Soil and Water Resource Management Program



|ARM-LWR-386 (Rev. Feb. 2014) |

|[pic] |Wisconsin Dept. of Agriculture, Trade & Consumer Protection |Soil and Water Resource Management Program |

| |Agricultural Resource Management Division | |

| |2811 Agriculture Drive, PO Box 8911 | |

| |Madison WI 53708-8911 | |

| |Phone: (608) 224-4648 or (608) 224-4610 | |

| |Use to qualify for economic hardship. |

|Financial Disclosure Affidavit | |

|(s. 92.14, Wis. Stats. ATCP 50.42(4), Wis. Admin. Code) | |

State of Wisconsin )

) ss.

      County )

I,       being first duly sworn, state that:

1. I am making this affidavit for the purpose of qualifying for economic hardship treatment in connection with a cost-share grant from       County Land Conservation Committee.

2. I am seeking an economic hardship determination to obtain cost-sharing to install one or more conservation practices on farm land that I either own or operate.

3. I have requested that       (an accredited financial institution)(a certified public accountant) [strike one] certify to the county land conservation committee that I qualify for economic hardship treatment, under s. ATCP 50.42(4), Wis. Admin. Code.

4. I have provided the (accredited financial institution) (certified public accountant) [strike one] identified in par. 3 a full and true disclosure of my financial condition, including a copy of my latest federal tax return.

_________________________________

APPLICANT SIGNATURE

|Signed and sworn to before me on _______________ , 20__, |

|(date) |

|by      __________________________________________ . |

|(name of person) |

|__________________________________________________ |

|SIGNATURE |

|Print name: ________________________________________ |

|Notary Public, State of Wisconsin, |

|My commission expires ______________________________ (is permanent). |

This document was drafted by the Wisconsin Department of Agriculture, Trade and Consumer Protection.

Personal information you provide may be used for purposes other than that for which it was originally collected (Sec. 15.04 (1) (m), (, Wis. Stats.).

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