HomeMy WebLinkAbout2022-508-E-DEAPR-North Carolina Department of Agriculture and Consumer Services-Approval of NCADFP grant contract for matached funds in acquisition of conservation easement of Poteat family farmDocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
NORTH CAROLINA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
Steven W. Troxler, Commissioner
Contract Check Off List for Grantee (Government State Funded)
INSTRUCTIONS: Check the "Yes" boxes in the 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 "No” has been checked off for you, that
document is not required for this grant program or project.
GRANTEE ORGANIZATION NAME:
PROJECT TITLE/NAME:
CONTRACT #:
GO Entities Only
Check One Box
Document Title Department Use –
Documents Attached
or On File
Grants and Contracts-
Documents Attached
or On File
Yes No Contractual “Check Off List for Grantee Yes No Yes No
Yes No Contract Cover (To be signed, dated & witnessed) Yes No Yes No
Yes No Attachment A – General Terms and Conditions – Government/University Yes No Yes No
Yes No Attachment B – Scope of Work (includes Timeline and Line Item Budget) Yes No Yes No
Yes No Attachment C – Certifications and Assurances Section Yes No Yes No
Yes No Attachment D – NC OpenBook Supplemental Information Yes No Yes No
Yes No Attachment E – Signature Card Yes No Yes No
Yes No Attachment F – W -9 Tax Information Yes No Yes No
Yes No Attachment G – Vendor Electronic Payment Form Yes No Yes No
Yes No Attachment H – FFATA Data Reporting Requirements (if applicable) Yes No Yes No
Yes No Attachment I – Federal Regulations (if applicable) Yes No Yes No
Rev. 6/17, 4/22 Attachments A, C-K have all been signed prior to contract signing and are saved in ADFP's files.
Orange County
Poteat Family Farm Conservation Easement +/- 110 Acres
22-086-4003
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DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
STATE OF NORTH CAROLINA
COUNTY OF WAKE
North Carolina Department of Agriculture and Consumer Services
Farmland Preservation Division
Agricultural Development and Farmland Preservation Trust Fund – Government
CONTRACT # _22-086-4003
ADFP Tracking # ADM-ADFP-RCPP-22-001
This Contract is hereby entered into by and between the North Carolina Department of Agriculture and
Consumer Services, Farmland Preservation Division, (the "Agency") and Orange County, (“Grantee”),
and referred to collectively as the “Parties.” The Grantee’s federal tax identification number is 56-6000327
and is physically located in Orange County and is further located at 1100 US 70 W, Hillsborough, NC 27278.
The purpose of this Contract is to encourage the preservation of qualifying farmland and to foster the growth,
development, and sustainability of family farms. The Grantee’s project title is Poteat Family Farm
Conservation Easement +/- 110 Acres. This Contract is funded by State appropriations. Funds awarded
under this Contract must be used for the purposes for which they are intended.
The Grantee’s fiscal year ends June 30.
Contract Documents:
This Contract consists of the Grant Contract and its attachments, all of which are identified by name as
follows:
1.This Contract
2.Scope of Work, including Timeline, Line-Item Budget and Budget Narrative (Attachment B)
These documents constitute the entire agreement between the Parties and supersede all prior oral or
written statements or agreements.
I.Precedence Among Contract Documents:
In the event of a conflict between or among the terms of the Contract Documents, the terms in the
Contract Document with the highest relative precedence shall prevail. The order of precedence shall be
the order of documents as listed in Paragraph 1, above, with the first-listed document having the highest
precedence and the last-listed document having the lowest precedence. If there are multiple Contract
Amendments, the most recent amendment shall have the highest precedence and the oldest amendment
shall have the lowest precedence.
Departmental Use Only
CENTER: 6208 1012 2022
ACCOUNT: 536406
AMOUNT: $189,645.15
TIME PERIOD: October 1, 2022 –
September 30, 2024
PO: 10ADFPPT22
Line 32
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II. Effective Period:
This Contract shall be effective on October 1, 2022 and shall terminate on September 30, 2024 with
the option to extend, if mutually agreed upon, through a written amendment as provided for in the
General Terms and Conditions as described in Attachment A. Per the Conservation Easement Contract
Grantee Duties and Reporting Requirements in Attachment B, a request for an amendment must be
submitted to the Farmland Preservation Director 60 days before the end of the contract.
III. Grantee's Duties:
The Grantee shall provide the services as described in Attachment B, Scope of Work.
IV. Agency’s Duties:
The Agency shall pay the Grantee in the manner and in the amounts specified in the Contract
Documents. The total amount paid by the Agency to the Grantee under this Contract shall not exceed
$189,645.15.
This amount consists of $189,645.15 in State funds.
[ ] a. There are no matching requirements from the Grantee.
[ ] b. There are no matching requirements from the Grantee; however, the Grantee has committed the
following match to this project:
In Kind $
Cash $
Other/Specify: $
[ x ] c. The Grantee’s matching requirement is $28,446.77, which consists of:
In Kind $28,446.77
Cash $
Other/Specify: $
[ ] d. The Grantee has committed to an additional $ _______ to complete the project as described in
Attachment B.
The contributions from the Grantee shall be sourced from non-federal funds.
The total Contract amount with matching funds is $218,091.92.
V. Conflict of Interest Policy:
The Agency has determined that the Grantee is a government agency and is not subject to N.C.G.S. §
143C-6-23(b). Therefore, the Grantee is not required to file a Conflict-of-Interest Policy with the Agency
prior to disbursement of funds.
VI. Statement of No Overdue Tax Debts:
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The Agency has determined that Grantee is a government agency and is not subject to N.C.G.S. §
143C-6-23(c). Therefore, the Grantee is not required to file a Statement of No Overdue Tax Debts with
the Agency prior to disbursement of funds.
VII. Reversion of Unexpended Funds:
Any unexpended grant funds shall revert to the Agency upon termination of this Contract.
VIII. Reporting Requirements:
(1) Agency:
The grantee shall provide the Agency with progress reports, both financial and
programmatic. The following is based upon the Agency contract with the grantee being
two years in time.
For grant awards of less than $250,000, reports are due semi-annually. Refer to the table
below for the reporting period and due dates for progress and budget reports:
Contract Year Reporting Period Report Due Dates
Year 1 October 1 – March 31 April 10
Year 1 April 1 – September 30 October 10
Year 2 October 1 – March 31 April 10
Year 2 April 1 – September 30 October 10
For grant awards of $250,000 or more, reports are due quarterly. Refer to the table below
for the reporting period and due dates for progress and budget reports:
Contract Year Reporting Period Report Due Dates
Year 1 October 1 – December 31 January 10
Year 1 January 1 – March 31 April 10
Year 1 April 1 – June 30 July 10
Year 1 July 1 – September 30 October 10
Year 2 October 1 – December 31 January 10
Year 2 January 1 – March 31 April 10
Year 2 April 1 – June 30 July 10
Year 2 July 1 – September 30 October 10
IX. Payment Provisions:
The grantee shall provide the Agency with the appropriate reimbursement request (downloadable at
www.ncadfp.org) and required documentation of performance and expenditures for associated grant
reimbursement. Upon approval by the Agency, payment shall be made within 30 days. Ten percent (10%) of
the total funds awarded under this Contract shall be retained by the Agency until both the final performance
and financial reports are submitted by the Grantee and approved by the Agency. All payments are subject to
the availability of funds.
The Grantee shall expend funds in accordance with G.S. 143C-6-23 (f1)(f2)(j). The Grantee shall account
for any income earned, which may result from any funds awarded under this Contract, on the Agency
“Request for Reimbursement” form. Eligible uses of income earned are:
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a) Expanding the project or program.
b) Continuing the project or program after grant ends; or
c) Supporting other projects or programs that further the broad objectives of the grant program.
If this Contract is terminated prior to the original end date, the Grantee may submit a final Request for
Payment form. All unexpended funds shall be returned by the Grantee to the Agency within 60 days of
the Contract termination date with a complete final financial report, accompanied by either a final invoice
or a refund of any funds received but not expended. The Agency shall have no obligation to honor
requests for payment based on expenditure reports submitted later than 60 days after termination or
expiration of the Contract period.
Reimbursement requests shall be completed on a “Request for Reimbursement” form furnished to the
Grantee by the Agency. All reimbursement forms must include support documentation, including but not
limited to copies of invoices, individual time sheets and travel logs that have been signed by the employee
and supervisor, salary registers or payrolls that include fringe benefits, hourly rates of pay, and signature
of the Grantee’s responsible financial person, cancelled checks and lease agreements. See the
Conservation Easement Contract Grantee Duties and Reporting Requirements document under
Attachment B for more details on payment provisions.
Eligible expenditures for payment must be within the effective period noted in the Contract.
Reimbursement may not be considered prior to the submission and final execution of the Contract.
All travel reimbursement shall be made in accordance with the current State rates, at the time of the
expenditure, and shall be made in accordance with the “State Budget Manual”
https://www.osbm.nc.gov/budget/budget-manual
All matching funds, including in-kind and cash, must be spent concurrently with funds provided by the
Contract. Both types of matching funds expended shall be accounted for on the monthly certified
invoices.
Indirect costs are not allowable expenditures under this Contract.
X. Fraud, Waste and Abuse
Grantee, including its employees, contractors, agents, interns, or any subrecipients, shall report
suspected fraud, waste and abuse activities related to any state employee, vendor or sub recipient of state
funds or state resources.
There are three methods for reporting suspected fraud, waste or abuse (FWA). Grantee can report
suspected FWA directly to the Agency’s Audit Services Division, to any member of the Agency’s
management team or through the FWA reporting website below.
N.C.G.S. 143-748 permits Audit Services to treat all information as confidential. However, if an
individual wishes to remain anonymous, reports can be submitted through the FWA reporting website:
https://www.ncagr.gov/internalaudit/ReportForm.htm
Under no circumstances should an individual attempt to personally conduct investigations or interviews
/interrogations related to any suspected FWA act.
