Ben Delatour Scout Ranch

(1)

(2)

Form 828- Rev.1 2/15/09

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_l_Jniversity

Colorado State Forest Service

Program Payment Request

GRANT PROGRAM (CHECK APPROPRIATE PROGRAM TYPE):

Forest Restoration Grant ($871 and HB1199) Volunteer or Rural Fire Assistance (a.k.a.: VFA/RFA) Insect and Disease Prevention and Suppression Program State Fire Assistance (a.k.a.: SFA)

Front Range Fuels Treatment Partnership (a.k.a.: FRFTP) Stevens Fuels Treatment Funds

Cooperative Fire Agreement (Active Fire Suppression Cooperators; CRS#R-24-103-206-01)

Emergency Supplemental Funds (a.k.a.: ESF)

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Checked for Federal suspension and debarment (State Office) http://www.epls.gov/

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Name:

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The above named has submitted a project application that has been reviewed and approved by the Colorado State Forest Service for funding from Federal Assistance.

Grant Number:

'530qlo0i

Cooperator Match:

$

L-f2,()43 .

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Approved Funding:

$lj6,060

Total Project:

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CSFS Account Number:

-S-36°tlee't -

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Amount of Payment:

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Circle one: 1st Payment 2nd Payment 3rd Payment

Approved by ____________ _ Date: _________ _

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(Program manager signature)

Colorado State Forest Service

(3)

FormC

LANDOWNER ASSISTANCE PROGRAMS

ACCOMPLISHMENT REPORT FOR REIMBURSEMENT

(Page 1)

Project No. __

5""""'3'-'0'"""-9-=-6=-9 _ _ _ _

(For Official Use Only-No. from original application)

Applicant name (please print): _Ben Delatour Scout Ranch - Longs Peak Council_

Total

Totals ·

Contracted

Landowner

~Prvi.-o" l ~---• ___ 2

A Labor Cost= $18,598.00

Labor Cost # 67977 $9850.00 $8748.00

(Actual)

Operating Exp'·· 0 B Oper. Exp.= 0

(Actual) 0

Value of donated C Total value of donations=

services and materials 0 $~,000.00

$.f.

J00.00

(not an actual cost)

Revenue Generated D Revenue= 0

(from sale of wood 0 0

4 *

products only) · Project Cost

ll,

1'-1-<6'

E Total Project

9850.00 (A+B+C-D) = $

_2t,SC1b

Amount Originally Approved = $40,000

How much of your total cost was paid to CSFS for Products and/or Amount to be Reimbursed 5

Services? _j_O (.5XE) not to exceed Actual Costs

$:

10,CLD

1 _{Any contracted services where payment was made for services.}

2 _{Use up to $ 17 .55/hour for Landowner and volunteer time. This is the maximum allowable.}

3 _{Equipment rental, supplies, etc. needed to complete project. (Tools and Equipment purchases are not reimbursable.)} 4 _{Any revenue generated from the sale of wood products is deducted from total project cost.}

5 _{Reimbursement amount cannot exceed amount approved. No partial payments.}

*Attach receipts, Cost Documen tion Form D (cont ctor osts, your time ledger, gas, oil, etc). Keep copies for your files.

Landowne' Signahrre Dateo

t/s

O (; _{

D

Mailing Address: Ben Delatour Scout Ranch-Longs Peak Council, 2331, County Road 68C City: Red Feather Lakes County: Larimer State: CO Zip· _

_,8'""0""5"""45"'---Practice certified

by:~

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lk-~forester

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Phone: 970-881-2144

Payment Approval: Amount: _ ___ _ Date: ____ _

CSFS program manager

Return this form, along with your completed Cost Documentation Form to your local Colorado State Forest Service District Office. Retain documentation such as receipts and payment for six (6) years. The IRS considers reimbursable funds as ordinary income. Please consult your tax advisor.

