We, the Undersigned, Attest That to the Best of Our Knowledge the Information Contained

Oregon Conservation Strategy Implementation Grant

Authorizations and Legal Requirements – Form C

We, the undersigned, attest that to the best of our knowledge the information contained in this application is true, and hereby make application for financial assistance under the terms and conditions of the Oregon Department of Fish (ODFW) and State Wildlife Grant (SWG) Program in the amount of $. The total cost of the project is $ as shown on page 1 of Form A.

We understand that if this proposal is funded:

·  No funds associated with the project will be expended until all compliance requirements have been met, the ODFW agreement is fully signed by all designated signatories, and the project manager receives email notification from ODFW staff to proceed;

·  In the event that a cultural resource survey is required for compliance under Section 106 of the National Historic Preservation Act, ODFW staff will notify the applicant by email that pre-award federal (SWG, other federal) and match funds are authorized to be expended at the rate of 1:1 for the purpose of obtaining the survey;

·  The funds, once approved, will be used solely for the purpose of carrying out the objectives and tasks contained in project narrative and budget;

·  No modifications or changes will be made to the project narrative or the associated budget without amendment and email notification to proceed from ODFW staff;

·  Match funds will be expended either concurrently (1:1) or prior to expending an equal amount of SWG and/or other federal funds;

·  Work associated with the project must be completed by September 30, 2013 unless an extension is granted by ODFW staff.

In addition, we will be required to:

·  Sign an agreement with ODFW containing the terms and conditions of the project;

·  Submit copies of all applicable permits and licenses from local, state or federal agencies or supply written evidence that such permits or licenses are not needed;

·  Certify that the project complies with local, state and federal regulations;

·  Disclose all sources of monetary and in-kind contributions (identifying whether non-federal or federal) for the entire project;

·  Submit documentation of sufficient match expenditures either concurrently or before federal (SWG and other federal) are expended;

·  Submit reimbursement requests and supporting documentation of expenditures (payroll records, volunteer match logs, paid invoices and receipts) before receiving reimbursement of SWG funds;

·  Submit project reports in accordance with USFWS and ODFW reporting requirements;

We understand that the submitted proposal and the funded project outputs are matters of public record.

By their signatures, the landowner(s) attest that they have no plans to sell their property as of the date of this application and they agree to provide written notification to the project manager and ODFW before the property is listed for sale. They further agree to provide, upon prior request and at a mutually acceptable time, site access to the applicant or representatives of ODFW for up to two years following project completion to allow for verification of implementation.

Authorizations and Legal Requirements Signature Page – Form C

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Applicant’s Designated Signatory Date
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Applicant’s Designated Signatory Name and Title (Print)
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Fiscal Agent Signature Date
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Fiscal Agent Name and Title (Print) / ______
Landowner Signature Date
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Landowner Name and Title (Print)

Attach additional signature pages, if needed.

1

Application Form C – 2011 (2)