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Investigation results will not be disclosed or discussed with anyone other than those who have a
legitimate need to know. This is important to avoid damaging the reputations of persons suspected but
subsequently found innocent of wrongful conduct.
It is the Agency’s policy that employees/contractors/sub recipients/interns will not suffer retaliation or
harassment for reporting in good faith any FWA concerns. The Agency encourages openness and will
support anyone who raises genuine concerns in good faith under this policy, even if they turn out to be
unsubstantiated.
XI. Contract Administrators:
All notices permitted or required to be given by one Party to the other and all questions about the
Contract from one Party to the other shall be addressed and delivered to the other Party’s Contract
Administrator. The name, post office address, street address, telephone number, fax number, and email
address of the Parties’ respective initial Contract Administrator are set out below. Either Party may
change the name, post office address, street address, telephone number, fax number, or email address of
its Contract Administrator by giving timely written notice to the other Party.
For the Agency:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Veronica Jamison, Office Manager Veronica Jamison, Office Manager
1001 Mail Service Center, Raleigh, NC 27699-
1001
2 W Edenton Street, Raleigh, NC 27601
Telephone: 919-707-3071
Email: veronica.jamison@ncagr.gov
Grants & Contracts General Email:
agr.grants@ncagr.gov
For the Grantee:
Grantee Contract Administrator- Mailing Address Grantee Principal Investigator or Key Personnel
Christian Hirni, Land Conservation Manager Name: Title:
Orange County Company Name:
PO Box 8181 Street Address:
Hillsborough, NC 27278 City: State: Zip:
Telephone: 919-245-2514 Telephone:
Email: chirni@orangecountync.gov Email:
XII. Supplementation of Expenditure of Public Funds:
The Grantee assures that funds received pursuant to this Contract shall be used only to supplement,
not to supplant, the total amount of federal, State, and local public funds that the Grantee otherwise
expends for activities involved with specialty services and related programs. Funds received under this
Contract shall be used to provide additional public funding for such services. The funds shall not be used
to reduce the Grantee's total expenditure of other public funds for such services.
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XIII. Disbursements:
As a condition of this Contract, the Grantee acknowledges and agrees to make disbursements in
accordance with the following requirements:
a. Will implement or already have implemented adequate internal controls over disbursements.
b. Pre-audit all invoices presented for payment to determine:
i. Validity and accuracy of payment
ii. Payment due date
iii. Adequacy of documentation supporting payment
iv. Legality of disbursement
b. Assure adequate control of signature stamps/plates.
c. Assure adequate control of negotiable instruments; and
d. Have procedures in place to ensure that account balance is solvent and to reconcile the account
monthly.
XI. Outsourcing:
The Grantee certifies that it has identified to the Agency all jobs related to the Contract that have been
outsourced to other countries, if any. Grantee further agrees that it will not outsource any such jobs during
the term of this Contract without providing prior notice to the Agency.
XIV. N.C.G.S. § 133-32 and Executive Order 24:
N.C.G.S. § 133-32 and Executive Order 24 prohibit the offer to, or acceptance by, any State employee
of any gift from anyone with a Contract with the State, or from any person seeking to do business with
the State. By execution of any response in this procurement or Contract, you attest, for your entire
organization and its employees or agents, that you are not aware that any such gift has been offered,
accepted, or promised by any employee of your organization.
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XV. Signature Warranty:
The undersigned represent and warrant that they are authorized to bind their principals to the terms of
this Contract.
IN WITNESS WHEREOF, the Grantee and the Agency execute this Contract in two (2) originals, one (1)
of which is retained by the Grantee and one (1) which is retained by the Agency. OR the Grantee and the
Agency execute this Contract as an electronic original, each party will be provided a fully executed copy
via electronic mail. It is required that each party retain a fully executed copy of this contract.
Grantee: _Orange County____________________________________________
Signature of Authorized Representative Date
Printed Name Title
Witness:
Signature Date
Printed Name Title
North Carolina Department of Agriculture and Consumer Services
Signature of Authorized Representative Date
N. David Smith, Chief Deputy Commissioner
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
County ManagerBonnie Hammersley
9/28/2022
Land Conservation Resource Manager
9/28/2022
Christian Hirni
a.Scope of Work and Map
b.ADFP Trust Fund Conservation Easement Contract Grantee Duties and Reporting Requirements
c.Line Item Budget with Narrative and Project Timeline
d. Conservation Easement Transfer of Entity
e.Survey Requirements and Checklist
f.Baseline Documentation Report Requirements and Checklist
g.Environmental Audit Requirements and Checklist
h.Appraisal Checklist
i.The Conservation Easement Content
j.Closing Agent Requirements for Easement Programs
k.ADFP Trust Fund Monitoring Policies
l.Option to Purchase an ADFP Trust Fund Agricultural Easement
Attachment B Contents for the Standard Conservation Easement Appraisal
Program:
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Scope of Work
The purpose of this contract is to place a perpetual agricultural conservation easement on
+/- 110 acres of the Poteat Family Farm in Orange County.
Landowner name(s): Peggy A Fuller
Physical address: 5211 Poteat Road Cedar Grove, NC 27231
Latitude and Longitude: 36.15937996077847, -79.20849541511986
Parcel Identification Number (PIN): 9837962756
Attached is a map of the proposed conservation easement:
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
UtUt
Ut
UtUt
UtUtPOTEAT RDMILL CREEK RDJ A KILLOUGH DRWAXSTAFF RD
SCNOBIA TAYLOR RD
QUANTUM LN
Legend
Roads
Streams
Access/ROW
Excluded
Farmstead Area
Easement Boundary
Tax Parcels
¶
0 400 800 1,200 1,600200 Feet
Poteat Family Farm (Fuller) Easement Aerial Map
Tract Information:
Landowner: Peggy FullerLat: 36' 09.51"Long: 79' 12.37"Date: 2/21/2021Image: 2017 Aerial PhotoCreated By: Christian HirniAcres: 111 (Farmstead ~2.5 Excluded ~ 5)
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
N.C. Department of Agriculture & Consumer Services
N.C. ADFP Trust Fund
Conservation Easement Contract Grantee Duties and Reporting Requirements
Approved 6/2022 1
1. The NCDA&CS ADFPTF conservation easement contract is a two-year contract. The
first contract year is to complete the conservation easement project, including recording
the conservation easement. The second contract year is reserved for the completion of the
conservation easement project due to documented hardships. The Grantee agrees to
record the conservation easement within the first year of the two-year contract following
the timeline below. Failure to follow the deliverable timeline is a breach of the contract,
and the Grantee must repay any grant funding received from the NCDA&CS ADFPTF. If
the Grantee fails to record an approved conservation easement according to the terms and
conditions of this contract within the contract period, the Grantee is responsible for
repaying all funds expended.
2. If the conservation easement is not recorded within the first 365 days of the two-year
contract, the Grantee must request a continuation of the project in writing to the Farmland
Preservation Director 60 days before the end of the first year of the contract (Day 305).
This request must provide proper documentation for the hardships that delayed
completing the grant project and a revised timeline to complete the conservation
easement project. All other required documents, including budget and progress reports,
must be current. Eligible hardships include:
a. Death of a landowner;
b. Severe illness or incapacitation of a landowner;
c. The Grantee has applied for federal funding and has not yet received funding
notification;
d. The Grantee has federal funds under contract and has not yet received approval to
release federal funds.
All other requests for continuing the conservation easement project shall be determined
on a case-by-case basis. If approved, the project may continue into the second year of the
contract. If denied, the Grantee must repay any grant funding from the NCDA&CS
ADFPTF. Note: Failure by the Grantee to initiate deliverables on the conservation
easement project, Grantee staff shortages or changes, and Grantee time management
issues are not acceptable hardships and will result in a breach of the contract, and the
Grantee must repay any grant funding received from the NCDA&CS ADFPTF.
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Required Grantee Deliverable Within the First Contractual Year
Deliverables (Documents)
Must be provided in the following order and submitted as a complete suite in Word or PDF
electronic format for ADFPTF review and approval.
Completion Date for
Documents Provided to the
Agency by the Grantee
Easement Parcel Identification Suite
• Preliminary Conservation Easement Survey, including GIS, per the ADFPTF
Survey Requirements and Checklist
• Preliminary Title Policy
• Preliminary Attorney's signed Title Opinion certifying title for a period of at least
sixty years
Within 180 days of the
beginning date of the grant
contract
Land Management Documents Suite
• Environmental Audit, including Hazardous Materials Checklist and Landowner
Interview, per the ADFPTF Environmental Audit Requirements and Checklist
• Certified Development Rights Appraisal, per the ADFPTF Conservation Easement
Appraisal Requirements and Checklist, dated within the contract period and dated
less than 365 days prior to closing. Supplemental appraisals, updated opinion
letters, or reaffirmation letters by the appraiser for the original appraisal are
acceptable if a closing occurs 365 days after issuance of the Certified Development
Rights Appraisal, provided the appraiser certifies the land value with an updated
effective date of valuation.
• Conservation Plan, if applicable
• Forestry Plan, if applicable
• Preliminary Baseline that includes applicable Conservation Plan and Forestry Plan,
Environmental Audit, and Conservation Easement Survey, per the ADFPTF
Baseline Documentation Report Requirements and Checklist
Within 210 days of the
beginning date of the grant
contract and no less than 60
days before the scheduled
conservation easement
recording date
Legal Conservation Document Suite
• Conservation Easement Survey in recordable format and approved by County
Review Officers
• Final Conservation Easement with applicable exhibits
• Preliminary HUD Statement
• Title Commitment
• Signed Subordination Agreement, if applicable
• Final Baseline that includes applicable Conservation Plan and Forestry Plan,
Environmental Audit, and Conservation Easement Survey, per the ADFPTF
Baseline Documentation Report Requirements and Checklist
Within 240 days of the
beginning date of the grant
contract and no less than 30
days before the scheduled
conservation easement
recording date
Set Target Date for Easement Closing
• NCDA&CS Legal Affairs must approve all Legal Conservation Document Suite
documents
• Approved Conservation Easement Closing Check Request form
Within 270 days of the
beginning date of the grant
contract, and shall be no less
than 30 days before the
contract end date.
