This is to certify that the following expenditure(s) were required to complete the work, which was recommended by the Virginia Department of Forestry; I now request reimbursement per program guidelines (use additional sheets if necessary).
SECTION 1 – Project Information
Project Type:	Application Number:
Tract Number:
SECTION 2 – Applicant Information
Applicant Name:
Applicant Address:
City:	State:	Zip:
E-mail:	Daytime Phone:
SECTION 3 – Expense Information
Personnel – Name or Group (for grants only, include volunteers)	Unit	Rate	Amount
1.	$
2.	$
3.	$
Subtotal	$
Equipment – Type	Unit	Rate	Amount
1.	$
2.	$
3.	$
Subtotal	$
Materials – Item	Unit	Rate	Amount
1.	$
2.	$
3.	$
Subtotal	$
Contractual Service – Name	Unit	Rate	Amount
1.	$
2.	$
3.	$
Subtotal	$
Grand Total	$
SECTION 4 – Applicant Agreement
I certify that the information provided on this application is complete and accurate.
Applicant Name (Print)	Applicant Signature	Date
SECTION 5 – VDOF Approval
I certify that the information provided on this application is complete and accurate.
VDOF Employee Name (Print)	VDOF Employee Signature	Title	Date
VDOF Headquarters Office/Finance Use Only
Cost Code:	Grant Amount:	Match Amount:	Approved for Payment: