2012-418 Soil - Water - NC Dept of Agriculture & Consumer Services Matching Technical Assistance Agreement $53,350

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■ w d a, 0 4-; a� o U :�y 4 C a, U cS i �C NORTH CAROLINA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES Steven W. Troxler, Commissioner NCDA &CS Division of Soil and Water Conservation CONTRACT "CHECK OFF LIST" for Grantee (Governmental) INSTRUCTIONS CHECK THE "YES" BOXES IN LEFT COLUMN FOR THE DOCUMENT TITLES THAT ARE BEING RETURNED WITH THE TWO SIGNED DATED and WITNESSED COPIES OF THE CONTRACT WITH SIGNATURES IN BLUE INK( BE SURE TO INCLUDE ALL THE OTHER DOCUMENTS SPECIFIED IN YOUR CONTRACT PACKAGE, IF -M " HAS BEEN CHECKED OFF FOR YOU, THAT DOCUMENT IS NOT REOURED FOR THIS GRANT PROGRAM OR PROJECT, GRANTEE ORGANIZATION NAME: Orange Soil & Water Conservation District PROJECT TITLE /NAME: DSWC- District Matching and Technical Assistance Agreement CONTRACT #: TRACKING #: 13- E- 179- SWC -DMT GOVERNMENTAL ENTITIES ONLY Check one Box DOCUMENT TITLE ALL SIGNATURES MUST BE IN BLUE INK DEPARTMENTAL ': .USE = DOCUMENTS 'ATTACHED OR ON FILf GRANTS k. CONTRACTS USE = DOCUMENTS , 1 ATTACHED Yes No Contract "Check Off List" for Grantee -Yes No' F1 Yes = No ; Yes p No Contract Cover To be signed, dated & witnessed Yes No Yes No ❑ Yes ❑ No ATTACHMENT A - Scope of Work & District Application Packet ❑ Yes ❑ No -Yes . No El Yes ❑ No ATTACHMENT B - General Terms & Conditions ❑ Yes ❑ No ❑ .Yes No;,.. ❑ Yes ❑ No ATTACHMENT C - Combined Certifications and Assurances ❑ Yes ❑ No Yes ❑ No Yes F1 No ATTACHMENT D - NCO enbook Supplemental Information M Yes ❑ No Yes No Yes No ATTACHMENT E - Signature Card = Yes '` No Yes No ❑ Yes ❑ No ATTACHMENT F - W -9 Tax Information L1 Yes 11 No Yes ❑ No ❑ Yes ❑ No I ATTACHMENT G - Electronic Payment Request ❑ Yes No ❑ -Yes ❑ No `0 Effective 7/11; Rev 1/12, 5/12, 8/12, 9/12