Final Legal Conservation Document Suite
• Recorded Conservation Easement
• Recorded Survey
• Final Title Opinion signed by the closing attorney
• Final Title Policy
• Recorded Subordination Agreement, if applicable
• Signed HUD Statement
• Signed Baseline Documentation Report
Due within 20 working days
(28 calendar days) following
the recording date of the
conservation easement
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3. The Grantee shall provide the Agency with progress reports, both financial and
programmatic. The following is based upon the Agency contract with the Grantee being
two years in time.
For grant awards of less than $250,000, reports are due semi-annually. Refer to the table
below for the reporting period and due dates for progress and budget reports:
Contract Year Reporting Period Report Due Dates
Year 1 October 1 – March 31 April 10
Year 1 April 1 – September 30 October 10
Year 2 October 1 – March 31 April 10
Year 2 April 1 – September 30 October 10
For grant awards of $250,000 or more, reports are due quarterly. Refer to the table below
for the reporting period and due dates for progress and budget reports:
Contract Year Reporting Period Report Due Dates
Year 1 October 1 – December 31 January 10
Year 1 January 1 – March 31 April 10
Year 1 April 1 – June 30 July 10
Year 1 July 1 – September 30 October 10
Year 2 October 1 – December 31 January 10
Year 2 January 1 – March 31 April 10
Year 2 April 1 – June 30 July 10
Year 2 July 1 – September 30 October 10
In-kind and cash match shall be a part of the required financial reports, and
documentation of the reported match shall be included with the reports. Documents shall
be in the form of individual timesheets that each employee has signed and approved by
the appropriate supervisor, travel logs and invoices for in-kind match, copies of checks,
bank deposits, and fund transfers for cash match. Other types of documents may be
acceptable with the approval of the Agency Manager.
This grant contract is for the below-marked amount:
☒ Less than $250,000
☐ $250,000 or more
4. The Grantee will use the selected easement template unless the exception category has
been designated and approved by the Agency. The selection of the appropriate template is
based on partnership funding used to secure the conservation easement. Unless clearly
delineated in the proposed conservation easement map, the landowner waives the rights
of creation of no more than three lots pursuant to N.C.G.S. 106-744(b)(1); therefore, no
lots shall be created in the easement area. The easement templates are downloadable at
www.ncadfp.org:
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Approved 6/2022 4
☐ADFPTF Perpetual Template Easement
☐ADFPTF Term Template Easement
☒ADFPTF-USDA Template Easement
☐ADFPTF-USDA-USAF Template Easement
☐ADFPTF-USDA-Navy Template Easement
☐ADFPTF-USDA-Army Template Easement
☐ADFPTF-USDA-County Template Easement
☐ADFPTF-USAF Template Easement
☐ADFPTF-Navy Template Easement
☐ADFPTF-Army Template Easement
☐ADFPTF-County Template Easement
☐ Exception, including the creation of no more than three lots pursuant to N.C.G.S.
106-744(b)(1). (Copy of the revised conservation easement language must be
attached hereto as an amendment to the NCDA&CS ADFPTF contract at the time of
approval)
The Agency legal counsel and Farmland Preservation Director must approve additions,
omissions, or modifications of said template. The final "Conservation Easement" must
meet with Agency approval to remain eligible for funding.
5. The Grantee shall provide the Agency with the appropriate reimbursement request
(downloadable at www.ncadfp.org) and required documentation of performance and
expenditures for associated grant reimbursement. The Agency shall make payments to the
Grantee on the following guidance:
a. No more than $25,000 if the grant award is $27,778 or greater and up to 90% of
the grant if the award is less than $27,778 before the recording of the
"Conservation Easement."
b. All payment requests must document the purpose of using grant funds and be
within the approved amounts designated in the contract grant budget.
c. At the time of a properly recorded "Conservation Easement," the Agency shall
pay the Grantee no more than 90% of the awarded grant amount.
d. The Agency shall decrease the contract award amount based on the current
conservation easement appraisal, if applicable.
e. The Grantee shall ensure that 110 acres are placed under an agricultural easement
with no more than a 5% variance in recorded easement acreage without the prior
written approval of the Agency.
i. If the variance is greater than 5% of the contracted acres and is greater
than the acres listed above, the additional acreage will be approved under
one of the following scenarios:
1. The additional acres are included in the original parcels, and the
variance is due to the Conservation Easement Survey updates.
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2. The additional acres are parcels or areas within the original parcels
under the same ownership as the original parcels, are in working
lands use, and are within, adjacent, or contiguous to the original
parcels.
ii. If the variance is greater than 5% of the contracted acres and is less than
the acres listed above, the grant funds for conservation easement purchase
will be reduced proportionally based on the new acreage.
f. The division of the funds used to purchase the agricultural easement from
matching resources and Agency resources must be maintained, as noted in the
grant contract budget. The Grantee may request the Agency for an exception to
the division of funds if the Agency is the only entity providing easement funding.
g. For the Standard Conservation Easement Appraisal Program, the Agency
easement purchase shall not exceed 50% of the appraised easement value. If the
Agency is the only grantor of funds used to secure the conservation easement
recording, the Grantee may request in writing with sound reasoning for the
Agency payment to exceed 50% of the appraised easement purchase value.
h. For the Present-Use Value (PUV) Conservation Easement Program, the Agency
easement purchase shall not exceed 75% of the easement value as determined by
the Conservation Easement Value Payout formula.
i. At no time shall the total payment of grant funding exceed the grant contract
value.
j. All Grantee payments must have receipts of expenditures to verify the use of
funding per contracted purposes.
k. The Agency shall make the payment within 60 days of any grant reimbursement
request by the Grantee with approved documentation.
6. The Grantee will use the selected conservation easement purchase funding program:
☒ Standard Conservation Easement Appraisal Program:
The Certified Development Rights Appraisal must be completed per the ADFPTF
Conservation Easement Appraisal Requirements and Checklist based on the funding
sources for the easement purchase. Final conservation easement values must be
determined by a Certified Development Rights Appraisal dated within the contract
period and dated less than 365 days prior to closing. Supplemental appraisals, updated
opinion letters, or reaffirmation letters by the appraiser for the original appraisal are
acceptable if a closing occurs 365 days after issuance of the Certified Development
Rights Appraisal, provided the appraiser certifies the land value with an updated
effective date of valuation.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 6/2022 6
☐ Present-Use Value (PUV) Conservation Easement Program
Select one of the following:
☐ Perpetual Conservation Easement:
• 75% of the conservation easement value as determined by the Final
Conservation Easement Value Payout formula in the PUV
Conservation Easement Program Worksheet attached in this
contract.
☐ 50-Year Term Conservation Easement:
• 60% of the conservation easement value as determined by the Final
Conservation Easement Value Payout formula in the PUV
Conservation Easement Program Worksheet attached in this
contract.
7. The conservation easement closing payment request may be submitted in writing using
the Easement Closing Check Request form by the Grantee 30 days before the set closing
date, provided the following items have been achieved:
a. All closing documents (conservation easement, HUD statement, title
commitment, and subordination agreement if required) have been reviewed and
approved by ADFPTF and NCDA&CS legal staff.
b. The Grantee is in "Green" status based on the ADFP Trust Fund Grantee
Eligibility Classification system. This status requires all progress/budget reports,
monitoring reports, audit reports, and other reporting documents to be current
with the Agency.
c. The Grantee has followed the contractually-obligated work schedule as detailed in
the grant contract. If Grantee fails to maintain the contractual agreement between
NCDA&CS and the Grantee, NCDA&CS ADFPTF shall consider additional
measures to ensure Grantee follows department policies and contract procedures.
d. The proposed conservation easement closing date shall be no less than 30 days
before the contract end date. This timeline eliminates the risk of losing grant
funds due to the contract's expiration.
e. All involved parties, including ADFPTF, Grantee, landowners, and all funding
partners with a financial interest in the conservation easement, will confirm the
closing date.
f. The closing check will be submitted to the closing attorney named in the grant
contract, provided all required information provided by the Grantee is complete
approved by ADFPTF and NCDA&CS legal staff.
g. If a contract is at risk of not being completed, NCDA&CS may provide
alternatives to reduce that risk, including revisions of the holdback provisions or
the payment delivery options for services rendered by contractual arrangement.
8. The Grantee shall also submit a final grant report. In the final report, the Grantee shall
provide all budget/progress reports, the final request for payment, and an accounting of
the final match claimed by the Grantee to fulfill the match requirement mandated under
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 6/2022 7
N.C.G.S. 106-744(c1)(1). Grant contract budgeting and payments shall hold-back 10%
on all line items until ADFPTF receives all required reports and documentation. The full
ADFPTF easement funding allocated for easement purchase may be submitted at closing,
provided the closing attorney holds the 10% in escrow until all recorded documents and
reports, including the recorded conservation easement, recorded survey, final title opinion
signed by the closing attorney, final title policy, recorded subordination agreement (if
applicable), signed HUD statement, and signed baseline documentation report, have been
received and approved by NCDA&CS. The final report and all invoices are due within 20
working days (28 calendar days) following the closing and recording date of the
conservation easement. If the Grantee fails to provide the final report and required
supporting documentation within the required period, the Grantee may not receive
reimbursement and shall be considered ineligible for reimbursement.
9. Grantees may request a lowering of the hold-back percentage provided the following
criteria have been provided:
a. An official request to the Commissioner of Agriculture with reasoning why the
10% hold-back is an undue burden and a proposed revised hold-back percentage.
b. The Grantee has no record of infractions or late reports for ADFPTF within the
last two years from the revised hold-back percentage request date.
c. If an infraction or late report occurs during the grant contract period, the hold-
back percentage shall be reinstated at 10% or higher as a corrective measure.
10. If the Grantee has not provided all closing documents and progress/budget reports 60
days before the contract's end date, the Grantee may request a contract extension of the
grant to the Farmland Preservation Director. This request must include reasons for not
completing the grant and following the timetable of scheduled activities to complete the
grant project. This request must provide proper documentation for the hardships that
delayed completing the grant project and a revised timeline to complete the conservation
easement project. All other required documents, including budget and progress reports,
must be current. Eligible hardships include:
a. Death of a landowner;
b. Severe illness or incapacitation of a landowner;
c. The Grantee has applied for federal funding and has not yet received funding
notification;
d. The Grantee has federal funds under contract and has not yet received approval to
release federal funds.
All other requests for continuing the conservation easement project shall be determined
on a case-by-case basis. If approved, the project may continue beyond the original
contract end date. If denied, the Grantee must repay any grant funding from the
NCDA&CS ADFPTF. Note: Failure by the Grantee to initiate deliverables on the
conservation easement project, Grantee staff shortages or changes, and Grantee time
management issues are not acceptable hardships and will result in a breach of the
contract, and the Grantee must repay any grant funding received from the NCDA&CS
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 6/2022 8
ADFPTF. All other grant contract extension requests shall follow the protocols outlined
in the NCDA&CS ADFPTF grant contract.
11. If the Grantee has not provided all closing documents and progress/budget reports 30
days before the contract's end date, the Grantee may request an emergency contract
extension of the grant to the Commissioner of Agriculture. This request must include
reasons for not completing the grant and following the timetable of scheduled activities to
complete the grant project. All other grant contract extension requests shall follow the
protocols outlined in the NCDA&CS ADFPTF grant contract.
12. After recording the "Conservation Easement" in the Register of Deeds Office, the
Grantee shall annually notify the landowner and conduct a monitoring visit to the
property to ensure that the easement agreement is being upheld. If structures are
permitted under the easement, the Grantee shall review plans and monitor construction
for compliance with the plans. Grantee monitoring shall be completed in accordance with
the Agency "Conservation Easement Monitoring Policy and Guidelines" and
amendments thereto. The Grantee shall electronically complete and submit to the Agency
the "Grantee Monitoring Report – Perpetual or Term Easement" to report its annual
monitoring findings. The "Grantee Monitoring Report – Perpetual or Term Easement" is
accessed through a portal at www.ncadfp.org. The first "Grantee Monitoring Report –
Perpetual or Term Easement" is due by December 31 of the following calendar year after
the "Conservation Easement" recording and annually thereafter.
13. The Grantee shall complete all reports in a prescribed format, which the Agency shall
provide. Reports and required documentation must be up-to-date for the Grantee to
receive payments.
14. All publicity and printed material regarding projects or activities supported in whole or in
part by this shall contain the following language: "The project received support from the
NCDA&CS ADFP Trust Fund." The NCDA&CS ADFP Trust Fund logo (digital
versions of which can be downloaded from the Agency website at www.ncadfp.org) shall
be displayed in all the Grantee's publicity and printed materials relating to this grant.
15. The Grantee will submit all reports and requested documents electronically unless
instructed differently by Agency staff. Reports and documents may be submitted by
email to ncadfp@ncagr.gov.
16. Noncompliance with Grantee duties will result in an immediate suspension of existing
Agency grant funding. The Grantee shall be ineligible for further Agency grants until the
noncompliance is corrected and the Agency has acknowledged the correction and is in
good standing. The Agency shall use the following guidance in placing a Grantee in
noncompliance:
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 6/2022 9
Classification Grant Contract / Monitoring Status Eligibility Status
Green All budget, progress, and
monitoring reports are on file and
up to date. No incidents noted in
the Suspension of Funding List or
other department or state grant
tracking reports.
No restrictions.
Yellow There is a late budget, progress, or
monitoring report in the previous
reporting period. No incidents
noted in the Suspension of Funding
List or other department or state
grant tracking reports.
All grant payments and proposed
grant contracts frozen until
reports are filed and approved.
Review of proposed grant
applications and requests may
continue, but no grant contract
may be offered.
Red There are late budget, progress, or
monitoring reports for two
reporting periods. No incidents
noted in the Suspension of Funding
List or other department or state
grant tracking reports.
All grant payments and proposed
grant contracts frozen until
reports are filed and approved.
Review of proposed grant
applications and requests are
discontinued, and no grant
contract may be offered.
Black There are late budget, progress, or
monitoring reports for three or
more reporting periods or the
Grantee is found as noncompliant
in the Suspension of Funding List
or other department or state grant
tracking reports.
All grant payments frozen.
Grantee is not eligible for an
ADFP Trust Fund grant
application or contract.
17. The grant contract budget and project timeline are as attached:
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Conservation Easement Budget Worksheet
- Poteat Family Farm
FINAL 5/11/22
Line Item ADFP Trust
Fund
90 Percent
Maximum
Projected USDA
NRCS
ALE/RCPP
Match
Projected
Military Match
Projected
Nonprofit Match
Projected
Landowner
Donation
Projected
County Match
Projected Other
Match Totals
Appraisal -$
Attorney Fees 6,500.00$ 5,850.00$ 6,500.00$
Baseline Documentation Report 2,900.00$ 2,610.00$ 2,900.00$
Closing Costs (Recording Fee, Title Insurance)1,300.00$ 1,170.00$ 1,300.00$
Easement Purchase 166,645.15$ 149,980.64$ 238,064.50$ 71,419.35$ 476,129.00$
Environmental Assessment / Audit 2,200.00$ 1,980.00$ 2,200.00$
Personnel / Administrative -$
Stewardship Endowment -$ -$
Survey 10,100.00$ 9,090.00$ 10,100.00$
Travel -$
Totals 189,645.15$ 170,680.64$ 238,064.50$ -$ -$ 71,419.35$ -$ -$ 499,129.00$
Easement Size (Acres)110.000 115.500 104.500
Line Item
ADFP Trust
Fund Grant
Expenditures
ADFP Trust
Fund Grant
Balance
Confirmed
USDA NRCS
ALE/RCPP
Match
Confirmed
Military Match
Confirmed
Nonprofit Match
Confirmed
Landowner
Donation
Confirmed
County Match
Confirmed
Other Match Totals
Appraisal -$
Attorney Fees 6,500.00$ -$
Baseline Documentation Report 2,900.00$ -$
Closing Costs (Recording Fee, Title Insurance)1,300.00$ -$
Easement Purchase 166,645.15$ 166,645.15$
Environmental Assessment / Audit 2,200.00$ -$
Personnel / Administrative -$
Stewardship Endowment -$ -$
Survey 10,100.00$ -$
Travel -$
Totals -$ 189,645.15$ -$ -$ -$ -$ -$ -$ 166,645.15$
Easement Size (Acres) 5 Percent Variance +/-
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Project Timeline
Quarter (Grant
Year 1)Tasks/Goals Grant Funding to
be Used
Matching Funds
(cash or in-kind)
to be Used
Total Funding
to be Used
October 1, 2022 -
December 31,
2022
Personnel and Administrative Duties
$ -
January 1, 2023-
March 31, 2023
Survey, Draft Easement Language,
Baseline, Applicable Conservation and
Forestry Plans, Environmental Audit,
Preliminary Title Opinion and Policy
$ 15,200.00 $ 15,200.00
April 1, 2023 -
June 30, 2023
Certified Appraisal, Set target date for
easement closing
$ -
July 1, 2023 -
September 30,
2023
Request Funds for closing, Preliminary
HUD, Record Easement, Record Survey,
Final Title Opinion and Policy, Final
Payment Request, Legal Fees, Closing
Costs $ 174,445.15 $ 309,483.85 $ 483,929.00
Grant Year 1
Subtotals $ 189,645.15 $ 309,483.85 $ 499,129.00
Quarter (Grant
Year 2)Tasks/Goals Grant Funding to
be Used
Matching Funds
(cash or in-kind)
to be Used
Total Funding
to be Used
October 1, 2023 -
December 31,
2023 $ -
January 1, 2024-
March 31, 2024 $ -
April 1, 2024 -
June 30, 2024 $ -
July 1, 2024 -
September 30,
2024 $ -
Grant Year 2
Subtotals $ - $ - $ -
Entire Grant
Period Totals $ 189,645.15 $ 309,483.85 $ 499,129.00
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
County government
County soil and water conservation district
Nonprofit conservation organization
N.C. Department of Agriculture & Consumer Services
N.C. ADFP Trust Fund
Conservation Easement Transfer of Entity
Approved 6/2022
The Grantee will be the Easement Holder. In the event the Grantee desires to transfer the
easement to a qualified entity herein below described, the ADFP Trust Fund must be notified in
writing immediately. This transfer request must be approved by the Farmland Preservation
Division Director no later than 60 days before the scheduled closing date.
Qualified entities include county governments, county soil and water conservation districts, or
nonprofit conservation organizations as defined by 02 NCAC 58 .0103 (8).
The Grantee will continue to fulfill the Grantee’s duties and responsibilities subject to the terms
and conditions of the contract. This includes, but is not limited to, submitting budget and
progress reports, final closing documents, and requests for payment. Upon recording, the
Grantee will give all investments and interests in the easement project to the Easement Holder.
Upon transfer and recording the easement, the Easement Holder will assume all responsibilities
for monitoring the easement and submitting annual monitoring reports as outlined in the
monitoring policy in this contract.
If the Grantee intends to transfer the easement to another entity, please include the name of the
entity and contact information:
Entity Name:
Entity Type:
Contact Name:
Contact Email:
Contact Phone:
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
N.C. Department of Agriculture & Consumer Services
N.C. ADFP Trust Fund
Conservation Easement Survey Requirements and Checklist
Approved 07/2022 1
1. The total surveyed acres referenced in the survey title block must be the same in the
conservation easement and all documents on the easement deliverables list, including,
but not limited to, the title policy, title opinion, environmental audit, certified
development rights appraisal, conservation plan, forestry plan, baseline documentation
report, conservation easement language, HUD statement, title commitment, and
subordination agreement.
2. The total survey acres contained in the survey title block must be at least to the
hundredth decimal point.
3. The minimum standards of specification to be observed in the practice of Land
Surveying for Rural and Farmland surveys (Class C) in the State of North Carolina are:
The linear error of closure shall not exceed one (1) foot per 5,000 feet of the perimeter
of the tract of land (1:5,000).
For special circumstances when a survey is needed that is not a Class C survey, the
following minimum standards of specification are to be observed:
a. Urban Land Surveys (Class A) – The linear error of closure shall not exceed one
(1) foot per 10,000 feet of the perimeter of the tract of land (1:10,000).
b. Suburban Land Surveys (Class B) – The linear error of closure shall not exceed
one (1) foot per 7,500 feet of the perimeter of the tract of land (1:7,500).
4. All surveys shall be tied to the North Carolina State Plane Coordinate System
NAD83(2011) Feet per the Standards of Practice for Land Surveying in North Carolina,
Title 21 NCAC 56.1602(g) and Title 21 NCAC 56.1607, regardless if the property is
not within 2,000 feet of a geodetic monument.
5. The survey must meet all current N.C. recording standards, pursuant to G.S. 47-30, and,
if applicable, any recording standards for the county where the property is located.
6. The stated linear error of closure shall be computed by latitudes and departures, and the
closure shall be stated before balancing.
7. A map shall be prepared of the tracts surveyed and shall be properly and accurately
drawn, revealing all the information developed by and during the survey. The size of the
map shall be such that all details can be shown clearly.
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Approved 07/2022 2
8. The certification to be shown on the map shall be in accordance with the example as set
forth in the “Manual of Practice for Land Surveying in North Carolina.”
9. The title block of each map shall contain the type of easement (ADFPTF, ALE,
military, etc.), name of the landowner(s), location, date surveyed, a scale of the
drawing, name, address, registration number and seal of the surveyor.
10. The North arrow shall be accurately positioned and designated as N.C. Grid north.
11. The total acres of land owned by the landowner(s) shall be indicated on the survey. The
survey shall indicate where the easement area sits in relation to the entire tract owned
by the landowner.
12. The total acres under the Conservation Easement shall be broken down as occurs for:
a. Full easement acres under restrictions.
b. Farmstead (area included in the easement for farm buildings, storage, shops, etc.)
c. Residential Lots (ADFP Only Easement) Landowner may elect up to three lots
located in the easement area that include but are not limited to homesites and
existing residences and are subject to limited restrictions regarding residential
living.
13. Property corners shall be adequately identified, marked, and labeled.
14. Two corners of the survey shall have N.C. Grid coordinates (using the current N.C. Grid
datum at the time of survey) and be shown on the survey plat.
15. Clear markings of easement boundaries shall be indicated with dark or thicker lines,
shading, etc., and clear points of a boundary line change.
16. Courses and distances of boundary lines and other lines shall be lettered neatly
thereupon in feet and hundredths of a foot and in degrees, minutes, and seconds, if
available.
17. The names of all adjoining owners or utilities bordering on or crossing the premises or
tract, the names of the principal and adjoining streams, the names and numbers of roads
and highways, easements, ingress and egress, ponds, lake boundaries, and other
pertinent details shall be indicated, defined and located on the map if they are visible
and cross or form a boundary of the property being surveyed. All control corners,
coordinated markers, and permanent markers or monuments on adjoining properties
shall be identified and located on the map.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 07/2022 3
18. Where a boundary of a tract is formed by a curved line, the actual survey data from the
point of curvature of the curve to the point of tangency shall be shown on the face of the
map. Where a boundary of a tract is formed by a creek or river, offset traverse shall be
run and offset points shown on map with reference to boundary points in center of
stream as called for in the deed.
19. All easements and encroachments on the property being surveyed shall be accurately
located and clearly indicated on the map.
20. The surveyor shall furnish to the ADFPTF a written description for each tract surveyed.
21. The surveyor agrees to fully complete all the surveys herein set out and to furnish the
ADFPTF an original copy of each survey together with a written description.
Additionally, the surveyor agrees to provide, by e-mail, a DWG file or shapefile before
payment is made. The digital file must be tied to the N.C. State Plane Coordinate
System (NAD 83) Grid (georeferenced).
22. The AutoCAD or GIS shapefile should contain a polygon clearly identifying the
Boundaries of the Conservation Easement. This requirement is an addition to any line
work.
23. Legal access from the easement area to the state-maintained road must be shown on the
survey.
24. The survey must show all access easements over and across the landowner’s property to
adjoining tracts. If the easement area is less than the landowner’s entire tract of land, the
survey must show access to the landowner’s remaining parcel of land.
25. Legal access is required for areas of the parcel excluded from the conservation
easement. Access easements for ingress, egress, and regress across the conservation
easement must be clearly identified on the survey and included in the legal description.
Access easements must be a minimum of 20 feet in width unless a larger width is
required by the county zoning and planning office, local ordinances, or applicable
regulations.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
N.C. Department of Agriculture & Consumer Services
N.C. ADFP Trust Fund
Baseline Documentation Report Requirements and Checklist
Approved 11/2021 1
Baseline documentation reports (BDRs) are important in establishing the condition and
characteristics of the land parcel at the time of easement closing and serve as the basis for
easement management and monitoring. BDRs also help document how the characteristics of the
land support the purposes of the conservation easement and help to justify the expenditure of
public funds.
BDRs include narrations, pictures, and maps to provide a complete understanding of a given
parcel. It is recognized no two land parcels are the same, and there is an expected level of
variation in the contents of BDRs. However, the following requirements, where applicable, are
considered a minimum that should be found in all BDRs.
*Note: Maps required for each section are emphasized with italics.
I. Title Page: Include the title of the easement as stated in the ADFP Trust Fund contract,
(e.g., Rocky Ridge Farm Easement), ADFP Trust Fund tracking number, NCDA&CS
contract number, date of the BDR and date of certification, and name, title, and affiliation
of the BDR author(s).
II. Table of Contents: Include all section headers, maps, and photographic documentation,
with page numbers.
III. Purpose of the Conservation Easement: Briefly summarize the purposes as found in
the easement document.
IV. Landowner Contact Information: Names, addresses, email, and phone numbers, etc. of
landowners. May also include names, email, and phone numbers of any land managers,
gatekeepers, etc. as appropriate.
V. Property Background:
a. Include a paragraph summarizing the property, including the following information:
i. Total parcel acreage and easement acreage (if different).
ii. General location in the county.
iii. Inclusion in a Voluntary Agricultural District (VAD) or Enhanced Voluntary
District (EVAD) (if applicable).
iv. History of the parcel, if available, including farming operation and land uses.
v. Current land uses.
vi. Environmental Audit (EA) or Environmental Site Assessment (ESA) in
accordance with the N.C. ADFP Trust Fund Environmental Audit (EA)
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 11/2021 2
Requirements and Checklist.
vii. Any other significant features identified by the grantee or landowner.
b. Aerial or satellite imagery of the property with the easement boundary map overlay.
Include callouts of significant features, including farmsteads and building envelopes,
and legal access (ingress/egress) from a publicly maintained road. The features in the
map must be tied to the N.C. State Plane Coordinate System (NAD 83) Grid
(georeferenced).
c. Location and Physical Setting – General description of the landscape and farming
operations in the general area, including adjacent land.
i. Include imagery of area within 5 miles of the easement property, showing the
specific location of the parcel. Include all other easements and protected lands
in proximity (if applicable).
VI. Impervious Surfaces and Existing Human Modifications: List each permanent
structure and other impervious surfaces, showing length/width measurement. Include a
calculation of the total extent of impervious structures, the maximum allowable
impervious surface area within the easement (2% of total acreage) converted to square
feet and acres, and remaining allowable surface area within the easement converted to
square feet and acres.
a. Map with labels for all human modifications to the property with the following
labeled:
i. structures, roads, trails, dikes and impoundments, wells, fences, utility lines and
corridors, cemeteries, trash piles/dumps, etc. within the easement area.
The following is an example of adequate documentation for impervious structures:
The farmstead envelope consists of several farm-related structures and the primary
residence. The residence is a 1,970 square feet brick ranch. The creamery building has
been restored from the original store building. Two open-sided barns are located within
this area.
Photo points 1-7, 15-18, 33, 34. Modifications in this area include the
following:
• Barns (2)
• Well (1)
• Creamery Building
• Residence
• Silage storage areas (2)
• Concrete Pad
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 11/2021 3
The dimensions and approximate impervious surface for each of these areas are listed
in the table below:
Impervious
surface item Photo point Dimensions Impervious
surface (sq. ft.)
Impervious
surface (acres)
Barn 1, storage
shed 17 40’ x 35’ 1,400 0.032
Barn 2 18 12’ x 24’ 288 0.007
Well 1 10’ x 6' 60 0.001
Creamer
building 2 50’ X 40’ 2,000 0.046
Residence 34A 2,240 0.051
Silo storage
areas 5 80’ x 200' 16,000 0.367
Concrete pad 16 27’ x 24’ 648 0.015
Total 22,636 0.519
The easement allows for a maximum impervious surface area of 2% or 85,987.20 sq.
ft. (1.97 acres). Based on the above approximations, a remaining 63,351.44 sq. ft.
(1.45 acres) of impervious surface is allowed under the easement.
VII. Existing Land Use and Management:
a. Include the landowner’s objectives for the management of the parcel and current
agricultural practices.
b. Statements on the general condition and management of the following key areas:
i. Pasture and cropland – acreage and percent of land use in the easement (if
applicable). Include a summary of the existing conservation plan and practices
and the adequacy in achieving management goals.
