Fillable Printable Form 50065
Fillable Printable Form 50065
Form 50065
Page 1 of 2
319-A, AGRICULTURE COST-SHARE
CLEAN WATER ACT SECTION 319 COST-SHARE PROGRAM
State Form 50065 (R5 / 9-09)
INSTRUCTIONS: See page 2 of this form.
SECTION A
Applicant name
Indiana county
IDEM contract/agreement number
Name of sponsoring organization
Location information farm number
Tract number
Field(s) number
Section number
Township
Range
Civil township
USGS quad name
12-digit HUC
Latitude and longitude or universal transverse mercatur (UTM) coordinates
I hereby agree and certify that a conservation pl an has been developed and will be followed in all fields that receive cost-sh are
funds. All best management practices (BMPs) implemented with these grant funds will be operated and maintained in
accordance with United States Department of Agriculture Natural Resources Conservation Service (NRCS) standards and
specifications (or other specifications cited b elow). Practices sh all be maintained as follows: vegetative and land manag em en t
practices, five (5) years; structural practices, ten (10) years.
Applicant signature Date (mm/dd/yyyy)
Landowner signature Date (mm/dd/yyyy)
Printed name
Printed name
Address (number and street)
Address ( number and street)
City
State, ZIP code City State, ZIP code
SECTION B
The following eligible BMPs are needed to improve or maintain water quality, and will reduce off-site sedimentation or nutrient,
pesticide or pathogen loads to receiving waters. These practices were implemented
consistent with NRCS standards and
specifications (or other specifications as listed below) and in accordance with the conservation plan.
Field
number
NRCS practice title or other
specifications followed
Maintain
for
Quantity
or unit
Total cost Cost-share
level (%)
Cost-share
amount
Install date
(mm/yyyy)
yrs
$ $
yrs
$ $
yrs
$ $
yrs
$ $
yrs
$ $
yrs
$ $
TOTAL
$ $
Printed name and signature of NRCS, IDNR, ISDA, TSP, or SWCD technical representative: Date (mm/dd/yyyy)
SECTION C
Critical area as described in the WMP and page number(s)
where referenced
NPS pollutant(s) of concern addressed within this critical area by BMP
implementation
The total cost-share amount in section B is recommended to IDEM for cost-share assistance and is approved for payment by the
sponsoring organization. The sponsoring organization or local SWCD office has a copy of the conservation plan available for
IDEM review.
Authorized signature for sponsoring organization
Date (mm/dd/yyyy)
INDIANA DEPARTMENT OF
ENVIRONMENTAL MANAGAMENT
Reset Form
Page 2 of 2
INSTRUCTIONS FOR COMPLETING STATE FORM 50065, 319-A
This form should be complete d when requesting reimbursement from the Section 319 Program for eligible cost-share and/or demonstration
best management practices (BMPs) implemented on agricultural land; defined as land that is currently in production (i.e., working lands)
such as cropland, pastureland, range land, native pastureland, other land used to suppor t livestock production, and tree farms.
SECTION A - This section requests general information on the BMP location and the app licant/landowner. Complete all blanks in Section A
for the BMPs implemented and listed in Section B.
• If the applicant does not own the land where practices will be implemented, the landowner's signature is required, unless the applicant
has power of attorney for the landowner. The landowner must sign the form before proceeding with the project.
• Include the twelve (12) digit Hydrologic Unit Code (HUC), and the latitude & longitud e or the UTM coordinates for a central location
where the BMP is implemented. If man y BMPs are impl emented in different places, one (1) general coordinate location will suffice.
• A conservation plan for the land in Secti on B, signed by a certified conservation planner, must be available i n the sponsor’s or local
SWCD office for audit purposes.
• Before signing, the landowner must understand the certification statements abov e the signature block.
SECTION B - This section certifies that the BMPs are needed to improve or maintain water quality, are in accordance with the conservation
plan, and were satisfactorily completed.
• Complete the field number, official NRCS practice title (found in the NRCS Field Office Technical Guide, or at
http://efotg.nrcs.usda.gov/efotg_locator.aspx?map=IN
) or other specifications followed, number of years of maintenanc e required (based
on Section A), quantity or unit, total practice cost (shown on attached receipts), percent of total cost to be paid to the landowner, total
amount paid to the lando wner, and date the practice was implemented for each BMP. Agricultural demonstration BMPs ma y have a
cost-share level of up to 100% (and must be located o n pu blic land). See definition of demonstration practice below.
• If the operation is an animal feeding operation (AFO), confined feeding operation (CFO), or a concentrated animal feedin g operation
(CAFO), see the Clean Water Act Section 319 Agricultural Cost-Share Guidance for Indiana
for BMP eligibility.
• This section must be completed and signed by an NRCS, IDNR, ISDA, TSP, or SWCD technical representative who can certify to the
statements at the top of Section B.
SECTION C - This section must be complete and signed by an official (with signatory authority) of the sponsoring organization.
• From the approved watershe d mana gement plan (or draft if impleme nting a demonstratio n BMP), reference the critica l area where the
BMP(s) were implemented and what nonpoint source (NPS) pollutants of concern within that critical area are being a ddressed.
FORM SUBMISSION
An invoice for payment should be prepared and submitted to IDEM with this form. As individual practices are implemented, invoices may be
submitted to IDEM. Payment will be forwarded to the sponsoring organization in approximately four weeks. The following items must
accompany this complete, signed 319-A Form and an invoic e for payment to IDEM:
1) Map, showing location of all BMPs in relation to adjacent ro ads;
2) Copies of bills or receipts for each BMP showing the total cost;
3) Copies of the Region 5 Load Estimation model worksheet(s), the ST EPL model workbook, or other appropriate tool to estimate the
pollutant load reductions for the practic es im plemented, when applic able. The above models may be found on EPA’s web site at:
http://it.tetratech-ffx.com/stepl/models$docs.htm
;
4) Appropriate NRCS Checklist if cost-share funds are us ed to develop a nutrient management plan, pest management plan or
comprehensive nutrient mana gement plan.
ADDITIONAL INFORMATION - For additional information on the cost-share program and requirements, see the Clean Water Act Section
319 Agricultural Cost-Shar e Guidance for Indiana or contact your IDEM project manager. Note to sponsors: The sponsoring organization
may need to provide a 1099 form for disbursements.
DEFINITIONS:
Demonstration practice
– a BMP used to introduce new techniques in the watershed a nd to encourage landowners to install the
practice. The BMP must: be located on public land or any area where the public has access on a regular basis, located in a critical
area as defined in the WMP, not have bee n cost-shared on before in the watershed with Section 319 funds, and be used/showcased as
part of an education/outreach event. Demo nstration practices must be authorized in the project’s grant agreement and implemented
according to the instructions on this form.
Land management practice
– Practice that requires primar ily management techniques and methods to implement the practice (such as
nutrient management, pest management, residue mana gement, and prescribed grazing).
Structural practice
– Practice that involves constructing desi gned (engineered) features us ing machinery (such as waterways, anim al
mortality facilities and water and sediment co ntrol basins).
Vegetative practice – Practice that only involves seeding or planting to establish or re-esta blish plant cover (such as pasture and hay
seeding, cover crop, filter strip, and tree planting).
