S Grant -Application to NC Agr Dev & Farmland Preservation Trust Fund -Breeze Farm

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NCDA &CS ADFP Trust Fund Easement Application Checklist This Easement Application Checklist is provided as a means to ensure that all Applications are submitted with the required information. Failure to include all information may result in ineligibility to receive funding. This document must be completed and filed with submission of the 2008 Easement Application no later than 5:OOPM on December 5, 2008. Applicant Name: Orange County, NC Applicant Tax Identification Number: 56- 6000327 Project Title: Breeze Farm Conservation Easement Phase II GRANTEE USE ONLY The following items are required for ALL applicants. ADFP USE ONLY ® 1. Project Budget Narrative (available at www.ncadfp.orci ❑ ® 2. Contact List for Funding Sources (available at www.ncadfmoro) ❑ ® 3. Photographs (limited to two 8 %x 11 pages) ❑ ® 4. Letters of intent from matching funds sources only ❑ ® 5. Location maps showing roads, proximity to towns, other conserved lands, markets, ❑ etc. ® 6. Map of property with bodies of water, structures, land cover, and dwellings ❑ ® 7. Soils map with boundaries developed under USDA -NRCS Cooperative Soil Survey ❑ (only one map with local SWCD officer signature verifying prime soils and acreage) ® 8. Photographs of landscape, structures, and equipment ❑ ❑ 9. Financial affidavit (only if claiming Limited Resource or Beginning Fanner) ❑ GRANTEE USE ONLY The following items are required for Non - Profit Non - Governmental Organization ADFP USE ONLY A licants Only. ❑ 1. 501(c)(3) Certification or Letter of Federal Tax Exemption Status from the Internal ❑ Revenue Service ❑ 2. Conflict of Interest Policy (addressing conflicts of interest involving the applicant's management, employees, and the members of its board of directors or other governing body that may arise): The policy shall address situations in which any of these individuals may directly or indirectly benefit, except as the applicant's employees or members of its board of other governing body, from the applicant's disbursing of State funds, and shall include actions to be taken by the applicant or the individual, or both, to avoid conflicts of interest and the appearance of impropriety. The policy shall be filed before the funds may be disbursed to the applicant. An example policy may be accessed from the State Auditor's website. ❑ 3. Sworn Statement of Overdue Taxes shall be made under oath and shall be filed ❑ prior to the disbursement of any State funds. Information can be accessed from the state auditor's website. 4. List of current grants held by the applicant organization and respective amounts ❑ ❑ 5. List of board members ❑ ❑ 6. Articles of Incorporation ❑ Page 1 of 17 Easement Application