(4)

LANDOWNER ASSISTANCE PROGRAMS COST DOCUMENTATION

Form D

I have incurred the following expenses for completion of the LOA Program practice for which I have been funded. These expenses are itemized below. Labor rate to be used if landowner is doing the work is $20 25/hr Separate expenses by compo ent (acti n VI "ty) Att h ac rece1p s. · t

~-

~~;-\J

\ ~ndowner Signature

Date By Whom: Activity/Expense: Hours Expenses

5/2/10 23 ASU Crew Membe slash cleanup and wood piling 80.5

5/4/10 16 ASU workers slash cleanup @ 3.5 hours 56

5/20/10 Bob Sturtevant assist with wood removal - 1 O hrs 10

5/21/10 Bob Sturtevant assist with wood removal - 8 hrs 8

5/23/10 Bob Sturtevant assist with wood removal - 10 hrs 10

5/26/10 Morgan Timber transport forwarder to BDSR $300

5/27/10 Bob Sturtevant slash hauling and wood cleanup 10

Andrew Mason slash hauling and wood cleanup 10

Katie Morqan slash hauling and wood cleanup Forwarder @150/hr x 1 Oh rs

=

1500

5/28/10 Bob Sturtevant slash haulinq and wood cleanup 8

Katie Morgan slash hauling and wood cleanup Forwarder @150/hr x 6 hrs

=

900

5/30/10 Bob Sturtevant slash cleanup 8

Tara Mickelburgh slash cleanup 8

6/1/10 Bob Sturtevant slash cleanup 8

6/14/10 Morqan Timber transport forwarder from BDSR $300

713/10 Bob Sturtevant cleanup work 6

7/15/10 Bob Sturtevant cleanup work 8

Terry Dunn cleanup work 3

7/14/10 Scouts slash hauling and wood cleanup 35 X 2 hrs 70

8/12/10 Bob Sturtevant chipping 6

432 $3,000

(5)

YOUR INVOICE NO. 1675 Item Quantity skidsteer work 50.5 cleanup 160

0\~\

10/2010 Check# 67977 INVOICE AMOUNT 9,850.00 3171 TREE T.INC. AMOUNT PAID 9,850.00 DISCOUNT TAKEN _.00 Check total

NET CHECK AMOUNT

9,850.00 9,850.00

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6/23/2010

I

Ben Delatour Scout Ranch

Description Rate Amount

skidsteer work moving logs for dates 5/1110-512110 and 100.00 5,050.00 5120110-5/23/10

man hours moving logs for skid steer to load for dates 30.00 4,800.00 5120110-5/23/10

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Total

$9,850.00

(6)

..

Bill To

Tree Top, Inc.

POBox1174

Wellington, CO 80549

970 443-1384

Longs Peak Council PO Box 1166 2213 23rd Ave. Greeley, CO 80632 Item Quantity P.O. No. Description

skidsteer work 50.5 skidsteer work moving logs for dates 5/1/l0-512110 and 5/20/10-5/23/10

cleanup 160 man hours moving logs for skid steer to load for dates

5120110-5123110

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Invoice

Date Invoice# 512412010 1675

Due Date Job Site Address 6/23/2010 Ben Delatour Scout Ranch

Rate Amount 100.00 5,050.00

30.00 4,800.00

(7)

Form 828 - Rev.12/15/09

Cbk>=

University

Colorado State Forest Service

Program Payment Request

Forest Restoration Grant (SB71 and HB1199) Volunteer or Rural Fire Assistance (a.k.a.: VFA/RFA) Insect and Disease Prevention and Suppression Program State Fire Assistance (a.k.a.: SFA)

Cooperative Fire Agreement (Active Fire Suppression Cooperators;

CRS#R-24-103-206-01)

Emer~ncy Supplemental Funds (a.k.a.: ESF)

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Checked for Federal sus pe nsion and debarment State Office htt : ) p // www.e Is. ov p g I ()

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Name:

Address:

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Payment

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The above named has submitted a project application that has been reviewed and

approved by the Colorado State Forest Service for funding from Federal Assistance.

