SECTION 1 – Violation Point Calculation
VIOLATION (check all that apply based on owner/operator failure to complete items as defined by the Special Order or Emergency Special Order)	VIOLATIONS INVOLVING
Stream Crossings	Haul Roads & Skid Trails	Log Decks & Other Soil Disturbances
Failure to remove improper crossing structure (other than culvert)
Failure to install properly spaced and constructed drainage structures
Failure to remove channelized flow (smooth ruts)
Failure to restore diverted stream channels
Failure to restore dimension and/or profile of stream channel
Failure to remove culvert as ordered
Failure to provide sediment and drainage control
Failure to protect fill slopes as ordered
Failure to apply mulch as ordered
Failure to establish a vegetative cover
Failure to control access
Other
Apply Damage Point Value to each checked box above indicating the degree of seriousness.	Column Totals:
Total Violation Points:
Damage Point Value (Damage to the Environment):	Slight = 3 points	Moderate = 6 points	Severe = 9 points
SECTION 2 – Civil Penalty Calculation (start with Total Violation Points and follow through calculations)
Resource Values Multiplier: (enter the appropriate Resource Values Multiplier)	X	=
Warm Water Fisheries	2 multiplier
Cold Water Fisheries	5 multiplier
Municipal & Domestic Water Supplies	10 multiplier
Threatened & Endangered Species Waters	10 multiplier
Waters of Special interest or Adverse Impacts to Personal Property	10 multiplier
Culpability Multiplier: (enter the appropriate Culpability Multiplier)	X	=
Not Negligent	1 multiplier	Total Points
Negligent	5 multiplier
Greater Degree of Fault than Negligence	10 multiplier
Dollar Multiplier: (multiply Total Points x established Dollar Multiplier)	X $3.00	=
History of Non-Compliance Base Rate: (enter the appropriate History Base Rate)	+	=
0 Special Orders in 3 Years	$0.00 base rate	Total Per Day Penalty (Minimum of $100; Maximum of $5,000)
1 Special Orders in 3 Years	$200.00 base rate
2 Special Orders in 3 Years	$400.00 base rate
3 Special Orders in 3 Years	$800.00 base rate
4 Special Orders in 3 Years	$1,600.00 base rate
5 Special Orders in 3 Years	$3,200.00 base rate
6 Special Orders in 3 Years	$5,000.00 base rate
Number of Days: (enter number of days not to exceed 30 days) [Dates: from to ]	X	=
Good Faith Effort (subtract 10%, if applicable) = Total Civil Penalty Recommended:	-	=
SECTION 3 – Prepared By Signature
VDOF Representative Name (Print)	VDOF Representative Signature	Date