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Form 230 ACEP ALE <br />Statement to Confirm Matching Funds <br />Agricultural Conservation Easement Program (ACEP) <br />Agricultural Land Easement (ALE) <br />The following information is required prior to federal fund disbursement. The purpose of this form is to <br />identify and confirm matching fund sources. <br />ACEP ALE Parcel Name <br />State <br />County, Parish, or Borough <br />A. Appraised Fair Market Value of the Agricultural Land Easement <br />Eligible Entity <br />B. Grantor (Landowner) Donation (the portion of A that is given to the <br />Appraisal (by certified appraiser to USPAP/UASFLA standards <br />Eligible Entity by the Grantor as a charitable donation or qualified <br />conservation contribution (as defined by section 170(h) of the Internal <br />Revenue Code of 1986)). Landowner shall not donate any part of C, D, <br />Closing Costs (legal fees) <br />or E back to the cooperating entity. <br />C. Agricultural Land Easement Purchase Price <br />D. Eligible Entity Contribution paid to the Grantor from the Eligible <br />Easement Monitoring (Landowner Cost limited to lesser of 2% or <br />$20,000 of A <br />Entities Cash Resources (D shall be at least 50% of E unless a waiver is <br />approved by NRCS. Eligible Entity shall attach waiver approval.)* <br />E. Federal Cash Contribution paid to the Grantor (Landowner) through <br />Eligible Entity (E shall not exceed 50% of A <br />* ACEP funds provided to the ENTITY may not be used for administrative costs such as appraisal, survey, <br />title insurance, legal fees, easement monitoring, or other related transaction costs or planning costs, such as <br />baseline documentation or Agricultural Land Easement Plan development. Administrative and planning <br />costs are not counted as part of the entity cash contribution or as part of the purchase price. <br />Administrative Costs Paid By: <br />Eligible Entity <br />Landowner <br />Appraisal (by certified appraiser to USPAP/UASFLA standards <br />Surve <br />Closing Costs (legal fees) <br />Title Insurance <br />Easement Monitoring (Landowner Cost limited to lesser of 2% or <br />$20,000 of A <br />Total <br />GRANTOR (landowner) <br />I certify that the information on this supporting form for Federal ACEP ALE acquisition is true, correct, <br />and complete. I have been informed that the dollar amount listed above is the appraised fair market value <br />of the conservation easement, and that I have agreed to grant a conservation easement on my property for <br />$ . (enter purchase price). I understand that false certification has serious <br />consequences and will result in ineligibility for the ACEP. <br />Grantor (Landowner) Name(s) (please print): <br />Signature: <br />Date: <br />GRANTEE (eligible entity) <br />I certify that the information on this form for Federal ACEP ALE acquisition is true, correct, and <br />complete. I further certify that the entity's cash contribution of the matching funds listed above have not <br />Attachment number 1 <br />F -7 Page 178 <br />