Grant Number:

5

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Cooperator Match:

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445 .

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F<!-Approved Funding:

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Total Project:

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₁

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CSFS Account Number:

530C1

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E•tof Payment:

31,30,000 .. -;)

Circle one:

2nd Payment

3rd

Payment

Final Payment

Date:

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__

_

(8)

Form 828 - Rev.12/15/09

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Co~1g

University

Colorado State Forest Setvice

Program Payment Request

Forest Restoration Grant (SB71 and HB1199) Volunteer or Ru ral Fire Assistance (a.k.a.: VFA/ RFA) Insect and Disease Prevention and Suppression Program State Fire Assistance (a.k.a.: SFA)

Cooperative Fire Agreement (Active Fire Suppression Cooperators; CRS#R-24-103-206-01)

Emergency Supplemental Funds (a.k.a.: ESF)

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D

Checked for Federal suspension and debarment (State Office) http://www.epls.gov/ Name:

Ben

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Address:

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The above named has submitted a project application that has been reviewed and approved by the Colorado State Forest Service for funding from Federal Assistance.

Grant Number:

S

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Cooperator Match: ....

1,t

3'01

Lf-4-5 ·

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Approved Funding:

$:. Lf0,000

Total Project:

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CSFS Account Number:

5 3 OC1

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Amount of Payment:

Sf,

d 01000

Circle one: 2nd Payment 3rd Payment Final Payment

Approved by ____________ _ Date: _ _________ _

(Program manager signature)

(9)

LANDOWNER ASSISTANCE PROGRAMS

ACCOMPLISHMENT REPORT (page 2)

Project No.

:5

30C(U2C\

To be completed by CSFS forester:

PROGRAM:

WUI Incentives D-space: I & D Prevention and Suppression - Bark Beetle: __ _

FRFTP: _ _ STEVENS' Fund: \/ SFA: ESF: Forest

Restoration Grant (SB71 and HBJ 199) __ _

WUI D-space Accomplishment:

No. of D-spaces = ___ _ Acres slash disposal = ___ _ Acres fuel breaks = ___ _

Acres thinned = () Acres runed =

I & D Prevention and Suppression Accomplishment: No. of infested trees treated: ___ _ Acres inspected and treated: _ _ _

Acres thinned: __ _

Accomplishment not included above - LOA Practice Number:

#1

Plan Acres =

#5

Acres=

#9

Acres treated =

#2

Acres tree planting=

#6

Acres treated =

#10

Acres of restoration =

Acres treated =

#7

Acres treated =

#11

Acres =

#3

Acres treated =

#8

Acres treated =

#4

Acres planted/ renovated =

nr

SERVICE

(10)

FormC

LANDOWNER ASSISTANCE PROGRAMS

ACCOMPLISHMENT REPORT FOR REIMBURSEMENT

(Page 1)

Project No .

53oq

lo9

(For Official Use Only-No. from original application)

Appl~a~name~ka~prinQ:

__

~L~o~n~g~s~P~e=a~k~C~o~u~n~c~il~-~B~e=n~D~e~~~t~o~u~r~S~c=o~ut~R~a~n=~~---Total

Total

Totals

Contracted

Landowner

Services

1 _l;i."rviC""2

#7852 - 18,098.51 A Labor Cost= $30,000

Labor Cost #7856 - 11901.49

(Actual)

Operating Exp3_{• •} _{B Oper. Exp.=}

(Actual)

Value of donated 1503.5 Hours C Total value of donations =

services and materials $30,445.88 $30445.88

(not an actual cost)

Revenue Generated D Revenue=

(from sale of wood products only) 4_{• •}

Project Cost E Total Project

(A+B+C-D) = 60,445.88

Amount Originally Approved = 40,000

How much of your total cost was paid to CSFS for Products and/or Amount to be Reimbursed 5_'6

Services?$ (.5XE) not to exceed Actual Costs

$30,000

Except for Emergency Supplemental Funds6

1 _{Any contracted services where payment was made for services.}

2 _{Use up to $ 20.25/hour for Landowner and volunteer time. This is the maximum allowable.}

