Application Number:
(DOF USE ONLY)
SECTION 1 – Applicant Information
Landowner/Organization Legal Name:
Mailing Address:
Contact:	Phone:	Email:
Property Location:	County:	Estimated Total Project Cost:
Have trees been treated before?	Yes	No	Date of Last Treatment (if applicable):
SECTION 2 – Treatment Strategy
Please check Hemlock Woolly Adelgid (HWA) Treatment Method:
Soil Drench	Soil Injection	Trunk Injection	Basal Bark Spray
Do you plan to treat trees?	By hiring a certified pesticide applicator	Yourself
If performing treatments yourself, please list product you intend to use:
SECTION 3 – Landowner Agreement
I request funding under the Hemlock Woolly Adelgid Treatment Cost-Share Program for the indicated project. I agree:
Assistance shall be 100% of direct project costs for the treatment of approved hemlock trees up to $500. If sum of project costs is over $500, then cost-share payment will be $500 OR 50% of direct project costs, whichever is higher. Cost-share payment may not exceed $1,500 per landowner per federal fiscal year. To notify DOF as soon as possible if the project is canceled. To refund any incentive payments along with a 10% penalty fee if the healthy living trees are removed within 3 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 of the project.	To ensure the treatment is done only by a VDACS state-certified pesticide applicator, or in accordance with the directions for use as they appear on the product label that has been approved by the EPA. To provide treatment quotes/bids or certification of expenses with the initial application and to provide proof of payment upon completion. 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 canceled. 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
Stand Size (Acres)	Is HWA Present? Yes No HWA Density High Med Low
Tree #	DBH (in)	Comments (Please include overall tree/stand condition):
or
Tract No.:	Latitude:	Longitude:
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 Hemlock Woolly Adelgid 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 within 90 days of approval.
I certify that this project was completed according to the recommendations.
Date(s) Treatment Performed:	Final Project Cost:
Final Cost-Share Amount:
Landowner/Agent Name (Print)	Landowner/Agent Signature	Date
Note:	In order 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 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: