This institution is an equal opportunity provider.	Application Number:
SECTION 1 – Applicant Information
Logger 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.
Logger NAID Number:	SHARP Logger ID:
Property Location:	Tract Number:	Parcel:
Latitude:	Longitude:
Note: Attach a map highlighting the project areas (IFRIS PDF file preferred).
SECTION 2 – Temporary Bridge Project Description
Project Type (check all that apply):	Steel Portable Bridge	Wood Portable Bridge	Wood Mats
Location:
Description of Plan:	(Include details of the project; attach additional sheets or copy of pre-harvest plan, if necessary.)
SECTION 3 – Applicant Agreement
I request funding under the Temporary Bridge Cost-Share Program for the indicated harvest project. I agree:
Each application is for ONE parcel and that assistance shall be 75% of direct project costs, not to exceed $12,000 per parcel for portable bridge installation involving the stream(s) identified in the harvest plan document. A maximum of 75% of the cost of the project not to exceed $6,000 per project if the project includes the purchase of wood mats To install the required Best Management Practices (BMPs) to the specifications established in the current book “Virginia’s Forestry Best Management Practices for Water Quality Technical Guide.” To provide receipts or a Form 3.9 Forestry Cost-Share or Grant Program Certification of Work Completed as an itemized statement of cost. Total cost-share not to exceed $12,000 per program year (10/01	to 09/30) per tax identification entity. One project per tax identification entity per program year. I am a certified SHARP Logger (or equivalent if not in Virginia). I do not currently owe the Virginia Department of Forestry any civil penalties or other outstanding debt. Failure to meet any of the standards described will result in forfeiture of these cost-share funds. That the project must be completed by September 30. Title to the bridge rests with the Recipient as long as the bridge is used for its intended purpose. A third-party audit is possible.
Logger Name (Print)	Logger Signature	Date
SECTION 4 – VDOF Approval
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 Temporary Bridge Cost-Share Program.
Water Quality Engineer or Specialist Name (Print)	Water Quality Engineer or Specialist Signature	Date
Temporary Bridge Cost-Share Manager Name (Print)	Temporary Bridge Cost-Share Manager Signature	Date
I certify that the above project was completed according to the above recommendations.
Stream Crossing Completed to Specifications	Portable Bridge Purchased and Used on Site (if applicable)
Final Project Cost Documentation Submitted	Mats Purchased and Used on Site (if applicable)
Completion Date:
Final Project Cost:	Final Cost-Share Amount:
(See Receipts or Form 3.9 attached)	(75% of Project Cost up to max. allowed)
Water Quality Engineer or Specialist Name (Print)	Water Quality Engineer or Specialist Signature	Date
VDOF Headquarters Office/Finance Use Only
Project Code:	Amount:	Approved for Payment: