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NCDA&CS ADI P Trust Fund <br />Grant Cycle VI Easement Application Checklist <br />This Easement Application Checklist is provided as a means to ensure that all applications are submitted with the <br />required information. Failure to include all information may result in ineligibility to receive funding. This document must <br />be completed IN BLUE INK and filed with submiss'lon of the 2012 Easement Application no later than 5:00 SAM can <br />December 17, 2012 in order to be considered. <br />Applicant Name: <br />Caba rrus Soil and Water Conservation District <br />Applicant Tax <br />Identification Number: <br />56 6000 (Cabarrus County) <br />ADFP USE <br />ONLY <br />❑ <br />DUNS Number <br />965929263 <br />Pro`ectTitle. <br />Michael Barrier _Perman Con seryation Easement (CabarrL:s) <br />The following items are required for ALL applicants. <br />1. Compliance with NC Openbook. <br />GRANTEE <br />USE ONLY <br />® <br />2. Letters of Commitment from matching funds sources only. <br />3. Location maps showing roads, proximity to towns, other conserved lands, markets, <br />etc. <br />4. Map or area photo of property with bodies of water, structures, land cover, and <br />dwellings_ <br />5. Soils map with boundaries developed under USDA -NRCS Cooperative Soil Survey <br />L <br />(only one map with fool VVCD officer signature verifying prime soils and acreage) <br />® <br />6. Photographs of landscape, structures, and equipment (limited to two 8% x 11 pages) <br />d <br />7. Financial affidavit (only If claiming Limited Resource or Beginning Farmer) <br />® <br />8. Mapped directions to land ,parcel from NCDA &CS Raleigh Office (2 W Edenton <br />Street, Raleigh, NC 27601) i,e.: Gocgle Flaps, MapQuest <br />® <br />9, Original Signatures in BLUE INK are needed on pages 14 and 22. <br />GRANTEES <br />USE ONLY <br />The following items are required for Non-Profit Ikon- Governmental Organ <br />_AaFP USE <br />ONLY <br />Applicants [7rily ALL DOCUMENTS REQUIRING SIGNATURE MUST BE <br />COMPLETED ININ BLUE INK OR THEY W ILL NOT BE ACCEPTED. <br />❑ <br />1, 501(c)(3) Certification and Letter of Federal Tax Exemption Status from the Internal <br />Revenue Service (Need 2 originals) <br />2. Current Conflict of Interest and Certification Policy (addressing conflicts of interest involving <br />❑ <br />the applicant's management, employees, and the members of its board of directors or other governing <br />body that may arise): <br />The policy shall address situations in which any of these individuals may directly or <br />indirectly benefit, except as the applicant's employees or members of its board of <br />other governing body, from the applicant's disbursing of State funds, and shaft <br />include actions to be taken by the applicant or the individual, or both, to avoid <br />conflicts of interest and the appearance of impropriety_ The policy shall be filed <br />before the funds may be disbursed to the applicant. An example policy may be <br />accessed from the State Auditor's website. (Need 2 originals) <br />❑ <br />3. Sworn Statement of No Overdue Taxes shall be made under oath and shall be filed <br />prior to the disbursement of any State funds. (Need 2 originals) <br />Q <br />Information can be accessed from the state auditor's website. <br />❑ <br />4. List of current grants held by the applicant organization and respective amounts <br />❑ <br />5. List of board members <br />6. Articles of Incorporation <br />Rage 1 of 20 Easement ApplicatidnAttacnment number 1 <br />WHI Page 168 <br />