Application Deadline – June 24, 2024
Have treatment(s) been previously performed?	Yes	No	Application Number:
(DOF USE ONLY)
SECTION 1 – Applicant Information
Landowner/Organization Legal Name:
Mailing Address:
Contact:	Phone:	Email:
Property Location:	County:	Date of Last Treatment (if applicable):
Estimated Total Cost:	Note: In order to process this application, a treatment quote or bid must be attached.
SECTION 2 – Ash Preservation Strategy
What measures have you previously taken to promote the health of your ash tree(s)? Explain how you/your organization plans to approach maintenance, monitoring, re-treatment and outreach/education efforts concerning your ash tree(s) in the next 5-10 years (i.e., pruning, mulching, hanging signage):
SECTION 3 – Landowner Agreement
I request funding under the Emerald Ash Borer Treatment Cost-Share Program for the indicated project. I agree:
Assistance shall be 50% of direct project costs for injection treatment of emamectin benzoate, not to exceed $1,250 per landowner (tax identification entity) or $5,000 per organization (tax identification entity) per federal fiscal year (10/01-09/30). To notify DOF as soon as possible if the project is cancelled. To refund any incentive payments along with a 10% penalty fee if the healthy living trees are removed within three years of treatment. To designate and assume responsibility for boundaries of the parcel where service work is to be performed; and to give DOF employees the right to enter the property for the purpose of inspecting the progress and maintenance of the project.	To provide treatment quotes/bids with the initial application and to provide receipts upon completion. This program provides cost-share for projects up to $15/inch in diameter. Incentive payment cannot exceed $7.50 per DBH inch. To complete the project within the appropriate treatment time frame and 90 days from the date of approval by the forest health budget manager. Otherwise, the project will be cancelled. To ensure the treatment is done by a VDACS state-certified pesticide applicator. 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 – DOF Forester Approval
Tree #	Species	DBH (in.)	Live Crown (Percent)	Comments
Site Comments (i.e., historic site, rare species, amount of EAB damage, etc.):
Tract No.:	Latitude:	Longitude:
I certify that the above project is needed and, if properly carried out according to the above agreements, qualifies for reimbursement payment under the Emerald Ash Borer Treatment Cost-Share Program.
DOF Forester Name (Print)	DOF Forester Signature	Date

Application Number:
(DOF USE ONLY)
SECTION 5 – DOF Forest Health Approval
Cost-Share Amount Allotted:
Forest Health Budget Manager Name (Print)	Forest Health Budget Manager Signature	Date
SECTION 6 – Certification of Completion
Section 6 must be completed, and all documentation submitted by September 23, 2024
I certify that this project was completed according to the recommendations.
Date Treatment Performed:	Final Project Cost:
Final Cost-Share Amount:
(50% of Project Cost)
Landowner/Agent Name (Print)	Landowner/Agent Signature	Date
Note:	To process this application, a Taxpayer ID Number is required. Complete a State W-9 (Request for Taxpayer Identification Number and Certification) and return it with your certification of completion to the DOF Headquarters Office.
If payment needs to be split between multiple landowners, a completed Form 3.10 Multiple Landowner Supplement and additional State W-9 form(s) are required.
To process your reimbursement, proof of payment is required. Return a paid invoice ($0.00 balance) with your certification of completion.
DOF Headquarters Office/Finance Use Only
CVN:
Cost Code:	Amount:	Approved for Payment: