street address) City State, ZIP code Date (mm/dd/yyyy) Landowner Signature Printed Name Address (full street address) City State, ZIP code Date (mm/dd/yyyy)

SECTION B
The following eligible BMPs are needed to improve or maintain water quality, and will reduce off-site sedimentation or nutrient, pesticide or pathogen loads to receiving waters. These practices were implemented consistent with NRCS standards and specifications (or other specifications as listed below) and in accordance with the conservation plan. Field NRCS Practice Title or other Maintain Quantity Total Cost Cost-share Cost-share Install Date Specifications Followed for or Unit Level (%) Amount (mm/yyyy) Number yrs $ $ yrs yrs yrs yrs yrs $ $ $ $ $ $ $ $ $ $ $ $ Date (mm/dd/yyyy)

TOTAL

Printed name and signature of NRCS, IDNR, ISDA, TSP, or SWCD technical representative:

SECTION C
Critical area as described in the WMP and page number(s) where referenced NPS pollutant(s) of concern addressed within this critical area by BMP implementation

The total cost-share amount in section B is recommended to IDEM for cost-share assistance and is approved for payment by the sponsoring organization. The sponsoring organization or local SWCD office has a copy of the conservation plan available for IDEM review. Date (mm/dd/yyyy) Authorized signature for sponsoring organization

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INSTRUCTIONS FOR COMPLETING STATE FORM 50065, 319-A
This form should be completed when requesting reimbursement from the Section 319 Program for eligible cost-share and/or demonstration best management practices (BMPs) implemented on agricultural land; defined as land that is currently in production (i.e., working lands) such as cropland, pastureland, rangeland, native pastureland, other land used to support livestock production, and tree farms. SECTION A - This section requests general information on the BMP location and the applicant/landowner. Complete all blanks in Section A for the BMPs implemented and listed in Section B. · If the applicant does not own the land where practices will be implemented, the landowner's signature is required, unless the applicant has power of attorney for the landowner. The landowner must sign the form before proceeding with the project. · Include the twelve (12) digit Hydrologic Unit Code (HUC), and the latitude & longitude or the UTM coordinates for a central location where the BMP is implemented. If many BMPs are implemented in different places, one (1) general coordinate location will suffice. · A Conservation Plan for the land in Section B, signed by a Certified Conservation Planner, must be available in the Sponsor's or local SWCD office for audit purposes. · Before signing, the landowner must understand the certification statements above the signature block. SECTION B - This section certifies that the BMPs are needed to improve or maintain water quality, are in accordance with the Conservation Plan, and were satisfactorily completed. · Complete the field number, official NRCS Practice Title (found in the NRCS Field Office Technical Guide, or at http://efotg.nrcs.usda.gov/efotg_locator.aspx?map=IN) or other specifications followed, number of years of maintenance required (based on Section A), quantity or unit, total practice cost (shown on attached receipts), percent of total cost to be paid to the landowner, total amount paid to the landowner, and date the practice was implemented for each BMP. Agricultural Demonstration BMPs may have a cost-share level of up to 100% (and must be located on public land). See definition of Demonstration Practice below. · If the operation is an Animal Feeding Operation (AFO), Confined Feeding Operation (CFO), or a Concentrated Animal Feeding Operation (CAFO), see the Clean Water Act Section 319 Agricultural Cost-Share Guidance for Indiana for BMP eligibility. · This Section must be completed and signed by an NRCS, IDNR, ISDA, TSP, or SWCD Technical Representative who can certify to the statements at the top of Section B. SECTION C - This section must be complete and signed by an official (with signatory authority) of the Sponsoring Organization. · From the approved watershed management plan (or draft if implementing a demonstration BMP), reference the critical area where the BMP(s) were implemented and what nonpoint source (NPS) pollutants of concern within that critical area are being addressed. FORM SUBMISSION An invoice for payment should be prepared and submitted to IDEM with this form. As individual practices are implemented, invoices may be submitted to IDEM. Payment will be forwarded to the Sponsoring Organization in approximately four weeks. The following items must accompany this complete, signed 319-A Form and an invoice for payment to IDEM: 1) Map, showing location of all BMPs in relation to adjacent roads; 2) Copies of bills or receipts for each BMP showing the total cost; 3) Copies of the Region 5 Load Estimation Model worksheet(s), the STEPL Model workbook, or other appropriate tool to estimate the pollutant load reductions for the practices implemented, when applicable. The above models may be found on EPA's web site at: http://it.tetratech-ffx.com/stepl/models$docs.htm; 4) Appropriate NRCS Checklist if cost-share funds are used to develop a nutrient management plan, pest management plan or comprehensive nutrient management plan. ADDITIONAL INFORMATION - For additional information on the cost-share program and requirements, see the Clean Water Act Section 319 Agricultural Cost-Share Guidance for Indiana or contact your IDEM project manager. Note to sponsors: The sponsoring organization may need to provide a 1099 form for disbursements. DEFINITIONS: Demonstration Practice ­ a BMP used to introduce new techniques in the watershed and to encourage landowners to install the practice. The BMP must: be located on public land and in a critical area as defined in the WMP, not have been cost-shared on before in the watershed with Section 319 funds, and be used/showcased as part of an education/outreach event. Demonstration practices must be authorized in the project's grant agreement and implemented according to the instructions on this form. Land Management Practice ­ Practice that requires primarily management techniques and methods to implement the practice (such as nutrient management, pest management, residue management, and prescribed grazing). Structural Practice ­ Practice that involves constructing designed (engineered) features using machinery (such as waterways, animal mortality facilities and water and sediment control basins). Vegetative Practice ­ Practice that only involves seeding or planting to establish or re-establish plant cover (such as pasture and hay seeding, cover crop, filter strip, and tree planting).

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