State Form 50065 (319-A) "Agriculture Cost-Share - Clean Water Act Section 319 Cost-Share Program" - Indiana

What Is State Form 50065 (319-A)?

This is a legal form that was released by the Indiana Department of Environmental Management - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2009;
  • The latest edition provided by the Indiana Department of Environmental Management;
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  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of State Form 50065 (319-A) by clicking the link below or browse more documents and templates provided by the Indiana Department of Environmental Management.

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319-A, AGRICULTURE COST-SHARE
INDIANA DEPARTMENT OF
ENVIRONMENTAL MANAGAMENT
CLEAN WATER ACT SECTION 319 COST-SHARE PROGRAM
State Form 50065 (R5 / 9-09)
INSTRUCTIONS: See page 2 of this form.
SECTION A
Applicant name
Indiana county
IDEM contract/agreement number
Name of sponsoring organization
         
Location information farm number
Tract number
Field(s) number
Section number
         
Township
Range
Civil township
USGS quad name
12-digit HUC
Latitude and longitude or universal transverse mercatur (UTM) coordinates
I hereby agree and certify that a conservation plan has been developed and will be followed in all fields that receive cost-share
funds. All best management practices (BMPs) implemented with these grant funds will be operated and maintained in
accordance with United States Department of Agriculture Natural Resources Conservation Service (NRCS) standards and
specifications (or other specifications cited below). Practices shall be maintained as follows: vegetative and land management
practices, five (5) years; structural practices, ten (10) years.
Applicant signature
Date (mm/dd/yyyy)
Landowner signature
Date (mm/dd/yyyy)
Printed name
Printed name
         
Address ( number and street)
Address (number and street)
State, ZIP code          
State, ZIP code  
City
City
SECTION B
The following eligible BMPs are needed to improve or maintain water quality, and will reduce off-site sedimentation or nutrient,
pesticide or pathogen loads to receiving waters. These practices were implemented consistent with NRCS standards and
specifications (or other specifications as listed below) and in accordance with the conservation plan.
Field
NRCS practice title or other
Maintain
Quantity
Total cost
Cost-share
Cost-share
Install date
specifications followed
for
or unit
level (%)
amount
(mm/yyyy)
number
yrs
$
$
yrs
$
$
yrs
$
$
yrs
$
$
yrs
$
$
yrs
$
$
$
$
TOTAL
Printed name and signature of NRCS, IDNR, ISDA, TSP, or SWCD technical representative:
Date (mm/dd/yyyy)
SECTION C
Critical area as described in the WMP and page number(s)
NPS pollutant(s) of concern addressed within this critical area by BMP
where referenced
implementation
The total cost-share amount in section B is recommended to IDEM for cost-share assistance and is approved for payment by the
sponsoring organization. The sponsoring organization or local SWCD office has a copy of the conservation plan available for
IDEM review.
Date (mm/dd/yyyy)
Authorized signature for sponsoring organization
Page 1 of 2
Reset Form
319-A, AGRICULTURE COST-SHARE
INDIANA DEPARTMENT OF
ENVIRONMENTAL MANAGAMENT
CLEAN WATER ACT SECTION 319 COST-SHARE PROGRAM
State Form 50065 (R5 / 9-09)
INSTRUCTIONS: See page 2 of this form.
SECTION A
Applicant name
Indiana county
IDEM contract/agreement number
Name of sponsoring organization
         
Location information farm number
Tract number
Field(s) number
Section number
         
Township
Range
Civil township
USGS quad name
12-digit HUC
Latitude and longitude or universal transverse mercatur (UTM) coordinates
I hereby agree and certify that a conservation plan has been developed and will be followed in all fields that receive cost-share
funds. All best management practices (BMPs) implemented with these grant funds will be operated and maintained in
accordance with United States Department of Agriculture Natural Resources Conservation Service (NRCS) standards and
specifications (or other specifications cited below). Practices shall be maintained as follows: vegetative and land management
practices, five (5) years; structural practices, ten (10) years.
Applicant signature
Date (mm/dd/yyyy)
Landowner signature
Date (mm/dd/yyyy)
Printed name
Printed name
         
Address ( number and street)
Address (number and street)
State, ZIP code          
State, ZIP code  
City
City
SECTION B
The following eligible BMPs are needed to improve or maintain water quality, and will reduce off-site sedimentation or nutrient,
pesticide or pathogen loads to receiving waters. These practices were implemented consistent with NRCS standards and
specifications (or other specifications as listed below) and in accordance with the conservation plan.
Field
NRCS practice title or other
Maintain
Quantity
Total cost
Cost-share
Cost-share
Install date
specifications followed
for
or unit
level (%)
amount
(mm/yyyy)
number
yrs
$
$
yrs
$
$
yrs
$
$
yrs
$
$
yrs
$
$
yrs
$
$
$
$
TOTAL
Printed name and signature of NRCS, IDNR, ISDA, TSP, or SWCD technical representative:
Date (mm/dd/yyyy)
SECTION C
Critical area as described in the WMP and page number(s)
NPS pollutant(s) of concern addressed within this critical area by BMP
where referenced
implementation
The total cost-share amount in section B is recommended to IDEM for cost-share assistance and is approved for payment by the
sponsoring organization. The sponsoring organization or local SWCD office has a copy of the conservation plan available for
IDEM review.
Date (mm/dd/yyyy)
Authorized signature for sponsoring organization
Page 1 of 2
INSTRUCTIONS FOR COMPLETING STATE FORM 50065, 319-A
This form should be completed when requesting reimbursement from the Section 319 Program for eligible cost-share and/or demonstration
best management practices (BMPs) implemented on agricultural land; defined as land that is currently in production (i.e., working lands)
such as cropland, pastureland, rangeland, native pastureland, other land used to support livestock production, and tree farms.
SECTION A - This section requests general information on the BMP location and the applicant/landowner. Complete all blanks in Section A
for the BMPs implemented and listed in Section B.
If the applicant does not own the land where practices will be implemented, the landowner's signature is required, unless the applicant
has power of attorney for the landowner. The landowner must sign the form before proceeding with the project.
Include the twelve (12) digit Hydrologic Unit Code (HUC), and the latitude & longitude or the UTM coordinates for a central location
where the BMP is implemented. If many BMPs are implemented in different places, one (1) general coordinate location will suffice.
A conservation plan for the land in Section B, signed by a certified conservation planner, must be available in the sponsor’s or local
SWCD office for audit purposes.
Before signing, the landowner must understand the certification statements above the signature block.
SECTION B - This section certifies that the BMPs are needed to improve or maintain water quality, are in accordance with the conservation
plan, and were satisfactorily completed.
Complete the field number, official NRCS practice title (found in the NRCS Field Office Technical Guide, or at
http://efotg.nrcs.usda.gov/efotg_locator.aspx?map=IN) or other specifications followed, number of years of maintenance required (based
on Section A), quantity or unit, total practice cost (shown on attached receipts), percent of total cost to be paid to the landowner, total
amount paid to the landowner, and date the practice was implemented for each BMP. Agricultural demonstration BMPs may have a
cost-share level of up to 100% (and must be located on public land). See definition of demonstration practice below.
If the operation is an animal feeding operation (AFO), confined feeding operation (CFO), or a concentrated animal feeding operation
(CAFO), see the
Clean Water Act Section 319 Agricultural Cost-Share Guidance for Indiana
for BMP eligibility.
This section must be completed and signed by an NRCS, IDNR, ISDA, TSP, or SWCD technical representative who can certify to the
statements at the top of Section B.
SECTION C - This section must be complete and signed by an official (with signatory authority) of the sponsoring organization.
From the approved watershed management plan (or draft if implementing a demonstration BMP), reference the critical area where the
BMP(s) were implemented and what nonpoint source (NPS) pollutants of concern within that critical area are being addressed.
FORM SUBMISSION
An invoice for payment should be prepared and submitted to IDEM with this form. As individual practices are implemented, invoices may be
submitted to IDEM. Payment will be forwarded to the sponsoring organization in approximately four weeks. The following items must
accompany this complete, signed 319-A Form and an invoice for payment to IDEM:
1)
Map, showing location of all BMPs in relation to adjacent roads;
2)
Copies of bills or receipts for each BMP showing the total cost;
3)
Copies of the Region 5 Load Estimation model worksheet(s), the STEPL model workbook, or other appropriate tool to estimate the
pollutant load reductions for the practices implemented, when applicable. The above models may be found on EPA’s web site at:
http://it.tetratech-ffx.com/stepl/models$docs.htm;
4)
Appropriate NRCS Checklist if cost-share funds are used to develop a nutrient management plan, pest management plan or
comprehensive nutrient management plan.
ADDITIONAL INFORMATION - For additional information on the cost-share program and requirements, see the
Clean Water Act Section
319 Agricultural Cost-Share Guidance for Indiana
or contact your IDEM project manager. Note to sponsors: The sponsoring organization
may need to provide a 1099 form for disbursements.
DEFINITIONS:
Demonstration practice – a BMP used to introduce new techniques in the watershed and to encourage landowners to install the
practice. The BMP must: be located on public land or any area where the public has access on a regular basis, located in a critical
area as defined in the WMP, not have been cost-shared on before in the watershed with Section 319 funds, and be used/showcased as
part of an education/outreach event. Demonstration practices must be authorized in the project’s grant agreement and implemented
according to the instructions on this form.
Land management practice – Practice that requires primarily management techniques and methods to implement the practice (such as
nutrient management, pest management, residue management, and prescribed grazing).
Structural practice – Practice that involves constructing designed (engineered) features using machinery (such as waterways, animal
mortality facilities and water and sediment control basins).
Vegetative practice – Practice that only involves seeding or planting to establish or re-establish plant cover (such as pasture and hay
seeding, cover crop, filter strip, and tree planting).
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