Applicant:
Address:
Phone #:
Contact Person:
Title:
Address:
Phone #: Fax #: E-mail:
Name of Project
Property Tax Parcel # Property Acreage
Trail Footage on Funded Parcels
County Grant Requested $ %
(Not to exceed grant amount specified in Grant Contract)
Municipal Funds $ %
State Funds $ %
Other Public Funds $ %
Private Funds $ %
Property/Easement Cost $ 100%
MUNICIPAL APPROVAL: If the final payment box is checked below, the municipality waives any and all claims for funds
remaining, on this grant contract, from the County for this project. This project is now complete.
By (Signature required) ___________________________________________Date
Name (typed) Title:
Partial Payment Request Final Payment Request
A. Settlement sheet and copy of canceled check or certification from settlement agent that money was received.
B. Copy of recorded deed or Solicitor's certification.
C. Copy of the Title Report and insurance in amount of land value.
D. For Final Reimbursement a letter from the solicitor certifying adherence to all municipal and other governmental codes,
laws, regulations, procedures, policies, and ordinances, etc.
E. Copy of recorded Declaration of Covenants, Conditions, and Restrictions.
F. Photograph of sign installed on site as well as photographs of acquired site.
G. Property survey if available.
H. Original executed 1099-S verification form if acquisition is an easement.
I. Baseline Documentation for Conservation Easements.
FOR INTERNAL OFFICE USE ONLY
Account Number: ______________________________________________Vendor Number: __________
Contract ID Number: ________________Return Check To: ____________________________________