3 _{Equipment rental, supplies, etc. needed to complete project. (Tools and Equipment purchases are not reimbursable.)} 4 _{Any revenue generated from the sale of wood products is deducted from total project cost.}

5 _{Reimbursement amount cannot exceed amount approved. No partial payruents.}

6 _{Reimbursement amount cannot exceed $470/acre for Actual Costs for Emergency Supplemental Funds.}

D (contractor costs, your time ledger, gas, oil, etc). Keep copies for your files. Date:

All expenses are true and accurate and all cost share is true and accurate.

Mailing Address: ---"B~e=n~D~el=at=o~ur~S~co~u=t~R=a=n=ch=·~2~3~3~1 ~C=o~u=nt,_,_y~R=o=a=d~6~8~C ___ _

County: Larimer _ State: . CTIO Zip: 80545

Practice certified

by~~('.

~

...;/ CSFS forester

Payment Approval: _______________ Amount: ____ _

CSFS program manager

S/

IC,

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City: Red Feather Lakes __ Phone: 970-881-2144

Date: ____ _

Return this form, along with your completed Cost Documentation Form to your local Colorado State Forest Service District Office. Retain documentation such as receipts and payment for six (6) years. The IRS considers reimbursable funds as ordinary income.

(11)

LANDOWNER ASSISTANCE PROGRAMS COST DOCUMENTATION

I have incurred the following expenses for completion of the LOA Program practice for which I have been funded. These expenses are itemized below. Labor rate to be used if landowner is doing the work is $17.55/hr. Separate expenses by component (activity). Attach receipts.

FormD

Landowner Signature

Date By Whom: Activity /Expense: Hours Expenses

11/14/09 9 CSFS Volunteers Locate and cut MPB trees within management area 49.5 $ 1,002.38

11/28/09 1 BDSR Volunteer mark unit for thinning 7 $ 141.75

11/30/09 1 BDSR Volunteer mark unit for thinning 2.5 $ 50.63

12/5/09 20 Parents thinning of Douglas fir understory 80 $ 1,620.00

12/12/09 6 CSFS Volunteers Cutting MPB trees 42 $ 850.50

12/20/09 1 BDSR Volunteer mark unit for thinning 7 $ 141 .75

3/6/10 21 CSU Forestry Stud tree cutting 126 $ 2,551.50

3/28/10 9 FRCC Interns tree cutting 54 $ 1,093.50

3/28/10 9 CSU Volunteers slash cleanup 54 $ 1,093.50

4/6/10 14 ASU Crew members slash cleanup and wood piling 49 $ 992.25

4/7/10 16 ASU Crew members slash cleanup and wood piling 56 $ 1,134.00

4/11/10 8 FRCC Interns wood processing 48 $ 972.00

4/11/10 13 ASU Crew members slash cleanup and wood piling 45.5 $ 921 .38

4/18/10 10 FRCC Interns wood processing 60 $ 1,215.00

4/25/10 12 FRCC Interns wood processing 72 $ 1,458.00

5/1/10 28 CSU Forestry Stud cutting and skidding 168 $ 3,402.00

5/2/10 8 CSU Forestry Stud skidding and wood processing 32 $ 648.00

~~~·'

(12)

..

Customer Name Address City Phone Qty 1 1 32 Payment Comments Name CC#

Larimer County Wildfire Safety/Emergency Services clo Betsey Nail

2501 Midpoint Fott Collins, CO 80525

Ben Delatour Scout Ranch 2331 County Road 68C

Red Feather lakes State CO ZIP 80545-9501 970-881-2144

Description

Labor and Benefits for fuels reduction work. October/November 2009 Materials Cost $15.00/day/saw

Fuel Cost $20.00/day

***** Please make check out to Larimer County****

Tax Rate(s)

-Expires _____________ _ Invoice No. Misc Date Order No. Rep FOB Unit Price $ 15,838.51 $ 1,620.00 $20 Sub Total Shipping

TOTAL

7852

I

INVOICE

I

11/30/2009

TOTAL

$ 15,838.51 $ 1,620.00 $ 640.00 $ 18,098.51 $ 18,098.51

(13)

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10/27/09 11/02/09 11/03/09 11/04/09 11/05/09 11/06/09 11/07/09 11/08/09 11/09/09 11/10/09 11/11/09 11/12/09 11/13/09 11/14/09 11/15/09 11/16/09 11/17/09 11/18/09 11/19/09 11/20/09 11/21/09 11/22/09 11/23/09 11/24/09 11/25/09 11/26/09 11/27/09 11/28/09 11/29/09 11/30/09 Nov Hours Wage Nov Total Benefits Nov Labor • Nov Mater Nov Total r

"

Wensman Biedsheid Stapleton Anderson Murray McCaffrey Grady

8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 130 168 138 158 140 168 110 $15.98 $13.89 $15.98 $15.33 $15.33 $13.89 $13.89 $2,077.40 $2,333.52 $2,205.24 $2,422.14 $2,146.20 $2,333.52 $1,527.90 $727.09 $280.02 $485.15 $290.66 $257.54 $280.02 $183.35 $2,804.49 $2,613.54 $2,690.39 $2,712.80 $2,403.74 $2,613.54 $1,711.25 $2,260.00 $18,098.51 Fuel Equip _.. 1 5 2 6 2 6 2 6 2 6 2 5 2 6 1 5 2 7 2 7 1 5 2 7 2 7 2 7 2 6 2 7 2 6 1 4 32 108 $20/day $15.00/saw $640.00 $1,620.00 $15,838.51 $2,260.00 $18,098.51

(14)

'

Customer Name Address City Phone Qty 1 1 21 Payment Comments Name CC#

Larimer County Wildfire Safety/Emergency Services cl o Betsey Nail

2501 Midpoint Fort Collins, CO 80525

Ben Delatour Scout Ranch 2331 County Road 68C

Red Feather lakes State CO ZIP 80545-9501 970-881-2144

Description

Labor and Benefits for fuels reduction work. Decemberr 2009 Materials Cost $15.00ldaylsaw

Fuel Cost $20.00lday

***** Please make check out to Larimer County****

I

Tax Rate(s) -Expires _____________ _ Invoice No. Misc Date Order No. Rep FOB Unit Price $ 10,446.49 $ 1,035.00 $20 Sub Total Shipping

TOTAL

7656

INVOICE

I 1213112009

TOTAL

$ 10,446.49 $ 1,035.00 $ 420.00 $ 11 ,901.49 $ 11,901.49

(15)

Wensman Biedsheid Stapleton Anderson Murray Mccaffrey Grady Fuel Equip 10/27/09 8 8 8 8 8 1 5 11/02/09 8 8 8 8 8 8 2 6 11/03/09 8 8 8 8 8 8 2 6 11/04/09 8 8 8 8 8 8 2 6 11/05/09 8 8 8 8 8 8 2 6 11/06/09 8 8 8 8 8 2 5 11/07/09 11/08/09

e

11/09/09 11/10/09 10 10 10 10 10 10 2 6 11/11/09 10 10 10 10 10 1 5 11/12/09 10 10 10 10 10 10 10 2 7 11/13/09 10 10 10 10 10 10 10 2 7 11/14/09 11/15/09 11/16/09 11/17/09 10 10 10 10 10 1 5 11/18/09 10 10 10 10 10 10 10 2 7 11/19/09 10 10 10 10 10 10 10 2 7 11/20/09 10 10 10 10 10 10 10 2 7 11/21/09 11/22/09 11/23/09 10 10 10 10 10 10 2 6 11/24/09 10 10 10 10 10 10 10 2 7

e

11/25/09 10 10 10 10 10 10 2 6 11/26/09 11/27/09 11/28/09 11/29/09 11/30/09 10 10 10 10 1 4 Nov Hours 130 168 138 158 140 168 110 32 108

Wage $15.98 $13.89 $15.98 $15.33 $15.33 $13.89 $13.89 $20/day $15.00/saw

Nov Total $2,077.40 $2,333.52 $2,205.24 $2,422.14 $2,146.20 $2,333.52 $1 ,527.90 $640.00 $1 ,620.00

Benefits $727.09 $280.02 $485.15 $290.66 $257.54 $280.02 $183.35

Nov Labor $2,804.49 $2,613.54 $2,690.39 $2,712.80 $2,403.74 $2,613.54 $1 ,711 .25

Nov Mater $2,260.00

(16)

Wensman Biedsheid Stapleton Anderson Murray Mccaffrey Grady Fuel Equip 12/01/09 5 8 5 12/11/09 10 10 10 10 10 10 2 6 12/15/09 10 10 10 10 10 10 10 2 7 12/16/09 10 10 10 10 10 10 2 6 12/17/09 10 10 10 10 10 10 10 2 7 12/18/09 10 10 10 10 10 10 10 2 7 12/19/09 10 10 10 10 10 10 10 2 7

e

12/22/09 10 10 10 10 10 10 10 2 7 12/28/09 10 10 10 1 3 12/29/09 10 10 10 10 10 10 10 2 7 12/30/09 10 10 10 10 10 10 2 6 12/31/09 10 10 10 10 10 2 6 Dec Hours 100 115 98 115 100 90 80 21 69

Wage $16.54 $13.89 $15.98 $15.33 $15.33 $13.89 $13.89 $20/day $15.00/saw

Dec Total $1,654.00 $1,597.35 $1 ,566.04 $1 ,762.95 $1 ,533.00 $1 ,250.10 $1 ,111 .20 $420.00 $1 ,035.00 Benefits $578.90 $191 .68 $344.53 $211 .55 $183.96 $150.01 $133.34 Declabor • $2,232.90 $1 ,789.03 $1 ,910.57 $1,974.50 $1,716.96 $1 ,400.11 $1 ,244.54 DecMateri, $1 ,455.00 Dec Total $12,479.08

e

•

(17)

Name: RUSTIC Date: 1/4/2010

Scale: 1 inch equals 1000 feet

Datum: NAD27

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Location: 040° 44' 22.73" N 105° 31' 11 .91" W NAD27 Caption: Ben Delatour 2009

Fuels Reduction Work

•

(18)

Name: RUSTIC Date: 1/4/2010

Scale: 1 inch equals 1000 feet

Datum: NAD27

1,..-

24

Location 040° 44' 22.73" N 105° 31' 11 .91" W NAD27 Caption: Ben Delatour 2009

Fuels Reduction Work

(19)

--Summary - PO S036128

Page 1 of 2

I

Summary - PO 5036128

PO/Reference No. Supplier S036128

DELATOUR SCOUT RANCH BEN General Information PO/Reference No. Revision No. Priority Supplier Name Add ress Phone S036128 0 Normal

DELATOUR SCOUT RANCH BEN

2331 CO RD 68C

RED FEATHER L, CO 80545 us

I

Supplier Fax No.

I

Purchase Order Date i Total Requisition Number 5/18/2009 40,000 .00 USD 11041057

ENCUMBERED

Shipping Information Ship To

Attention: Karen Carlin Building: 1050 Room Number: -Department: 5060 Colorado State University 200 West Lake Street 0001 Campus Delivery Fort Collins, CO 805230001 United States ShipTo Address 0001-1 Code Bi lling/ Payment Bill To Accounts Payable Colorado State Univ 6003 Campus Delivery Fort Collins, CO 80523-6003 United States BillTo AP Address Code Billing Options Accounting Date

l

Contact Information Delivery Options Expedite

x

_Payment Terms 0% 0, Net 30 ' Owner Name Owner Phone

I

Owner Email

I

I Karen Ca rlin +1 (970) 491-3006

Karen. Carli n@ColoState. EDU

I Distribution Information

Ship Via Delivery

!

Distribution Methods The system will distribute purchase orders using the method(s) indicated below:

'

j Email (HTML Attachment) JOHN . SW ARO@COLOSTATE. EDU

j 6 Distribution options have been overridden for this PO

I

Joistr ibution Options Supplier

Terms and Conditions

1 _Order _{<FONT SIZE=2>Purchase Order Terms and Conditions}

Best Carrier-Best Way _{F.0 .B.} _Destination Supplier Information Supplier Information Contract Account Code Pricing Code Quote number no value

Note to Supplier no note Attachments for supplier

I

acceptance http: //www. purchasing .colostate .edu/pages/pdf/potermsconditions. pdf

1

instructions

Accounting Codes

Account Sub Code

530969 5980

07 HAZ FUELS FC -USDA-USFS-FOREST RESEARCH

Line Item Details

Product Description Catalog Size _No _PackagingI Unit Price Quantity Ext. Price

I 1 ,/ CHECK ORDER REQUESTS (AFE) ~() 40,000.00 USO 1 40,000.00 USO

AFE 3-Payments for Taxable

x

Requisition 11041057

EXCEPTION program obligations _{Capital Expense}

_x

Number

LIST which have been pre- _{External Note} _{no note}

Descript ion FINANCIAL Commodity no value

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https://solutions.sciquest.com/apps/Router/POSummaryPrinterFriendly?pold=6809060

5118/2009

(20)

LANDOWNER ASSISTANCE PROGRAMS

APPLICATION FOR COST-SHARE

Form A

~

SERVICE

PROJECT NUMBER: ____

_

(For Official Use Only)

NAME:

MAILING ADDRESS:

2331 County Road 68C

City:

Red Feather Lakes

State: CO

Zipcode:

80545

TELEPHONE NO: Camp: 970-881-2144 Sheryl McBride's office: 970-330-6305 ext. 101

PROJECT ADDRESS/LEGAL DESCRIPTION: 2331 County Rd. 68C, Red Feather Lakes,

Larimer County, CO 80545

PRACTICES TO BE COMPLETED BY: August 15, 2009

Date

Landowner and CSFS forester:

CSFS forester:

Practice No. &

Quantity

Maximum

Component Title

Requested

Approved C/S Amount

eligible

LOA-9 Fire and

(!))acres

Wac res NIA

Catastrophic Risk

Reduction

Total:

C/S Amount C/S Amount

Requested

Approved

$40,000

Request for cost-share assistance under the LOA program is to meet the objective stated in the

management plan.

CSFS forester: make sure the correct program is checked below.

One practice per application is allowed. If cost-sharing is approved for the practice requested, I agree to cover expenses at the time of implementation, knowing I will be receiving cost-share funds not exceeding 50% of actual cost.

I understand that I will not be reimbursed for any expenses incurred prior to approval of my

application.

Work must be completed according to approved plan and application, and must meet the

standard set for each component. For FLEP and I & D, practices must be maintained for a minimum of I 0 years. There are no partial payments fl~

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LANDOWNER SIGNATURE:

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4. DATE:

"1-t...~'"-07

To be completed by CSFS forester:

CSFS FIELD REVIEW SIGNATURE: __________

DATE: _ _ _

_

(Additional USFWS guidelines addressed)

PROGRAM:

WU/ Incentives D-space:

FLEP: __

_

I & D

Prevention and Suppression - Bark Beetle: ___ _

FRFTP:

Stevens' Funds:

X

_{SF A:}

----C/S Allocated: ____________ AMOUNT:=-$ _ _

DATE: ___

_

CSFS District Forester

Program eligibility is without regard to race, color, religion, national origin, age, gender, sexual orientation, veteran status or disabi lity. For more information contact your local Colorado State Forest Service District Office.

(21)

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INSTRUCTIO NS:

Expe11dilure Approved:

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