Application Number:
SECTION 1 – Applicant Information
Landowner Name:
Note: In order to process this application, a Taxpayer ID Number is required. Therefore, please complete a State W-9 (Request for Taxpayer Identification Number and Certification) and return it with your application.
Property Location:	Tract Number:	Parcel:
Latitude:	Longitude:
Note: Attach a tract map highlighting the entire acreage to be treated (IFRIS PDF file preferred).
SECTION 2 – Project Description (check all that apply)
Pre-Planting Site Prep:	Scalping	Herbicide	Burn	Other (describe)
Planting:	Trees per Acre:	Seedling Source:
Post-Planting Treatment:	Herbicide	Stand Age:
Burn	Stand Age:
Other (describe)	Stand Age:
SECTION 3 – Landowner Agreement
I request funding under the Pine Bark Beetle Prevention – Longleaf Pine Restoration Cost-Share Program for the indicated projects. I agree:
Assistance shall be 60% of direct project costs, not to exceed $225 per acre, for longleaf pine restoration, which may include costs associated with site preparation, planting or post-planting treatments within the first five years of plantation establishment; and cost-share payments shall not exceed $10,000 per federal fiscal year (10/01-09/30) per landowner (tax identification entity). To refund any incentive payments along with a 10% penalty fee, if the project is not completed as prescribed, or if seedlings planted are intentionally removed or destroyed (by current or subsequent landowners) within a period of ten (10) years following the completion date, except for a commercial thinning or final harvest approved by the Virginia Department of Forestry.	To designate and assume responsibility for boundaries of the parcel where service work is to be performed; and to give VDOF employees the right to enter the property for the purpose of inspecting the progress and maintenance of the project. To provide receipts or contractor’s statement of cost. To complete the project within 12 months from the date of approval by the Forest Health Budget Manager. Otherwise, the project will be cancelled unless a 6-month request for extension (Form 3.11 Cost-Share/AMP Project Amendment) is received within three weeks of the cancellation date. Failure to meet any of the standards described will result in forfeiture of these cost-share funds.
Landowner/Agent Name (Print)	Landowner/Agent Signature	Date
SECTION 4 – VDOF Approvals
I certify that the above project is needed and, if properly carried out according to the above recommendations, will qualify for incentive payment under the Pine Bark Beetle Prevention – Longleaf Pine Restoration Cost-Share Program.
Forester Name (Print)	Forester Signature	Date
Forest Health Budget Manager Name (Print)	Forest Health Budget Manager Signature	Date
I certify that the above project was completed according to the above recommendations.
Acres Completed:	Final Project Cost:	Final Cost-Share Amount:
(60% of Project Cost)
Forester Name (Print)	Forester Signature	Date
VDOF Headquarters Office/Finance Use Only
Cost Code:	Amount:	Approved for Payment: