NC Department of Agriculture & Consumer Services
NCDA&CS ADFP Trust Fund
ADFP Trust Fund Cycle VII, TVA Sourced Grant Funds, Military Sourced Grant Funds
Easement Application Checklist
This Easement Application Checklist is provided as a means to ensure that all applications are submitted with the required information. Failure to include all information may result in ineligibility to receive funding. This document must be signed IN BLUE INK and filed with submission of the 2013 Easement Application no later than 5:00 PM on Monday, December 16, 2013 in order to be considered. *Please do not print two-sided or duplex and do not staple application pages.*
|Applicant Name: | |
|Project Title: | |
|Applicant Tax Identification Number: | |
|DUNS Number: | |
|GRANTEE USE ONLY |The following items are required for ALL applicants. |ADFP USE ONLY |
| | | |
| |1. Compliance with NC Openbook. | |
| | | |
| |Letters of Commitment from matching funds sources only. | |
| | | |
| |Location maps showing roads, proximity to towns, other conserved lands, markets, etc. | |
| | | |
| |Map or area photo of property with bodies of water, structures, land cover, and dwellings. | |
| | | |
| |Soils map with boundaries developed under USDA-NRCS Cooperative Soil Survey | |
| |(only one map with local SWCD officer signature verifying prime soils and acreage) | |
| | | |
| |Photographs of landscape, structures, and equipment (limited to two 8 ½ x 11 pages) | |
| | | |
| |Financial affidavit (only if claiming Limited Resource or Beginning Farmer) | |
| | | |
| |Mapped directions to land parcel from NCDA&CS Raleigh Office (2 W Edenton Street, Raleigh, NC 27601) i.e.: Google Maps,| |
| |MapQuest | |
| | | |
| |Original Signatures in BLUE INK are needed on pages 14 and 21. | |
| | | |
|GRANTEE USE ONLY |The following items are required for Non-Profit Non-Governmental Organization Applicants Only. ALL DOCUMENTS REQUIRING |ADFP USE ONLY |
| |SIGNATURE MUST BE COMPLETED IN BLUE INK OR THEY WILL NOT BE ACCEPTED. | |
| | | |
| |501(c)(3) Certification and Letter of Federal Tax Exemption Status from the Internal Revenue Service (Need 2 originals)| |
| | | |
| |Current Conflict of Interest and Certification Policy (addressing conflicts of interest involving the applicant's | |
| |management, employees, and the members of its board of directors or other governing body that may arise): | |
| |The policy shall address situations in which any of these individuals may directly or indirectly benefit, except as the| |
| |applicant's employees or members of its board of other governing body, from the applicant's disbursing of State funds, | |
| |and shall include actions to be taken by the applicant or the individual, or both, to avoid conflicts of interest and | |
| |the appearance of impropriety. The policy shall be filed before the funds may be disbursed to the applicant. An example| |
| |policy may be accessed from the State Auditor’s website. (Need 2 originals) | |
| | | |
| |Sworn Statement of No Overdue Taxes shall be made under oath and shall be filed prior to the disbursement of any State | |
| |funds. (Need 2 originals) | |
| |Information can be accessed from the state auditor’s website. | |
| | | |
| |List of current grants held by the applicant organization and respective amounts | |
| | | |
| |List of board members | |
| |Articles of Incorporation | |
| | | |
| | | |
NCDA&CS Farmland Preservation Grants
ADFP Trust Fund Cycle VII
Easement Application
For Agricultural, Horticultural, & Forestry Programs
[pic] [pic]
Please direct all questions and concerns to:
NCDA&CS ADFP Trust Fund
1001 Mail Service Center
Raleigh, NC 27699-1001
919.707.3071
|ncadfp@ | |
All information in this application is required. Incomplete applications will be considered ineligible for funding. Application must be delivered to the ADFP Trust Fund office no later than 5:00 PM on December 16, 2013.
RFP funding resources include general state appropriations, TVA settlement grant funds, and military resource funding. RFPs will be matched up with appropriate funding source. All counties are eligible for general appropriation funds.
Please identify which region applies to your grant application. Note: If choosing TVA or Military regions, the easement must be contained exclusively in the listed counties.
TVA: Avery, Buncombe, Burke, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Swain, Transylvania, Watauga, Yancey.
Military: Beaufort, Bertie, Bladen, Brunswick, Camden, Carteret, Chatham, Chowan, Columbus, Craven, Cumberland, Currituck, Dare, Duplin, Durham, Edgecombe, Franklin, Gates, Greene, Halifax, Harnett, Hertford, Hoke, Hyde, Johnston, Jones, Lee, Lenoir, Martin, Moore, Nash, New Hanover, Northampton, Onslow, Pamlico, Pasquotank, Pender, Perquimans, Pitt, Richmond, Robeson, Sampson, Scotland, Tyrell, Wake, Washington, Wayne, Wilson.
Other: Includes counties outside of the previously mentioned regions.
IDENTIFYING INFORMATION
|Project Title (5 words or less): |
|All Counties Included in Easement: |
|Funds Requested of ADFP: $ |Secured Matching Funds: $ |
|Size of Easement: acres |Estimated Easement Value: $ |
| Permanent Easement Term Easement |If term easement, designate number of years: |
| |
|Applicant Organization: |
|Applicant Tax Identification Number: |DUNS Number: |
|Primary Applicant Contact: |Primary Contact Title: |
|Primary Office Telephone: |Primary Mobile Telephone: |
|Primary Email: |Primary Fax Number: |
|Alternate Applicant Contact: |Alternate Contact Title: |
|Alternate Office Telephone: |Alternate Mobile Telephone: |
|Alternate Email: |Alternate Fax Number: |
|Applicant Mailing Address (if delivered by US Postal Service) |Applicant Physical Address (if delivered by any other means) |
|Address: |Street: |
|City: |City: |
|State: |State: |
|Zip Code: |Zip Code: |
|County: |County: |
PROJECT PROFILE
Projects may not begin before July 1, 2014.
Property Identification Information
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|Property Address: |
|Street: |
|City: |
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|State: |
|Zip Code: |
|County: |
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|Attach a Map showing the property location – County road map or equivalent. This must be adequate to allow ease of travel to the site from 2 W Edenton Street, |
|Raleigh, NC 27601 |
| | | |
|Landowner’s Contact Information: | |
|Name: | |
| | |
|Street: | |
|City: | |
| | |
|State: | |
|Zip Code: | |
|County: | |
| | |
|Home Phone: | |
|Mobile Phone: | |
|Email: | |
| | |
|If this involves multiple ownerships (as noted on the property deed), does the individual listed above have the authority to represent all owners? Yes|
|No |
|If yes, include written authorization. |
Matching Funds Rate & Matching Funds
1.) Designate (circle) whether the Applicant is:
➢ a county agency (if designated go to #2)
OR
➢ a private non-profit organization (if designated go to #3)
2.) County Agencies ONLY
A.) Please see the Matching Funds Rate (MFR) Worksheet on page 22 to determine the applicant county’s MFR.
B. The Matching Funds Rate (MFR) for this proposal as determined in question 2A above is:
(This will be used in question number 10.)
C. Provide a Letter of Intent from each matching source.
3.) Non-Governmental Agencies ONLY
A.) If the applicant is a private non-profit conservation organization, the Matching Funds Rate (MFR) must equal or exceed 30% (0.30). (This will be used in question number 10.)
B) Provide a list of all matching funds and a commitment authorization from each source.
Length of Easement
4.) Is this application for a Permanent Easement? Yes No
A. If yes, your Easement Multiplier (EM) is 1. Go to question 5.
B. If no, then this is an application for a term easement of:
| 20 years | 30 years | 40 years | 50 years | years (if different) |
The Easement multiplier is the decimal equivalent of the years in the Term Easement. Use the following guidelines to determine term multiplier for this project.
• For less than 50 years use .01 for each year
• For 50 years and greater use .10 + .01 for each year up to .99
|Term Years |
|Easement Multiplier (Question 4): |
|Maximum Allowable Request (MAR): $0.00[pic]$0.00 |
9.) What is the grant amount requested from the ADFP Trust Fund? $0.00
This may not exceed the MAR established in question 8. (Place in appropriate line on page 2.)
10.) To determine the Minimum Required Match needed for the project, multiply the Grant Request (determined in question 9) by the Matching Funds Rate (MFR) (identified in question 2 or 3).
|Grant Request: $0.00 |
|Matching Funds Rate (as decimal): |
|Minimum Required Match: $0.00[pic]$0.00 |
| |
|Total Secured Matching Funds (Committed in writing): $0.00 |
|Total Unsecured Matching Funds (Not committed but requested): $0.00 |
|Total Matching Funds: $0.00[pic]$0.00 |
(Total Secured Matching Funds must be the same as noted on page 2; must meet Minimum Required Match; Based on Commitment Letters included with application)
All secured match resources, both of cash and in-kind, must provide a letter of commitment and any qualifying parameters associated with those commitments.
Description of Land Unit Subject to Easement
1. Is the land unit a portion of a larger farm / forestry operation? Yes No
If yes, what are the number acres in the entire farm / forestry operation? acres.
2. What is the number of total acres in the subject easement property? acres.
3. Describe the easement property.
|Acres in cropland | acres |
|Acres in pasture | acres |
|Acres in forestry | acres |
|Acres in horticulture | acres |
|Acres in aquaculture | acres |
|Acres in ponds, streams, wetlands, or other natural areas not being used for production purposes | acres |
|Acres to be included for support purposes (barns, sheds, tenant housing, etc.) | acres |
|Describe the existing homestead in the easement (if applicable): |
← Total of all described easement acres in question 3 must equal subject easement acres in question 2 of this page.
4. List species and approximate numbers of livestock, poultry, crop acreage and aquaculture that the farm has currently.
Name of Species Numbers
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5. What percentage of the proposed easement acreage of land is Prime, Unique or soils of statewide importance?
|0.00% |
a. Please list the contact information of Soil Conservationist providing the determination.
|Name: |
|County: |
|Phone Number: |
|Email: |
Landowner Information
1. Is the land owner the operator of the farm operation or is the farm leased? If partially leased then explain who is responsible for production decisions on which land.
| |
2. What percentage of the landowner(s)’s gross income is derived from agriculture, horticulture and forestry?
|0.00% |
3. Are the landowners:
a. Beginning Farmers as defined by USDA? Yes No
Definition of A Beginning Farmer is person who has not operated a farm or ranch or who has operated a farm or ranch for not more than 10 consecutive years.
b. Limited Resource Farmers as defined by USDA? Yes No
Definition of A Limited Resource Farmer or Rancher or Forest Owner is a person with direct or indirect gross farm sales not more than $155,200 in each of the previous two years AND A person with a total household income at or below the national poverty level for a family of four or less than 50 percent of county median household income in each of the previous two years.
4. Is anyone else directly involved in agriculture, forestry, horticulture production on the easement property?
Yes No
If yes, briefly list and describe duties.
| |
Planning, Management and Operation
|Does the county in which the easement is located have a Voluntary Agricultural District (VAD) Program? | Yes | No |
|Is the proposed easement property enrolled in a VAD? | Yes | No | N/A |
|Does the county in which the easement is located have an Enhanced Voluntary Agricultural District (EVAD) Program? | Yes | No |
|Is the proposed easement property enrolled in an EVAD? | Yes | No | N/A |
|Does the county in which the easement is located have an approved Farmland Protection Plan (FPP)? | Yes | No |
|Is the landowner a member of an advisory committee with a VAD, EVAD, or FPP? | Yes | No | N/A |
1. Are any of the property owners members of:
|Goodness Grows in North Carolina | Yes | No |
|American Tree Farmer | Yes | No |
|Forest Stewardship Program | Yes | No |
|Century Farm Family | Yes | No |
2. Management Plans:
A.) Does the property have a conservation plan on file at the NRCS / Local Soil & Water District office?
