DOF Program Name:
SECTION 1 – Applicant /Property Information
Landowner (Owner of Record):	Tract Number:
Mailing Address:
Phone:	Email:
Property Address or Location of the Property (see map attached):
Forested Riparian Buffer?	Yes	No	Conservation Easement Property?	Yes	No
SECTION 2 – Project Description
Stand:	Project Acres:	Project Term Length (months/years):
Project Type:
Specific Prescription:
SECTION 3 – Recommendations and Future Management
Management Type:	Season/Year:
Specific Prescription:
SECTION 4 – Landowner Agreement
I request assistance from DOF to perform management activities as described in Section 2. I represent and agree as follows:
To designate the boundaries of the Property as necessary to perform the practices as outlined in the attached specific Plan of Work (“Plan”); to instruct DOF how to access the Property; and notify and inform DOF, its agents, employees and approved contractors as to the location of any known utilities that may affect the practices to be performed on the Property. To grant DOF, its agents, employees and approved contractors a revocable, nontransferable license to enter the property during the Term of this Agreement to perform the practices as outlined in the Plan. If a forested buffer is created as a result of this Agreement, to keep, assure survival, and maintain the area as a forested riparian buffer for the Project Term Length (identified in section 2) and to avoid grazing or plowing, and to permit DOF a limited right of entry to the Property to monitor and inspect the forested buffer during the Project Term Length. This section shall survive the Term of this Agreement.	If the project is destroyed by the current or successive landowner during the Project Term Length (identified in section 2), to refund to DOF the original costs incurred by DOF for the practices, pro-rated based on the length of time from practice implementation. This section shall survive the Term of this Agreement. To perform necessary future management such as those practices identified in Section 3, whether or not financial assistance is available. This section shall survive the Term of this Agreement. To accept responsibility for damage to the Property and injuries to self or others attributable to actions performed by DOF, along with its agents, employees, and approved contractors.
To acknowledge that DOF has not agreed to provide any indemnification or save harmless agreements running to the landowner. No provision, covenant, or agreement contained in this Agreement shall be deemed, in any manner, to be a waiver of the sovereign immunity of the Commonwealth of Virginia, or of DOF, from tort or other liability. To acknowledge that project information (name, address, location, etc.) may be protected by disclosure limitations; but that some information may be shared with others associated with the project (e.g., potential sub-contractors), or for accomplishment reporting purposes. This agreement shall be governed by, and construed according to, the laws of the Commonwealth, and any legal action against DOF shall be instituted and	legal action against DOF shall be instituted and maintained only in the state courts of the Commonwealth. To perform, or cause to be performed, all such further acts, and shall execute and deliver all such other agreements, certificates, instruments and documents, as DOF may reasonably request in order to carry out the intent and accomplish the purposes of this Agreement. This Agreement may be revoked by DOF or Landowner at any time. Unless otherwise revoked, the Term of this Agreement shall begin on the date of the last signature to this Agreement (the “Effective Date”) and shall extend for no more than twelve months from the Effective Date, unless otherwise noted below, at which point this Agreement will Terminate.
Term of this Agreement:
Landowner/Agent Name (Print)	Landowner/Agent Signature	Date
SECTION 5 – Project Planner/Contractor Agreement
Project Planner/Contractor agrees to:
Implement the practices described in the Plan with due diligence to achieve a successful outcome with the understanding that the work is done in a natural environment where success is not assured. Provide necessary and required documentation to DOF regarding implementation of the Plan as outlined in this Agreement. Perform the practices described in the Plan without cost to the landowner, unless otherwise agreed. Ensure any pesticide applications are done only by a Virginia Department of Agriculture and Consumer Services certified pesticide applicator.
Project Planning Organization	Contact Email	Phone
Name (Print)	Signature	Date
SECTION 6 – DOF Program Agreement
I approve of the above agreement.
Project Number:
DOF Representative Name (Print)	DOF Program Representative Signature	Date
SECTION 7 – DOF Representative Certification
I certify that the above project was completed according to the Plan.
Acres Completed:
Certifier Name (Print)	Certifier Signature	Date
DOF Headquarters Office/Finance Use Only
Cost Code:	Amount:	Approved for Payment: