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HomeMy WebLinkAboutNRCS-CPA-41_Entity_Application_for_an_ALE_Agreement_Final 3U.S. Department of Agriculture Natural Resources Conservation Service NRCS-CPA-41 1212016 ENTITY APPLICATION for an AGRICULTURAL LAND EASEMENT (ALE) AGREEMENT Clear Form This is an Entity Application for an Agricultural Land Easement (ALE) Agreement through the: (Select ONE) ❑ Agricultural Conservation Easement Program —Agricultural Land Easement (ACEP ALE) © Regional Conservation Partnership Program (RCPP)—ACEP-ALE Entity Name: NEST Application Number: 'orterra NW I AGENCY USE Entity Address: Application Date: orterra NW This is an Entity Application for an ALE Agreement, as established by the Agricultural Act of 2014. By signing and submitting this application, you agree to comply with the requirements of ACEP ALE. I. ❑✓ Yes ElOo Do you have entity records established with the appropriate USDA service center agency? If no, you must establish them with the appropriate USDA service center agency prior to submitting this application. 2. A Dun & Bradstreet Data Universal Numbering System (DUNS) number and current registration in the System for Award Management (SAM) is required for receiving payment under an EIN. If you do not have a DUNS number information is available at httD-1,fedaov.dnb.com/webfo►mTo register with SAM, go tohttns.-1Ayww.sam.00v/ DUNS Number: b90020616 3. ❑✓ Yes ❑ No Do you have the authority and capability to acquire, manage, and enforce agricultural land easements? 4. How many entity staff are dedicated to monitoring and easement stewardship? 5 ❑ Yes ✓❑ No Are you an NRCS Certified Entity'? 6. [2]Yes [—]No Are all parcelsll associated with this application subject to a written pending offer"A signed by the eligible entity for purchase of an agricultural land easementP' by an eligible entity j? PAGE1 of5 Entity Type: ❑ State Government ❑ Local Government Entity Email: ❑ Indian Tribe 3draper@forterra.org ©Non-governmental Organization F Entity TIN Application PPlion Total Acres: 73.6 Telephone: State: 206) 905-6956 WA Land Eligibility Category for Agreement (8elect one 15: ❑ Has prime, unique, or other productive soil ❑ Contains historical or archaeological resourcesp © Protects grazing uses and related conservation values ❑ Furthers a State or local government policy consistent with the purposes of ACEP. Cite the State or local government policy consistent with ACEP: Is this an application for a Grassland of Special Environmental Significance (GSS) ALE Agreement: ❑ Yea n N4 This is an Entity Application for an ALE Agreement, as established by the Agricultural Act of 2014. By signing and submitting this application, you agree to comply with the requirements of ACEP ALE. I. ❑✓ Yes ElOo Do you have entity records established with the appropriate USDA service center agency? If no, you must establish them with the appropriate USDA service center agency prior to submitting this application. 2. A Dun & Bradstreet Data Universal Numbering System (DUNS) number and current registration in the System for Award Management (SAM) is required for receiving payment under an EIN. If you do not have a DUNS number information is available at httD-1,fedaov.dnb.com/webfo►mTo register with SAM, go tohttns.-1Ayww.sam.00v/ DUNS Number: b90020616 3. ❑✓ Yes ❑ No Do you have the authority and capability to acquire, manage, and enforce agricultural land easements? 4. How many entity staff are dedicated to monitoring and easement stewardship? 5 ❑ Yes ✓❑ No Are you an NRCS Certified Entity'? 6. [2]Yes [—]No Are all parcelsll associated with this application subject to a written pending offer"A signed by the eligible entity for purchase of an agricultural land easementP' by an eligible entity j? PAGE1 of5 U.S. Department of Agriculture NRCS-CPA-41 Natural Resources Conservation Service 1212016 7. ❑✓ Yes ❑ No Will any other entity co -hold an agricuiturai land easement on one or more of the parcels associated with this application? If the answer is Yes, then the intended co -holders must co-sign this application for an Agricultural .Land Easement Agreement, provide a DUNS number, and be registered with SAM. Name: 'ttitas County Tax Number; 1-6001349 DUNS Number: 1-020-2547 Co -Holder Signature: Name: ax Number: DUNS Number: Co -Holder Signature; 8. ❑✓ Yes ❑ No Will another entity, other than the United States, hold a third -party right, contingent right, or any other real property interest in an agricultural land easement on one or more of the parcels associated with this application, excluding entities co-signing this application as a co -holder? If the answer is Yes, list the Names and Tax Identification Number for all other intended holders of interests in the agricultural land easement Name: WA State RCO Tax Number: 1-0780046 DUNS Number: 8-$405852 Name: JTax Number: DUNS Number: Name: Tax Number: DUNS Number: 9. The land offeredF" under this application is (check all that apply): R] Private Land []Tribal, Allotted, Ceded, or Indian Land 10. How many parcels are associated with this application: 09 You must complete an ACEP-ALE Parcel Sheet NRCS-CPA-41A for each parcel associated with this application and attach it to this Entity Application for an ALE Agreement. 11. Complete the below table with the sum totals for all parcels associated with this application. These values may be estimates, subject to the final values being determined by an NRCS-approved appraisal report or easement valuation methodology. A. Total Estimated Fair Market Value of all ALEs $1,875,000 B. Total Estimated Entity Non -Federal Cash Contribution to all ALES (excluding Landowner donation) $937,500.00 C. Total Requested Federal Share for ALEs $937,500.00 D. Total Estimated Purchase Price of ALEs (D = B + C) E. Total Estimated Landowner Donation for all ALES (E = A — D) $1,875,000.00 $0.00 12. All entities that will be identified as either a holder, co -holder, or other holder of interest on any agricultural land easement deed associated with this application must be listed on the table below. For those that will contribute cash or receive ALE funds, identify on the table below the estimated entity non -Federal cash contribution (item B above) and the requested Federal share (item C above) by individual entity. PAGE 2 of 5 U.S. Department of Agriculture Natural Resources Conservation Service NRCS-CPA-41 1212016 The Entity has reviewed the template Agricultural Land Easement(ALE) Agreement that stipulates the terms and conditions under which the entity would be permitted to use the cost -share assistance applied for herein. the Entity agrees to participate in the Agricultural Land Easement component of the Agricultural Conservation Easement Program (ACEP) if NRCS and the Entity enter into an ALE -Agreement. However, nothing in this application obligates the United States or the Entity to purchase all or any of the Agricultural Land Easements listed on the Parcel Sheets attached to this application. To identify future roles should this application be funded, the undersigned Entity shall hereafter be referred to as the "Participant." The Participant understands that unless an Entity is certified by NRCS, acquiring an Agricultural Land Easement without the NRCS required minimum deed terms and conditions or prior to NRCS approval of the appraisal or easement valuation determination and title causes the Agricultural Land Easement to be ineligible for ACEP cost -share assistance. An Entity may only be certified by the Chief of NRCS. The Participant certifies that highly erodible land conservation/wetland conservation, adjusted gross income certifications, and member information for all Landowners are on file with the appropriate USDA service center agency and are up to date. It is the responsibility of the Participant to provide accurate data to support all items addressed in this application at the request of NRCS. Participants acknowledge that NRCS is relying upon the veracity of the information submitted for purposes of awarding Federal funds and that the submittal of false information may be subject to criminal or civil fraud statutes. The Participant is required to be registered in the System for Award Management (SAM) before submitting this application and must provide a valid DUNS number on this application. Each Participant must continue to maintain an active SAM registration with current information at all times during which it has an active application for funding under consideration and at all times for the duration of any ALE -agreement entered into under the program. NRCS may not enter into an ALE Agreement with an Entity until all applicable DUNS and SAM requirements have been met. If an Entity has not fully complied with these requirements by the time NRCS is ready to award the ALE -Agreement, NRCS may determine that the Entity is not qualified to receive an ALE -Agreement and use that determination as a basis for making an award to another applicant. initial 13. FZ]- I certify that the Entity has its own cash resources to provide the Total Estimated Entity Non -Federal Cash Contribution stated in 11.B. above. 14.Z- Non -certified entities:l have received and reviewed a copy of the required ALE -Cooperative Agreement Template and United States Secretary of Agriculture's required minimum deed terms and conditions for an Agricultural Land Easement. 15. P- Certified entities: I have received and reviewed a copy of the required ALE -Grant Agreement P- or, entities which includes the United States Secretary of Agriculture's regulatory deed requirements that must be address in the Agricultural Land Easement Deed. PAGE 3 of 5 Entity Role (identify either): B1• Estimated Individuai I C1. Individual Entity Entity Name: - Holder or co-holder(#2 above), Entity Non -Federal Cash Contribution portion of requested - Co -holder (#7 above), or to all ALEs Federal Share for ALEs - Holder of interest (#8 above) (total must equal item B (total must equal item C above) above) Forterra NW Co -holder 0.00 937,500.00 WA - RCO Holder of Interest 937,600.00 0.00 Klttttas County Co -holder 0.00 0.00 The Entity has reviewed the template Agricultural Land Easement(ALE) Agreement that stipulates the terms and conditions under which the entity would be permitted to use the cost -share assistance applied for herein. the Entity agrees to participate in the Agricultural Land Easement component of the Agricultural Conservation Easement Program (ACEP) if NRCS and the Entity enter into an ALE -Agreement. However, nothing in this application obligates the United States or the Entity to purchase all or any of the Agricultural Land Easements listed on the Parcel Sheets attached to this application. To identify future roles should this application be funded, the undersigned Entity shall hereafter be referred to as the "Participant." The Participant understands that unless an Entity is certified by NRCS, acquiring an Agricultural Land Easement without the NRCS required minimum deed terms and conditions or prior to NRCS approval of the appraisal or easement valuation determination and title causes the Agricultural Land Easement to be ineligible for ACEP cost -share assistance. An Entity may only be certified by the Chief of NRCS. The Participant certifies that highly erodible land conservation/wetland conservation, adjusted gross income certifications, and member information for all Landowners are on file with the appropriate USDA service center agency and are up to date. It is the responsibility of the Participant to provide accurate data to support all items addressed in this application at the request of NRCS. Participants acknowledge that NRCS is relying upon the veracity of the information submitted for purposes of awarding Federal funds and that the submittal of false information may be subject to criminal or civil fraud statutes. The Participant is required to be registered in the System for Award Management (SAM) before submitting this application and must provide a valid DUNS number on this application. Each Participant must continue to maintain an active SAM registration with current information at all times during which it has an active application for funding under consideration and at all times for the duration of any ALE -agreement entered into under the program. NRCS may not enter into an ALE Agreement with an Entity until all applicable DUNS and SAM requirements have been met. If an Entity has not fully complied with these requirements by the time NRCS is ready to award the ALE -Agreement, NRCS may determine that the Entity is not qualified to receive an ALE -Agreement and use that determination as a basis for making an award to another applicant. initial 13. FZ]- I certify that the Entity has its own cash resources to provide the Total Estimated Entity Non -Federal Cash Contribution stated in 11.B. above. 14.Z- Non -certified entities:l have received and reviewed a copy of the required ALE -Cooperative Agreement Template and United States Secretary of Agriculture's required minimum deed terms and conditions for an Agricultural Land Easement. 15. P- Certified entities: I have received and reviewed a copy of the required ALE -Grant Agreement P- or, entities which includes the United States Secretary of Agriculture's regulatory deed requirements that must be address in the Agricultural Land Easement Deed. PAGE 3 of 5 U.S. Department of Agriculture NRCS-CPA-41 Natural Resources Conservation SerAce 1212016 NONDISCRIMINATION STATEMENT The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers. If you believe you experienced discrimination when obtaining services from USDA, participating in a USDA program, or participating in a program that receives financial assistance from USDA, you may file a complaint with USDA. Information about how to file a discrimination complaint is available from the Office of the Assistant Secretary for Civil Rights. USDA prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex (including gender identity and expression), marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual's income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) To file a complaint of discrimination, complete, sign and mail a program discrimination complaint form, available at any USDA office location or online at www.ascr.usda.gov, or write to: USDA Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, S.W. Washington, D.C. 20250-9410 Or call toll free at (866) 632-9992 (voice) to obtain additional information, the appropriate office or to request documents. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay service at (800) 877-8339 or (800) 845-6136 (in Spanish). USDA is an equal opportunity provider, employer, and lender. Persons with disabilities who require alternative means for communication of program information (e.g., Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). PRIVACY ACT STATEMENT The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a). Fumishing this information is voluntary; however, failure to furnish correct, complete information will result in the withholding or withdrawal of such technical or financial assistance. The information may be furnished to other USDA agencies, the Internal Revenue Service, the Department of Justice, or other State or Federal law enforcement agencies, or in response to orders of a court, magistrate, or administrative tribunal. This information collection is exempted from the Paperwork Reduction Act under 16 U.S.C. 3801 note and 16 U.S.C. 3846. i To be considered as an Eligible Entity under ACEP ALE a non-governmental organization must be: (1) organized for, and at all times since the formation of the organization been operated principally for, 1 or more of the conservation purposes specked in clause (i), (ii), (iii), or (iv) of section 170(h)(4)(A) of the Internal Revenue Code of 1986; (2) an organization described in section 501(c)(3) of that Code that is exempt from taxation under section 501(a) of that Code; or (3) described in "(1) section 509(a) (1) and (2) of that Code; or (11) section 509(a)(3) of that Code and is controlled by an organization described in section 509(a)(2) of that Code. ii Select only one. ACEP-ALE applications are organized by Eligible Land type; ACEP-ALE agreements are specific to the Eligible Land type. The Eligible Land type will affect minimum deed terms and ALE Plan. requirements. Applications with more than one selection may be deferred until corrected. iii Historical and archaeological resources mean resources that are: (1) Listed in the National Register of Historic Places (established under the National Historic Preservation Act (NHPA), 16 U.S.C. 470, et seq.); (2) Formally determined eligible for listing in the National Register of Historic Places (by the State historic preservation officer (SHPO) or Tribal historic preservation officer (THPO) and the Keeper of the National Register in accordance with section 106 of the NHPA); PAGE 4 of 5 U.S. Department of Agriculture Natural Resources Conservation Service MRCS -CPA -41 1212016 (3) Formally listed in the State or Tribal Register of Historic Places of the SHPO (designated under section 101(b)(1)(B) of the NHPA) or the THPO (designated under section 101(d)(1)(C) of the NHPA); or (4) Included in the SHPO or THPO inventory with written justification as to why it meets National Register of Historic Places criteria. iv Certified Entity means an eligible entity that NRCS has determined to meet the requirements of 7 CFR § 1468.27. An Entity may only be certified by the Chief of NRCS. v Parcel means a farm or ranch submitted for consideration for funding under ACEP ALE. vi Pending offer means a written bid, contract, or option extended to a Landowner by an eligible entity to acquire a conservation easement before the legal title to these rights has been conveyed for the purpose of- (1)The agricultural use and future viability, and related conservation values, of eligible land by limiting non-agricultural uses of that land; or (2) Grazing uses and related conservation values by restoring and conserving eligible land. vii Agricultural land easement means an easement or other interest in eligible land that is conveyed for the purpose of protecting natural resources and the agricultural nature of the land, and of promoting agricultural viability for future generations, and permits the Landowner the right to continue agricultural production and related uses subject to an agricultural land easement plan, as approved by the NRCS. viii The NRCS may not use ACEP funds for the purposes of acquiring an easement on lands owned by an agency of the United States, other than land held in trust for Indian Tribes; and lands owned in fee title by a State, including an agency or a subdivision of a State, or a unit of local government. Such lands are ineligible for ACEP. ix Purchase price means the fair market value of the agricultural land easement as determined by an NRCS approved methodology, minus the Landowner donation. x Landowners shall not donate any part of the Federal share or non -Federal cash contribution back to the entity as a condition of purchase or closing. PAGE 5 of 5