NC Department of Agriculture & Consumer Services

NCDA&CS

ADFP Trust Fund

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 completed and filed with submission of the 2008 Easement Application no later than 5:00PM on December 5, 2008.

Applicant Name:
Applicant Tax Identification Number:
Project Title:
GRANTEE USE ONLY / The following items are required for ALL applicants. / ADFP USE ONLY
1.Project Budget Narrative (available at )
2.Contact List for Funding Sources (available at )
3.Photographs (limited to two 8 ½ x 11 pages)
4.Letters of intent from matching funds sources only
5.Location maps showing roads, proximity to towns, other conserved lands, markets, etc.
6.Map of property with bodies of water, structures, land cover, and dwellings
7.Soils map with boundaries developed under USDA-NRCS Cooperative Soil Survey
(only one map with local SWCD officer signature verifying prime soils and acreage)
8.Photographs of landscape, structures, and equipment
9.Financial affidavit (only if claiming Limited Resource or Beginning Farmer)
GRANTEE USE ONLY / The following items are required for Non-Profit Non-Governmental Organization Applicants Only. / ADFP USE ONLY

501(c)(3) Certification or Letter of Federal Tax Exemption Status from the Internal Revenue Service

Conflict of Interest 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.

Sworn Statement of Overdue Taxes shall be made under oath and shall be filed prior to the disbursement of any State funds.
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

Page 1 of 13Easement Application

NCDA&CS

ADFP Trust Fund

Agricultural Conservation Easements Application

For Agricultural, Horticultural, & Forestry Programs

Please direct all questions and concerns to:

Holly Gilroy

NCDA&CS

ADFP Trust Fund

2 W. Edenton Street

Raleigh,NC27601

919.733.7125

Fax: 919.716.0105

/  /

All information in this application is required. Incomplete applications will be considered ineligible for funding.

APPLICANT IDENTIFYING INFORMATION

Project Title:
(5 words or less; Must denote ownership)
Applicant Organization:
Applicant Tax Identification Number:
Applicant Contact and Title:
Applicant Mailing Address:
(if delivered by US Postal Service) / Applicant Physical Address:
(if delivered by any other means)
Street: / Street:
City: / City:
State: / State:
Zip Code: / Zip Code:
County: / County:
Applicant Website Address (if applicable):
Applicant Email Address (if applicable):
Applicant Telephone(s): / ;
County/Counties of Project Location:
Length of Time to Complete Proposed Project:

APPLICATION MUST BE DELIVERED NO LATER THAN 5:00PM ON DECEMBER 5, 2008.

PROPERTY IDENTIFYING INFORMATION

Property Address:
Street:
City:
State:
Zip Code:
County:
Owner(s) of Property (List in order of percentages from greatest to least):
Owner / Percentage / Owner’s Address
Street:
City:
State:
Zip Code:
County:

DESCRIPTION OF THE TYPE OF APPLICANT ORGANIZATION and MATCHING FUNDS

I. / Is your organization a non-profit conservation organization? / YES / NO
II. / Is your organization a non-profit conservation organization with 30% matching funds from sources other than NC ADFP Trust Fund? / YES / NO
III. / Is your organization a county agency? / YES / NO
IV. / Is your county agency in a Tier Two (2) or Tier Three (3) EnterpriseCounty? / Tier 2 / Tier 3
With a NCDA&CS approved Farmland Protection Plan and a minimum of 15% matching funds? / YES / NO
or
Without a NCDA&CS approved Farmland Protection Plan and a minimum of 30% matching funds? / YES / NO
V. / Is your county agency in a TierOne(1) EnterpriseCounty? / YES / NO
With a NCDA&CS approved Farmland Protection Plan? (no match required) / YES / NO
or
Without a NCDA&CS approved Farmland Protection Plan and a minimum of 30% matching funds? / YES / NO

If you answered “No” to questions I-V, please re-evaluate eligibility criteria outlined in the Application Guidelines.

(Note: List of tiers is available from the North Carolina Department of Commerce at:

VI. / Agricultural Conservation Easement
A. / Select desired length of easement:
Perpetual
50 yeas
40 years
30 years
20 years
10 years
B. / Amount of Funds Requested: / $
Amount of Matching Funds Acquired: / $
C. / Estimated CurrentLand Value of Project: / $
D. / Estimated Easement Value: / $
E. / Estimated Agricultural Value: / $
F. / Target Project Start Date:
G. / Target Project Completion Date:
H. / Percentage of Property Owner(s) Gross Income from Agricultural, Horticultural, or Forestry Operation: / %

PROJECT AFFILIATIONS and PARTNERSHIPS

VII. / Additional Considerations for Project Options (see Application Guidelines for definitions)
A. / Is the property enrolled in aVoluntary Agricultural District? / YES / NO
B. / Is the property enrolled in anEnhanced Voluntary Agricultural District? / YES / NO
C. / Are the property owner(s) members of the following programs:
1) / Goodness Grows in NC Members? / YES / NO
2) / American Tree Farmers? / YES / NO
3) / Forest Stewardship Program Members? / YES / NO
D. / Are the property owner(s)Beginning Farmers?
(If yes, financial affidavit required.) / YES / NO
E. / Are the property owner(s)Limited Resources Farmers?
(If yes, financial affidavit required.) / YES / NO
F. / Are the property owner(s)Century Farm Members? / YES / NO
G. / Please list any other affiliations with agricultural or conservation groups.
(Examples include NC Farm Bureau, NC Grange, Commodity Associations, NC Agribusiness Council, NC Black Farmers & Agriculturalists Association, and NC Forestry Association.
VIII. / Operation and Management Plans
A. / Does the property have a conservation plan prepared?
(If so, copy will be needed if funded.) / YES / NO
B. / Does the property have a forest management plan prepared?
(If so, copy will be needed if funded.) / YES / NO
C. / Does the property have a waste management plan prepared?
(If so, copy will be needed if funded.) / YES / NO
D. / Is property in accordance with CountyLand Use Plan?
(If so, copy will be needed if funded. / YES / NO

IX.FARM DESCRIPTION

A.Agricultural Operations Only.

(See following sections for horticultural and forestry operations).

Entire Farm DescriptionEasement Area ONLY( if different)

Property Description / Property Description
Type / Acres / Type / Acres
Total Property Acres / Easement Acres
Leased
Owned
Crop Production / Crop Production
Type / Acres / Type / Acres

Agritourism Activities

Type / Visitors/year / Type / Visitors/year
Poultry/Livestock / Poultry/Livestock
Type / Number / Type / Number

Aquaculture Production

Type / Number / Type / Number
Structures & Dwellings / Structures & Dwellings
Type / Number / Type / Number
Bodies of Water / Bodies of Water
Type / Acres / Type / Acres
Prime Soils / Prime Soils
Type / Acres / Type / Acres
Equipment ($5,000 and greater)
Type / Number
Employees
Type / Individuals
Full Time
Part Time

Horticultural Operations Only

Entire Farm DescriptionEasement Area ONLY( if different)

Property Description / Property Description
Type / Acres / Type / Acres
Total Property Acres / Easement Acres
Leased
Owned
Horticultural Production / Horticultural Production
Type / Acres / Type / Acres

Agritourism Activities

Type / Visitors/year / Type / Visitors/year
Poultry/Livestock / Poultry/Livestock
Type / Number / Type / Number

Aquaculture Production

Forestry Operations Only.

Entire Farm DescriptionEasement Area ONLY( if different)

Property Description / Property Description
Type / Acres / Type / Acres
Total Property Acres / Easement Acres
Leased
Owned
Forestry Production / Forestry Production
Type / Acres / Type / Acres

Agritourism Activities

Type / Visitors/year / Type / Visitors/year
Poultry/Livestock / Poultry/Livestock
Type / Number / Type / Number

Aquaculture Production

X.EXECUTIVE SUMMARY

[1125 characters with spaces (250 words) or less; Click here and type.]

XI.PROPERTY BACKGROUND AND HISTORY

A.Please describe operations ownership and history of agricultural operations.

[900 characters with spaces (200 words) or less; Click here and type.]

B.What values does this easement hold?

[900 characters with spaces (200 words) or less; Click here and type.]

C.How will it benefit the landowners to place their property in an easement?

[900 characters with spaces (200 words) or less; Click here and type.]

D.List any major capital investments of $5,000 or more in the agricultural, horticultural, or forestry operation within the last 15 years. (List items in chronological order with the newest being first.)

Capital Purchased / Year Purchased

XII.FUTURE SUSTAINABILITY

What, if any, projected changes will the operators establish in the future?

(Examples include future products, livestock operation, shifts in markets, new tree plantings, etc.)

[1350 characters with spaces (300 words) or less; Click here and type.]

Has a formal notarized estate plan been done for this property?

(Please describe the measures taken to ensure the successful transition of the property to the next generation of producers.)

[1350 characters with spaces (300 words) or less; Click here and type.]

Has a written business plan been developed?

YES -NO

XIII.THREAT OF CONVERSION

Is there a threat of conversion?

YES -NO

If YES, please describe the conditions that threaten project. Is the property subject to potential forced sale or estate settlement sale? Is the property actively marketed for voluntary sale?

(Please include neighboring tracts, road frontage, development pressure, sewer, and zoning issues etc.)

[1350 characters with spaces (300 words) or less; Click here and type.]

Property proximity to urban/commercial development:

(i.e. – town/city limits or land use other an agriculture/forestry)

miles

XIV.CONSERVATION AND ENVIRONMENTAL CONCERNS

Please describe any conservation and environmental practices and assistance programs currently associated with the project.

[1350 characters with spaces (300 words) or less; Click here and type.]

Property proximity to other privately owned protected/conserved agricultural, horticultural, and forestry lands:

miles

Property proximity to military base or state or federal property used for the preservation of agriculture, plants, and/or wildlife:

miles

XV.SCOPE OF WORK

Applicant Name:
Applicant Tax Identification Number:
Project Title:

What is the purpose of the project?

[1125 characters with spaces (250 words) or less; Click here and type.]

What community need(s) will the project serve?

[2250 characters with spaces (500 words) or less; Click here and type.]

Are other organizations, programs, projects, etc. serving this community need or these community needs? If yes, how is this project different/why is this project necessary?

[1350 characters with spaces (300 words) or less; Click here and type.]

Are there sustainability plans for the project? If yes, please describe. If not, please explain why.

[1125 characters with spaces (250 words) or less; Click here and type.]

PROJECT TIMELINE

Applicant Name:
Applicant Tax Identification Number:
Project Title:
Task / Projected Start Date / Projected Completion Date / NC ADFP Trust Fund Funding to be Used / Total Funding to be Used

Page 1 of 13Easement Application

PROJECT BUDGET(The Project Budget Narrative and Contact List for Funding Sources are separate documents that must be attached to the application. If more space is needed, please attach additional project budget sheet.)

Program Name
Federal Tax ID Number
Total Project Value / $
Funding Categories
Expenditure Categories / ADFP Funds / Matching Funds / In-Kind / Total Budget for Category
211 / Stewardship Endowment
220 / Easement Purchase
212 / Survey
213 / Appraisal
204 / Travel (applicable state rates)
214 / Baseline Documentation Report
215 / Environmental Assessment/Audit
207 / Personnel/Administrative
216 / Legal Fees
217 / Closing Costs
Total Budget
Applicant's Signature: / Date
ADFP Signature: / Date

Page 1 of 13Easement Application

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)

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______

Please direct all questions and concerns to:

Holly Gilroy

NCDA&CS

ADFP Trust Fund

2 W. Edenton Street

RaleighNC27601

919.733.7125

Page 1 of 13Easement Application