Yes No N/A
If No, you must provide reasoning for not having by a NRCS / District representative.
B.) If the property has 20 or more acres of woodland, does it have a current forest
management plan? Yes No N/A
|Explain: |
C.) Is the farm required to have an animal waste management plan? Yes No
If yes, provide your state General Permit number or NPDS permit number:
3. Is the property currently being used for agriculture production? Yes No
|If No, Why not? |
Regional Landscape Interests
|1. What is the distance to nearest privately owned farm or forest land that is protected by easement? Provide farm name, easement holder and distance. |
| |
|2. What is the distance to any nearby (within 5 miles) state or federally owned land that is protected or managed for the protection of agriculture, plants, |
|forestry, wildlife, historic or cultural sites? Provide farm name, property managing agency and distance. |
| |
|3. Identify any nearby military installations (within 5 miles) or where there is a designated military air space over the proposed easement property or other |
|interaction with military exercises (Must provide documentation). State the branch of the military, distance from the property and describe any relationship that |
|may be appropriate. |
| |
|4. Provide a county/regional map that shows the location proximity of the easement property to the properties described in questions 1, 2 and 3 above. |
|5. Provide a map or aerial photo that identifies farm structures, water features and property boundaries. |
|6. What is the closest distance to a town or city limits? miles |
|7. What is the closest distance to non-farm development (identify) that has been constructed within the previous 5 years. |
| |
OVERVIEW
|1. Provide a background on the ownership and use of the easement property. This should relate the farm to the region, economy, and history. (200 words or less) |
| |
|2. Explain any threats of conversion to the easement site. This should focus on actions that may occur within the next 5 years (This may include such items as |
|condemnation, loss of supply and market infrastructure, inheritance or estate issues, etc.). (200 words or less) |
| |
|3. Describe any conservation or environmental practices which have been implemented on the property. (200 words or less) |
| |
|4. Explain any limitations on production due to lack of, or distance to farm infrastructure (e.g. equipment parts and repair, feed, seed, fertilizer, chemicals, |
|markets, processing, etc.). (200 words or less) |
| |
|5. Explain actions the landowners have taken to transition the land to future farmers/foresters. (200 words or less). |
| |
|6. List any capital investments by year, related to production on the easement, of $5,000 or greater that have occurred in the past 10 years. This may include farm|
|equipment, barns, housing for labor, conservation practices and others. |
|Equipment |Cost |Year |
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SCOPE OF WORK
|Applicant Name: | |
|Project Title: | |
|DUNS Number: | |
|Applicant Tax Identification Number: | |
A. Please provide a brief description of the easement.
(150 words or less.)
| |
B. List specific outcomes to be achieved.
(150 words or less.)
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C. What community need(s) will the project serve?
(150 words or less.)
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D. Please provide a brief description of the easement.
(150 words or less.)
| |
| |
|Exclusive Application for TVA sourced grant funds: |
| |
|If the RFP is exclusively designated for the TVA defined counties, please check all applicable uses of the requested grant funds that apply. |
| |
|Documentation of grant expenditures will be required of agricultural and forestry sectors use and production of renewable energy and carbon sequestration measures |
|that are checked. The RFP objective must encourage the preservation of qualifying agricultural, horticultural and forestlands or foster the growth, development and|
|sustainability of family farms. |
| |
|Anaerobic digestion of poultry, swine, or dairy manure to produce methane as a fuel source to displace conventional fuel use |
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|Installation of wind and solar power projects at farms to power irrigation and provide heat and / or hot water for farm operations |
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|Production of biodiesel from high oil producing crops grown and converted on-farm for on-farm use |
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|Funding the procurement of land and necessary equipment to establish urban farms and support the education and institution of urban farming practices in these |
|communities |
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|Use of agricultural or forestry waste products in support of biofuel production |
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|Development of co-products and by-products of biofuel production from agricultural or forestry resources |
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|Other innovative agricultural or forestry projects, including education and training that meet environmental improvement standards and are approved by the State |
|and / or review committee |
|Purchasing land buffering national or state forests, parks, and refuges that link important ecological systems in the region to support carbon sequestration |
|efforts* |
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|*Term and perpetual agricultural land easements are considered applicable uses |
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|Exclusive Use of Military sourced grant funds: |
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|If the RFP is exclusively designated for the military defined counties, please check all applicable uses of the requested grant funds that apply. |
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|Documentation of grant expenditures will be required. The RFP objective must encourage the preservation of qualifying agricultural, horticultural and forestlands |
|or foster the growth, development and sustainability of family farms. |
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|Strengthening and enhancing local agribusiness / military interdependence |
| |
|Development and implementation of farmland preservation plans |
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|Education and encouragement of qualified landowners to enroll land in Present Use Value (PUV) |
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|Encouraging the placement of veterans in agribusiness sectors |
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|Encouragement and placement of agricultural easements or conservation contracts on agriculture and forest land parcels |
PROJECT TIMELINE
Projects may not begin before July 1, 2014.
*Projects receiving military funds must be completed by June 30, 2015
|Applicant Name: | |
|Project Title: | |
|DUNS Number: | |
|Applicant Tax Identification Number: | |
|Applicants Fiscal Year: | to |
Grant Year One
|Quarter (Year One) |Tasks/Goals |Grant Funding to be Used |Matching Funds (cash or in-kind) |Total Funding to be Used |
| | | |to be Used | |
|July 1 - Sept. 30 | |$0.00 |$0.00 |$0.00[pic]$0.00 |
|Oct. 1 - Dec. 31 | |$0.00 |$0.00 |$0.00[pic]$0.00 |
|Jan. 1 - March 31 | |$0.00 |$0.00 |$0.00[pic]$0.00 |
|April 1 - June 30 | |$0.00 |$0.00 |$0.00[pic]$0.00 |
| | | | | |
|Grant Year 1 Subtotal | |$0.00[pic]$0.00 |$0.00[pic]$0.00 |$0.00[pic]$0.00 |
Grant Year Two
|Quarter (Year Two) |Tasks/Goals |Grant Funding to be Used |Matching Funds (cash or in-kind) |Total Funding to be Used |
| | | |to be Used | |
|July 1 - Sept. 30 | |$0.00 |$0.00 |$0.00[pic]$0.00 |
|Oct. 1 - Dec. 31 | |$0.00 |$0.00 |$0.00[pic]$0.00 |
|Jan. 1 - March 31 | |$0.00 |$0.00 |$0.00[pic]$0.00 |
|April 1 - June 30 | |$0.00 |$0.00 |$0.00[pic]$0.00 |
| | | | | |
|Grant Year 2 Subtotal | |$0.00[pic]$0.00 |$0.00[pic]$0.00 |$0.00[pic]$0.00 |
| | | | | |
|Entire Grant Period Total | |$0.00[pic]$0.00 |$0.00[pic]$0.00 |$0.00[pic]$0.00 |
← Project Timeline Totals must match Project Budget Totals on page 14
PROJECT BUDGET
List the funds requested from grant, the cash match anticipated, and in-kind match in the table below by line item and state the totals for each. Then, state the “Total Project Value” on the line below by adding the total grant funds requested, the total cash match anticipated, and the total in-kind match anticipated. In the Budget Narrative section, provide an explanation of how the grant funds will be expended.
If more space is needed, please attach additional sheets.
|Applicant Name: | |
|Applicant Tax Identification Number: | |
|DUNS Number | |
|Project Title: | |
|Applicant’s Fiscal Year | to |
|Expenditure Categories |Grant Funds Requested |Cash Match |In-Kind Match |Total |
|204 |Travel (applicable state rates) | |$0.00 |$0.00 |$0.00[pic]$0.00 |
|207 |Personnel and Administrative | |$0.00 |$0.00 |$0.00[pic]$0.00 |
|211 |Stewardship Endowment | |$0.00 |$0.00 |$0.00[pic]$0.00 |
|212 |Survey |$0.00 |$0.00 |$0.00 |$0.00[pic]$0.00 |
|213 |Appraisal | |$0.00 |$0.00 |$0.00[pic]$0.00 |
|214 |Baseline Documentation Report |$0.00 |$0.00 |$0.00 |$0.00[pic]$0.00 |
|215 |Environmental Assessment/Audit |$0.00 |$0.00 |$0.00 |$0.00[pic]$0.00 |
|216 |Legal Fees |$0.00 |$0.00 |$0.00 |$0.00[pic]$0.00 |
|217 |Closing Costs |$0.00 |$0.00 |$0.00 |$0.00[pic]$0.00 |
|220 |Easement Purchase |$0.00 |$0.00 |$0.00 |$0.00[pic]$0.00 |
|Total Budget |$0.00[pic]$0.00 |$0.00[pic]$0.00 |$0.00[pic]$0.00 | |
| | | | | | |
Total Project Value (Please Add Grant Funds + Cash Match + In-Kind Match) = $0.00
← Project Budget Totals must match Project Timeline Totals on page 13.
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|Applicant Signature |Date |
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|ADFP Trust Fund Budget Officer Signature |Date |
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|ADFP Trust Fund Program Manager Signature |Date |
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BUDGET NARRATIVE
|Provide a short explanation of the purpose of the line expenditures listed below based on the budget completed on page 14. |
| | Expenditures Budget Narrative |
| | |
| | |
|Line | |
| | |
|Item | |
|204 |Travel (applicable state rates) | |
|207 |Personnel & Administrative | |
|211 |Stewardship Endowment | |
|212 |Survey | |
|213 |Appraisal | |
|214 |Baseline Documentation Report | |
|215 |Environmental Assessment/ Audits | |
|216 |Legal Fees | |
|217 |Closing Costs | |
|220 |Easement Purchase | |
| |
|Source of Funds |Amount of Funds |Cash (C) or In-kind|Description |Rate of Pay & Hours |
| | |(IK) | | |
|Example: ABC Agency |$300 |IK |Administration Assistant |$10/hr for 30 hrs. |
| |$0.00 | | | |
| |$0.00 | | | |
| |$0.00 | | | |
| |$0.00 | | | |
| |$0.00 | | | |
| |$0.00 | | | |
| |$0.00 | | | |
| |$0.00 | | | |
| |$0.00 | | | |
| |$0.00 | | | |
|Total: |$0.00[pic]$0.00 | |
|Notes: |
|Contact Information for Outside Funding Sources Listed Above |
|Name |Agency |Phone Number |Email Address |
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← Match Funds should be the same as noted in the Project Budget and Project Timeline on pages 13 and 14.
NC OPENBOOK SUPPLEMENTAL INFORMATION
|INSTRUCTIONS: Complete the information below and return it to the Contract Administrator identified in your original contract. This information must be|
|submitted as part of your contract. If you have questions, please contact the Contract Administrator or the Alternate Contact as reflected in your |
|contract. |
PURPOSE: in January 2009, the Governor of North Carolina signed Executive Order 4. This Executive Order requires certain information be collected from Grantees to enhance accountability and transparency of State funds. Therefore, the information outlined below shall be submitted prior to the disbursement of any State funds by the North Carolina Department of Agriculture and Consumer Services.
|DUNS Number: |Amendment Number: |
|Grantee Name: |TAX ID Number: |
|Fiscal Year Ends: |Contract Number: |
1. Brief Description and Background/History of your Organization.
|Be sure to include the number of years in existence, number of employees, mission and goals of your organization. |
| |
2. Current project timeline: Begin: End:
3. Expected outcomes and specific deliverables.
|(Example: Expected Outcome: Aquaculture operation will remain in business. Deliverable: Healthy food will be made available for human |
|consumption.) |
| |
4. The Grantee’s website URL:
5. * Primary County of Performance. County Name:
(CONGRESSIONAL DISTRICT # MUST BE IDENTIFIED) Congressional District #:
6. **County of Benefit:
|Single County: | Yes | No |County Name: |
|Statewide: | Yes | No | |
|Regional: | Yes | No | |
7. If the answer to question number 6 is “Regional”, list the counties receiving benefit.
| |
*Primary County of Performance: County in which grantee is located.
**County of Benefit: Identified county or counties in which funding will be spent and/or food commodities will be received.
REQUESTING A D-U-N-S NUMBER
|D-U-N-S Request by Email |
Dun & Bradstreet (D&B) provides a D-U-N-S Number, a unique nine digit identification number, for each physical location of your business.
D-U-N-S Number assignment is FREE for all businesses required to register with the US Federal government for contracts or grants.
To request your D-U-N-S Number via the Web. If one does not exist for your business location, it can
be created within 1 business day.
For technical difficulties, contact govt@
|D-U-N-S Request by Phone |
|1-866-705-7511 |
| |
|For U.S., Puerto Rico, and US Virgin Islands Requests only |
| |
|Contact the D&B Government Customer Response Center |
|U.S. and U.S Virgin Islands: 1-866-705-5711 |
|Alaska and Puerto Rico: 1-800-234-3867 (Select Option 2, then Option 1) |
|Monday - Friday 7 AM to 8 PM C.S.T. |
| |
|The process to request a D-U-N-S® Number by telephone takes between 5 and 10 minutes. |
| |
|You will need to provide the following information: |
|Legal Name |
|Tradestyle, Doing Business As (DBA), or other name by which your organization is commonly recognized |
|Physical Address, City, State and Zip Code |
|Mailing Address (if separate) |
|Telephone Number |
|Contact Name |
|SIC Code (Line of Business) |
|Number of Employees at your location |
|Headquarters name and address (if there is a reporting relationship to a parent corporate entity) |
|Is this a home-based business? |
Have the following attachments been included?
Failure to provide all applicable attachments may result in application disqualification.
Map to Property and YES NO
Directions from 2 W Edenton St, Raleigh, NC 27601.
Authorization to represent landowner(s) . YES NO
A letter must be provided from either NRCS or YES NO
the local Soil and Water Conservation District
which certifies the percentage of Prime Unique
and Soils of Statewide Importance, and a statement
of an existing conservation plan.
Provide a list of all matching funds and sources. YES NO
All sources of matches, both cash and in-kind, YES NO
must provide a letter of commitment or explain
any circumstances where the match has been
applied for and is awaiting review and approval.
Provide a county/ regional map that shows the YES NO
location and proximity of the easement property
to protected farmlands, military bases and operational
areas, cultural or historic sites, state or federal lands
managed for the protection of agriculture, forestry,
plants or wildlife.
Provide a map or aerial photo that identifies farm YES NO
structures, water features and property boundaries.
A listing of capital investments. YES NO
Financial affidavit (only if claiming Limited Resource YES NO
or Beginning Farmer).
Photographs of typical landscape, structures and YES NO N/A
equipment. Maximum of two 8.5X 11 inch pages.
Budget, Timeline and Budget Narrative sheets. YES NO
Non-governmental Applicants must also provide: YES NO N/A
A copy of the organization’s Articles of
Incorporation.
A list of current Board Members.
A list of current grants. YES NO N/A
A copy of the organization’s current conflict YES NO N/A
of interest and certification policy statement.
(Documents must be completed and signed in
BLUE INK. Must have two originals).
A Sworn Statement of No Overdue Taxes. (This YES NO N/A
must be notarized and dated in BLUE INK. Must
have two originals).
Signed and dated in BLUE INK pages 14 & 21 YES NO
[pic] [pic]
ADFP Trust Fund
NCDA&CS
I certify that the information contained in this document is true and accurate and will follow reporting requirements for use of state funds as mandated by G.S. 143C-6-23.
I certify that I am authorized by the applicant organization or agency to enter into a contractual arrangement on its behalf, with the granting agency.
I understand that this application and all attachments submitted with it are public records subject to the Freedom of Information Act.
|Signature: |Date: |
|(Representative Authorized to Sign on Behalf of the Applicant Organization) |
| |
|Title: |
| |
|Organization: |
I agree not to pursue or contract the sales of my property for 240 days after the application date,
unless petition to board for reasons of bankruptcy, death, and or financial hardship.
|Landowner Signature: |Date: |
|Print Landowner Name: |
|Co-owner Signature: |Date: |
|Co-owner Signature: |Date: |
|Co-owner Signature: |Date: |
Please direct all questions and concerns to:
Elizabeth Heath
NCDA&CS ADFP Trust Fund
1001 Mail Service Center
Raleigh, NC 27699-1001
919.707.3071
ncadfp@
Matching Funds Worksheet for County Agencies
County2013 Tier DesignationsNCDA&CS Approved Farmland Protection Plan?Matching Funds Rate (MFR)County2013 Tier DesignationsNCDA&CS Approved Farmland Protection Plan?Matching Funds Rate (MFR)Alamance2Yes15%Johnston3Yes15%Alexander2No30%Jones1Yes0%Alleghany1No30%Lee2Yes15%Anson1No30%Lenoir1Yes0%Ashe2No30%Lincoln2Yes15%Avery2No30%Macon2No30%Beaufort2No30%Madison2No30%Bertie1No30%Martin1No30%Bladen1Yes0%McDowell1No30%Brunswick3No30%Mecklenburg3No30%Buncombe3Yes15%Mitchell1No30%Burke1No30%Montgomery1Yes0%Cabarrus3Yes15%Moore3Yes15%Caldwell1No30%Nash2Yes15%Camden1No30%New Hanover3No30%Carteret3No30%Northampton1No30%Caswell1Yes0%Onslow2Yes15%Catawba2Yes15%Orange3Yes15%Chatham3Yes15%Pamlico2Yes15%Cherokee1Yes0%Pasquotank2No30%Chowan1No30%Pender3No30%Clay1Yes0%Perquimans2No30%Cleveland2No30%Person2No30%Columbus1No30%Pitt2No30%Craven2No30%Polk2Yes15%Cumberland2Yes15%Randolph2Yes15%Currituck2Yes15%Richmond1Yes0%Dare2No30%Robeson1Yes0%Davidson2Yes15%Rockingham1Yes0%Davie2No30%Rowan2No30%Duplin2Yes15%Rutherford1No30%Durham3Yes15%Sampson2Yes15%Edgecombe1Yes0%Scotland1Yes0%Forsyth3No30%Stanly2Yes15%Franklin3Yes15%Stokes2No30%Gaston2Yes15%Surry2Yes15%Gates1No30%Swain1Yes0%Graham1No30%Transylvania2Yes15%Granville2No30%Tyrrell1No30%Greene2Yes15%Union3No30%Guilford2Yes15%Vance1No30%Halifax1No30%Wake3Yes15%Harnett2Yes15%Warren1No30%Haywood3Yes15%Washington1No30%Henderson3Yes15%Watauga3Yes15%Hertford1No30%Wayne2Yes15%Hoke1Yes0%Wilkes1No30%Hyde1No30%Wilson1No30%Iredell3Yes15%Yadkin2No30%Jackson1No30%Yancey1No30%
-----------------------
|Departmental Use Only |
|Date Received: |________________ |
|Application #: |_________________ |
|Requested Amount: |$_________ |
|Project Value: |$_______________ |
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