1. Include a copy of the current USDA-NRCS or local Soil and Water
Conservation District conservation plan (required for crop or pasture
land).
ii. Forest and woodlands – acreage and percent of land use in the easement (if
applicable). Include current forestry management plan and practices (e.g.,
managed for maximum timber production or let stand as a natural area for
wildlife habitat).
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 11/2021 4
1. Include a copy of the current forestry management plan developed by
the NC Forest Service or a registered private forester (required for 20
or more acres of forestry).
iii. Other significant land uses – acreage and percent of land use in the easement of
each (if applicable). Provide general descriptions of uses (e.g., irrigation pond,
canals, etc.).
VIII. Land Parcel Topography and Soil Types:
a. Topography: Short paragraph summarizing the general topography of the easement
area, highlighting any extremes.
i. Contour map (overlay of an aerial/satellite view, if possible) of the property, or
the best available map showing the property’s elevation profile.
b. Soils: The protection of the soil resource base and the sustainable production of food
and fiber are essential purposes of conservation easements. Therefore, explaining the
soil resources on the easement property is very important. The BDR should include a
discussion of all soil types within the land parcel, including a description of each. All
soil types and descriptions are available through USDA-NRCS. The following is
provided as an example:
There are six soil units mapped on the parcel, as shown on the General Soils Map.
Four of the six soils are classified as prime farmland or farmland of statewide
importance.
The soil types are as follows: (Note: Only one soil type is shown as an example. All
soils shown on the soils map should be listed.)
Georgeville silty clay loam, 2-6% slopes.
GeB2 — Georgeville silty clay loam, 2-6% slopes. Georgeville soils are very deep,
well-drained, and moderately permeable. Parent material for the soil is weathered
fine-grained metavolcanic rocks. It is a moderately eroded soil found on uplands with
elevations ranging from 300-750 feet. It is a well-drained soil with moderate available
water capacity. Georgeville is considered a prime farmland soil.
c. Utilize the following table format to list all soils found within the easement area:
Soil Type Name Acreage % of Total
Prime or
Statewide
Importance?
Y/N
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 11/2021 5
i. Accompanying USDA-NRCS soils map (available through USDA Web Soil
Survey) with appropriate labels.
IX. Descriptions of the Property’s Natural Features:
a. Forest/Woodland: General description of forest types within the easement area (e.g.,
hardwood, pine, ornamental, etc.).
i. Accompanying stand map or reference map with labeled stands (if applicable).
b. Aquatic Features: List and description of all significant aquatic features (streams
water bodies, wetlands, major waterways, etc.). Provide a brief narrative regarding
how the easement positively impacts those features.
i. Accompanying labeled aquatic map (overlay of an aerial/satellite view, if
possible).
c. Wildlife and Natural Communities (Optional): List and describe all wildlife habitat
and natural communities of significance found within the easement area (e.g.,
common wildlife, rare and endangered species, etc.).
i. Accompanying map of wildlife and natural communities.
X. Archeological and Historical Features: List and description of all historical features of
significance, including cemeteries (if applicable).
a. Labeled map of archeological and historical features on the property (if applicable).
XI. Photographic Documentation: Provide a photographic record of the protected property.
This section must include photos that are easily replicable from roads, permanent
features, or using GPS waypoints. Photographs are recommended to include timestamps
and latitude and longitude.
a. Photographs must be taken at regular intervals along the property line that capture the
property in its entirety, including photos from each property corner.
b. Photographs of each permanent structure within each building envelope or farmstead
area.
c. If not included above, all other impervious surfaces in the easement.
d. Photographs of any other human modifications to the property (including roads,
ditches, dams, etc.).
e. General landscape pictures that are representative of the easement area.
f. Photographic index with descriptions of each photo (photos must have descriptions
next to them).
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 11/2021 6
g. Photographic documentation map with photos numbered. Include a compass
direction to note the direction the photo was taken.
XII. Additional Maps: Accompanying descriptions are optional:
a. U.S. Geological Survey (USGS) U.S. Topo or 7.5-minute quadrangle topo map.
b. General hydrology map.
XIII. Signature Page (Acknowledgement of Property Condition Form): Signatures of
acknowledgment that the landowner(s) agree with the BDR and the condition of the
property at the time the easement is placed on the property. A final review, with any
applicable updates, of the BDR must be approved 30 business days before closing. No
edits are permitted within five (5) business days before closing. The BDR must be
signed at closing by an authorized signatory of the grantee organization and all
landowners listed in the easement.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 11/2021 7
Baseline Documentation Report Checklist
Introduction and Contacts
Title Page: Include the title of the easement as stated in the ADFP Trust Fund
contract, (e.g., Rocky Ridge Farm Easement), ADFP Trust Fund tracking number,
NCDA&CS contract number, date of the BDR and date of certification, and name,
title, and affiliation of the BDR author(s).
Table of Contents: Include all section headers, maps, and photographic
documentation, with page numbers.
Purpose of the Conservation Easement: Briefly summarize the purposes as found in
the easement document.
Landowner Contact Information: Names, addresses, email, and phone numbers, etc. of
landowners. May also include names, email, and phone numbers of any land
managers, gatekeepers, etc. as appropriate.
Property Background
Total parcel acreage and easement acreage (if different).
General location in the county.
Inclusion in a Voluntary Agricultural District (VAD) or Enhanced Voluntary District
(EVAD) (if applicable).
History of the parcel, if available, including farming operation and land uses.
Current land uses.
Environmental Audit (EA) or Environmental Site Assessment (ESA) in accordance
with the N.C. ADFP Trust Fund Environmental Audit (EA) Requirements and
Checklist.
Any other significant features identified by the grantee or landowner.
Map: Aerial or satellite imagery of the property with the easement boundary map
overlay. Include callouts of significant features, including farmsteads and building
envelopes, and legal access (ingress/egress) from a publicly maintained road. The
features in the map must be tied to the N.C. State Plane Coordinate System (NAD 83)
Grid (georeferenced).
Location and Physical Setting – General description of the landscape and farming
operations in the general area, including adjacent land.
Map: Imagery of area within 5 miles of the easement property, showing the specific
location of the parcel. Include all other easements and protected lands in proximity (if
applicable).
Impervious Surfaces and Existing Human Modifications
List of each permanent structure and other impervious surfaces, showing
length/width measurement.
Map: All human modifications to the property with the following labeled:
structures, roads, trails, dikes and impoundments, wells, fences, utility lines and
corridors, cemeteries, trash piles/dumps, etc. within the easement area.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
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Calculation of the total extent of impervious structures.
Calculation of the maximum allowable impervious surface area within the
easement (2% of total acreage) converted to square feet and acres.
Calculation of the remaining allowable surface area within the easement converted
to square feet and acres.
Existing Land Use and Management
Landowner’s objectives for the management of the parcel and current agricultural
practices.
Statement on the general condition and management of pasture and cropland.
Include acreage and percent of land use in the easement (if applicable). Include a
summary of the existing conservation plan and practices and the adequacy in
achieving management goals.
Include a copy of the current USDA-NRCS or local Soil and Water Conservation
District conservation plan (required for crop or pasture land).
Statement on the general condition and management of forest and woodlands.
Include acreage and percent of land use in the easement (if applicable). Include
current forestry management plan and practices (e.g., managed for maximum
timber production or let stand as a natural area for wildlife habitat).
Include a copy of the current forestry management plan developed by the NC
Forest Service or a registered private forester (required for 20 or more acres of
forestry).
Statement on the general condition and management of other significant land uses.
Include acreage and percent of land use in the easement of each (if applicable).
Provide general descriptions of uses (e.g., irrigation pond, canals, etc.).
Land Parcel Topography and Soil Types
A short paragraph summarizing the general topography of the easement area,
highlighting any extremes.
Map: Contour map (overlay of an aerial/satellite view, if possible) of the property,
or the best available map showing the property’s elevation profile.
Discussion of all soil types within the land parcel, including a description of each.
Table of all soils found within the easement area. Include soil type, name, acreage,
percent of total soils in the easement, and designation as prime or statewide
importance.
Map: USDA-NRCS soils map (available through USDA Web Soil Survey) with
appropriate labels that match figures in the table.
Description of the Property’s Natural Features
Optional: List and describe all wildlife habitat and natural communities of
significance found within the easement area (e.g., common wildlife, rare and
endangered species, etc.).
Optional: Map: Wildlife and natural communities.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
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General description of forest types within the easement area (e.g., hardwood, pine,
ornamental, etc.).
Map: Stand or reference map with labeled stands.
List and description of all significant aquatic features (streams water bodies, wetlands,
major waterways, etc.). Provide a brief narrative regarding how the easement
positively impacts those features.
Map: Aquatic map (overlay of an aerial/satellite view, if possible).
Archeological and Historical Features
List and description of all historical features of significance, including cemeteries
(if applicable).
Map: Archeological and historical features on the property (if applicable).
Photographic Documentation
All photos are easily replicable from roads, permanent features, or GPS waypoints.
Photographs are recommended to include timestamps and latitude and longitude.
Photographs at regular intervals along the property line that capture the property in
its entirety, including photos from each property corner.
Photographs of each permanent structure within each building envelope or
farmstead area.
All other impervious surfaces in the easement if not included above.
Photographs of any other human modifications to the property (including roads,
ditches, dams, etc.).
General landscape pictures that are representative of the easement area.
Photographic index with descriptions of each photo (photos must have descriptions
next to them).
Map: Documentation map with photos numbered. Include a compass direction to
note the direction the photo was taken.
Additional Maps
Map: USGS US Topo or 7.5-minute quadrangle topo map.
Map: General hydrology map.
Signature Page
A final review, with any applicable updates, of the BDR must be approved 30
business days before closing.
No edits are permitted within five (5) business days before closing.
Signature of authorized signatory of grantee organization at closing.
Signature(s) of all landowners listed in the easement at closing.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
N.C. Department of Agriculture & Consumer Services
N.C. ADFP Trust Fund
Environmental Audit (EA) Requirements and Checklist
Approved 06/2022 1
An Environmental Audit (EA) or Environmental Site Assessment (ESA) identifies potential or
existing environmental contamination liabilities. The analysis addresses both the underlying land
as well as physical improvements to the property.
An EA is a stand alone document, and some required documents included in the EA will match
other submitted materials in the survey, baseline documentation report, and title work.
An EA can be conducted by USDA NRCS staff using the latest version of the NRCS Hazardous
Materials Checklist and Landowner Interview, local soil and water conservation district staff
using the latest version of the NRCS Hazardous Materials Checklist and Landowner Interview or
equivalent, or with an environmental firm qualified to conduct Phase I Environmental Site
Assessments.
For USDA NRCS Agricultural Land Easement (ALE) projects, only an EA conducted by USDA
NRCS staff using the latest version of the NRCS Hazardous Materials Checklist and Landowner
Interview will be accepted.
Below are the requirements for an EA for a conservation easement project with the N.C. ADFP
Trust Fund (ADFPTF):
1.Map of the Conservation Area associated with the EA that includes any land
improvements or special land use features.
a.Must match the map found in the baseline documentation report.
b.Acreage of the assessed site must match the surveyed acres of the Conservation Area.
2.Documentation of land ownership associated with the EA, such as a property tax card,
land deed, etc.
a.Must match the preliminary title policy and preliminary attorney’s signed title
opinion.
3.Description of current land uses.
a.Must match the uses found in the baseline documentation report.
4.Pictures of land area defined in the EA with the location of pictures identified on a map or
survey. Please submit at least one picture for each different land use or land improvement
placed on the land parcel.
a.Must match the pictures found in the baseline documentation report.
5.Any implied and prevalent easement or ingress/egress use must be defined by picture and
mapped.
a.Must match the preliminary conservation easement survey.
6.Any trash, chemical or non-natural land use must be defined by picture and mapped.
7.An environmental opinion review of the land by the agency performing the EA.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
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8.Date of land parcel visit and site evaluation.
9. Name, signature, and date of the land investigator/reviewer.
10.A completed, dated, and signed Hazardous Materials Checklist and Landowner Interview
or equivalent. Approved formats include the latest USDA NRCS versions. Attached is an
example.
If on-site or off-site reviews find recognized environmental conditions that negatively impact
the property, such as the presence petroleum products or hazardous substances in the
subsurface of the site, and these findings necessitate further investigation of environmental
conditions with a Phase II ESA or equivalent, the Grantee is required to conduct these
assessments.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
U.S. Department of Agriculture
Natural Resources Conservation Service Hazardous Materials Field Inspection Checklist
1
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HAZARDOUS MATERIALS FIELD INSPECTION CHECKLIST
A.BACKGROUND INFORMATION Clear Form
NRCS PROGRAM LANDOWNER NAME
PROPERTY ADDRESS NUMBER OF ACRES
NEST APPLICATION NUMBER COUNTY STATE
FIELD INSPECTOR’S NAME & TITLE DATE INSPECTED
B.INSTRUCTIONS:
•For each question, indicate if you find any evidence of past or present hazardous materials.
•For any suspected evidence found, display the location on the parcel map and attach photographic evidence as an
addendum to this document.
•If you need more room to explain your findings attach additional sheets.
•When complete, attest that a field inspection has been completed and that to the best of your knowledge the
information included is accurate.
C.Field Conditions:Onsite Nearby None
1.Dumps or landfills (especially with drums/containers)
2.Other debris: household or farm waste
3.Fills (possible cover for dumps)
4.Unusual chemical odors
5.Above/below ground storage tanks
6.Buildings: chemical storage, equipment repair solvents
7.Structures: evidence of asbestos
8.Vegetation different from surrounding area for no apparent reason
(e.g., stressed or dead, bare ground)
9."Sterile" or modified water bodies
10.Oil seeps, stained ground, discolored stream banks
11.Unnatural characteristics of water: oil slicks, unusual color, etc.
12.Spray operation base: air strip, equipment parking area chemical
staging, storage, and mixing areas
13.Machinery repair areas
14.Pipelines, power lines, gas lines
15.Oiled or formerly oiled roads
16.Mounted transformers - evidence of leakage
17.Any mining activity or mining residue: past, present, or future
18.Wastewater treatment equipment, septic system, sewage lagoons
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U.S. Department of Agriculture
Natural Resources Conservation Service Hazardous Materials Field Inspection Checklist
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19.Treatment for vegetation or invasive species
20.Spills or releases of pollution
D.EVIDENCE OF PAST USE (check all that are applicable)
Manufacturing
Service station
Dry cleaning
Air Strip
Pipeline
Railroad line
Facilities with large electrical transformers
Petroleum production
Landfills
Scrap metal, auto, or battery recycling
Military
Laboratories
Wood preserving
Tanning
Monitoring wells
Wells no longer providing water
Piles of soil, rock, debris
Any unnatural topographic features
Other (describe)
E.PHYSICAL EVIDENCE OF EASEMENTS OR RIGHTS-OF-WAY (power lines, pipelines, railroads, roads)
F.NEARBY LAND USES: (describe all surrounding land uses – especially those upstream or upgradient)
G.CONTAMINATED SITES RECORD SEARCH:
List all known contaminant sites within a 1-mile radius of the site. Check with Federal or State environmental
protection agencies and local authorities. Are there any known hazardous material problems on or near the site
(National Priority List, State sites, etc.)? (Attach additional sheets as necessary)
H.INTERVIEWS:(Interviewee Name) (Title) (Interview Date)
Present Owner(s)
Past Owner(s)
County Agent
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
U.S. Department of Agriculture
Natural Resources Conservation Service Hazardous Materials Field Inspection Checklist
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Other Authorities
I.AGRICULTURAL HISTORY:
Type, Duration and Extent of Agricultural Activity:
Surface Drains Present PRESENT NOT PRESENT
Subsurface Drains Present PRESENT NOT PRESENT
J.RECOMMENDATION:
In my professional opinion and based on my inspection of the site this project should move forward:
YES NO FURTHER INVESTIGATION NEEDED
K.CERTIFICATION:
I hereby certify that on , 20 I made a personal examination and inspection of the tract or
parcel of land identified above, and that I am fully informed as to the boundaries, lines and corners of said tract. Based
upon a careful and thorough investigation and inquiry I hereby certify that the Hazardous Materials Field Inspection
Checklist and the attachments are true to the best of my knowledge and belief.
EXAMINER (Name and Signature)OFFICIAL TITLE
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
USDA - Natural Resources Conservation Services Landowner Hazmat Interview
1
HAZARDOUS MATERIALS LANDOWNER INTERVIEW
A. Property Information
NRCS PROGRAM LANDOWNER NAME
PROPERTY ADDRESS
NUMBER OF ACRES
NEST APPLICATION NUMBER COUNTY STATE
Interview Information
INTERVIEWER NAME INTERVIEW DATE
INTERVIEWEE NAME INTERVIEWEE PHONE NO.
AFFILIATION WITH PROPERTY (e.g., Owner, Operator,
Caretaker, Previous Owner, Tenant, Neighbor)
TIME FRAME OF AFFILITION
(YRs & MOs)
“To the Best of Your Knowledge…”
A. Property Uses
1. Do you have or know of the existence of any of the following
records related to the property? (If yes, please provide copies or
make them available.)
Yes No Copy
Attached No Copy
Available
a. Radon, asbestos, or lead-based paint surveys
b. Environmental compliance audit reports
c. Environmental permits related to current or previous site activities
(e.g., waste disposal permits, wastewater permits, NPDES permits)
d. Registrations for underground and above-ground storage tanks.
e. Hazardous materials management plans (Emergency Planning and
Community Right-To-Know Act (EPCRA))
f. Facility safety plans
g. Preparedness and prevention plans
h. Spill prevention, control, and countermeasure (SPCC) plans
i. Hydrogeologic and geotechnical reports on the property or
surrounding area
j. Notices or other correspondence from any government agency
relating to past or current violations of environmental laws with
respect to the property
k. Notices or other correspondence from any government agency
relating to environmental liens encumbering the property
l. Hazardous waste generator notices or reports
m. Risk assessments
n. Recorded deed or environmental land use restrictions
o. Other environmental studies or investigations
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
USDA - Natural Resources Conservation Services Landowner Hazmat Interview
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2.Has the property ever been used for an industrial or commercial use (e.g., official and unofficial shooting
ranges; processing, handling, management, disposal, storage, manufacture, or transportation of hazardous
substances or petroleum products, such as a gasoline station, motor repair facility, commercial printing
facility, dry cleaners, photographic developing laboratory, methamphetamine laboratory, junkyard, bone yard,
or landfill, or as a waste treatment, storage, disposal, processing, or recycling facility). If yes, describe the
activities and provide the time frames, types, locations, and quantities of hazardous substance use and storage.
Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
3.Has there ever been permitted or planned mining activity or oil and gas exploration or development on the
property? If yes, describe the activities and provide the time frames, locations, and scope of operations.
Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
4.Has the property ever been used for agricultural purposes, such as livestock or crops? If yes, describe the
operations and indicate the locations and time frames involved. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
a.If yes, did the operation involve the use or storage of chemicals such as pesticides, fertilizers, and
or solvents? If yes, describe and provide locations and the type, quantity, duration of use, and
management practices. Yes □ No □ Unknown □
______________________________________________________________________________
______________________________________________________________________________
______
5.Are there, or have there been, any improvements, such as buildings, water towers, smokestacks, smelters, and
old building foundations on the property? If yes, describe each improvement, including construction date for
each improvement; location on the property; square footage; past and current uses; dates of major
renovations, additions, modifications; number of stories; type of construction; heating and cooling sources;
water sources; sewage, solid and hazardous waste disposal; and removal date (if applicable).
Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
B.Hazardous Materials and Substances
1.Do the current operations on the property involve the use and storage of chemicals? If yes, please describe
the operations and indicate the locations, types, and quantities of materials used. Describe locations of
chemical storage, mixing, and loading. Discuss any use, storage, mixing, or disposal of automotive or other
batteries, pesticides (e.g., insecticides, herbicides, and fungicides), paints, solvents, or other chemicals on
fence lines, rights-of-way, or other structures such as airstrips, heliports, or crop duster operations.
Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
a)If yes, has there been a spill or release of hazardous substances, petroleum products, or other potential
environmental problems on the property associated with current operations? If yes, describe the
nature and locations of the release and the quantities and types of hazardous substances. This
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
USDA - Natural Resources Conservation Services Landowner Hazmat Interview
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includes staining or soils and floors in areas utilized for the use and storage of hazardous materials.
Yes □ No □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
b)If there had been a spill or release of hazardous substances or petroleum products, did someone report
the incident to the National Response Center or a local or State emergency response authority? If yes,
identify the agency. Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
c)If a spill or release of hazardous substances or petroleum products has occurred, has the release been
mitigated? If yes, describe the mitigation, identify the lead regulatory agency that oversaw the
mitigation and indicate if the lead regulatory agency issued a no-further action (NFA) determination.
Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
d)If remediation is completed, does the property have contamination or residual contamination? If yes,
are there any institutional controls or land use restrictions in place or long-term monitoring and
maintenance requirements? Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
2.Are there any past operations at the property that involved the use or storage of hazardous materials and
substances? If yes, describe the operations and the locations, types, and quantities of materials.
Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
a)If yes, has there been a spill or release of hazardous substances, petroleum products, or other potential
environmental problems on the property associated with past operations or tenants? If yes, describe
the nature and locations of the release and the quantities and types of hazardous substances.
Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
b)If a spill or release of hazardous substances or petroleum products had occurred, was it reported to the
National Response Center or a local or State emergency response authority? If yes, identify the
agency. Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
c)If a release of hazardous substances or petroleum products had occurred, was the release mitigated?
If yes, describe the mitigation, identify the regulatory agency that oversaw the mitigation and indicate
if the lead regulatory agency issued a no-further action (NFA) determination.
Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
USDA - Natural Resources Conservation Services Landowner Hazmat Interview
4
d)If remediation is completed, does the property now have contamination or residual contamination
present? If yes, are there any institutional controls or land use restrictions in place or long-term
monitoring and maintenance requirements? Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
3.Have there ever been any easements, rights-of-way, pipelines, utility lines, railways, entry or exit ports and
associated structures, either buried or overhead, crossing the property? If yes, please describe and indicate the
locations, approximate construction date, and the owner’s identity. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
a)If yes, are you aware of any spills or releases associated with these features? If yes, please describe
the spills and releases and indicate the date, type, and quantities of materials involved.
Yes □ No □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
b)If a spill or release has occurred, are you aware if the release has been mitigated? If yes, who did the
mitigation and what regulatory agency oversaw the mitigation? If known, indicate whether the lead
regulatory agency issued a no-further action (NFA) determination. Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
c)If remediation is completed, are you aware if there the property still has contamination or residual
contamination? If yes, are there any institutional controls or land use restrictions in place or long-
term monitoring and maintenance requirements? Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
4.Are you aware if the property’s topography has been altered or if the property has any unnatural topographic
features present? If yes, please describe the topographic alterations or unnatural features. Indicate their
locations on the property and, if known, when the alterations occurred and by whom.
Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
5.Has fill material ever been brought onto the property that originated from a contaminated site or that was of
an unknown origin? If yes, describe the date and quantity of material brought to the property, indicate the
location where the material was placed. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
a)If fill material came from a contaminated site, identify the fill’s origin and describe the
contamination.
_________________________________________________________________________________
_________________________________________________________________________________
b)Is there any evidence that waste materials were dumped above grade, buried, or burned, either
currently or previously, on the property? Examples include hazardous materials, petroleum products,
labeled or unlabeled drums or containers, pesticide containers, household and farm debris, automotive
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
USDA - Natural Resources Conservation Services Landowner Hazmat Interview
5
or industrial batteries, building demolition debris, or other waste materials. Yes □ No □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
6. Are there any floor drains in the onsite structures or areas where chemicals (e.g., waste oil, antifreeze,
solvents, and pesticides) were used or stored? If yes, indicate the locations of the structures and the types,
quantities, and time frames related to the associated chemical use or storage. For each area or structure, also
indicate the discharge location for the floor drains. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
7. Do the walls, floors, or ceilings of the structures used to store hazardous materials have any chemical stains?
If yes, indicate the areas in each structure that has chemical staining. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
8. Are there or have there been any floors, drains, walls, or ceilings stained by substances other than water or
that are emitting foul or unnatural odors (e.g., mold, mildew, algae)? If yes, describe the locations and the
nature of the past and current site operations. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
9. Are there electrical transmission lines, transformers, capacitors, lighting ballast, or hydraulic equipment (e.g.,
elevators, presses, lifts, or doors) on the property? If yes, identify the locations and approximate age of the
equipment. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
a) If the site has electrical transmission lines, transformers, capacitors, lighting ballast, or hydraulic
equipment, has testing been done to determine the presence of polychlorinated biphenyls (PCBs) or
has any onsite equipment contained PCBs? If yes, indicate the locations, type of equipment, and
dates. Yes □ No □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
b) If the site has or had PCBs, are you aware of any release of PCBs that have occurred? If yes, describe
the release and indicate the date, locations and whether the release was mitigated.
Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
10. Has there ever been any mercury-containing equipment (e.g., switches, thermostats, thermometers,
manometers, or sink traps) on the property? If yes, indicate the locations and type of equipment and dates.
Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
11. Are you aware of any radon, asbestos-containing materials, or lead-based paint on the property? If yes,
indicate the type, locations and dates. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
USDA - Natural Resources Conservation Services Landowner Hazmat Interview
6
a)If yes, has anyone done any radon, asbestos-containing materials, or lead-based paint surveys on the
property? If yes, indicate whether radon, asbestos-containing materials, or lead-based paint has been
identified in any onsite buildings. Identify the dates of the surveys, the structures, the results, and
condition of the materials. Yes □ No □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
12.Is there current or past use of above-ground or underground storage tanks, including drums or other fuel
containers, on the property? If yes, identify the tanks locations, installation dates, and the types and quantities
of materials stored. If the tanks were removed, indicate the removal date and whether the lead regulatory
agency issued a closure certification notice. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
a)If above-ground or underground storage tanks are or were used on the property, was there ever a spill
or release of hazardous substances associated with the tank system? If yes, indicate the date and
nature of the spill or release. Yes □ No □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
b)If a spill or release has occurred related to an onsite tank system, was it mitigated to the satisfaction of
the lead regulatory agency? If no, describe further actions that must be undertaken to address the spill
or release. Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
13.Are you aware of any hazardous substance or pollutant or contaminant spill or release, or other potential
environmental problems on any adjacent or nearby properties? If yes, please describe (if known) the
locations of the release, the type and quantities of materials involved, and the approximate dates. If known,
also indicate the owner of the property where the release occurred. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
a)If there was a release of hazardous substances, petroleum products on any adjacent or nearby
properties are you aware if the release was mitigated? Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
b)Are you aware of contamination or residual contamination on adjacent or nearby properties that
poses a threat or may pose a future threat to the property? If yes, describe the threat or potential
threat. Yes □ No □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
c)Are you aware of any institutional controls, land use restrictions, long-term monitoring, or
maintenance requirements in place on adjacent or nearby properties that affect the property? If
yes, please describe and identify the adjacent or nearby property and the property owner.
Yes □ No □ N/A □ Unknown □
_____________________________________________________________________________________
_____________________________________________________________________________________
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
USDA - Natural Resources Conservation Services Landowner Hazmat Interview
7
C.Water and Wastewater
1.Does the property currently or has it ever been supplied by an onsite drinking water supply well? If yes,
provide the well locations and construction dates. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
a)Have contaminants ever been identified in the onsite drinking water well or the water system that
exceeded acceptable levels? If yes, describe the contamination and indicate the dates, contaminant
levels and the source of the contamination, if known. Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
b)If an onsite drinking water well is no longer used, has it been properly abandoned according to
applicable regulatory requirements? If yes, indicate the date the well was abandoned.
Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
2.Has the property ever had an onsite wastewater treatment and disposal systems (e.g., septic systems or sewage
lagoons). If yes, please describe of the system, including the locations, size, date constructed, and which
buildings discharge to the system. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
a)If the onsite wastewater treatment and disposal system is no longer used, has it been closed? If yes,
describe method of closure and date closed. Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
3.Does the property have any monitoring wells? If yes, explain the purpose of the wells and provide the
locations, dates of construction, and any analytical results. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
a)If the monitoring wells are no longer used, were they properly abandoned according to applicable
regulatory requirements? If yes, indicate the date the well was abandoned.
Yes □ No □ N/A □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
4.Does the property have surface water (e.g., pits, ponds, lagoons, rivers, creeks, or oceans)? If yes, describe
the locations and type of surface water. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
a)If the property has surface water, are you aware of any unnatural characteristics such as color, sheens,
odors, or sterility? If yes, please describe and indicate whether the situation is new or pre-existing.
Yes □ No □ N/A □Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
USDA - Natural Resources Conservation Services Landowner Hazmat Interview
8
5.Has the property ever discharged industrial or other wastewater (excluding storm water runoff or sanitary
wastewater discharges from restrooms, kitchens, or other household-type uses) onto or adjacent to the
property? If yes, describe the discharge and indicate the locations and dates. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
D.Compliance/Permits
1.Have there been any environmental permits or licenses issued for current or past operations associated with
the property (e.g., air quality, water discharge, or landfills)? If yes, describe the permitted operations, indicate
the permitting agency, date the permit was issued, and whether the permit is still effective.
Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
2.Are you aware of any environmental liens against the property that were filed or recorded under Federal,
Tribal, State or local law? If yes, describe the lien and indicate the date and effect on the current and future
use of the property. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
3.Are you aware of any activity and land use limitations that are in place on the property or that were filed or
recorded under Federal, Tribal, State or local environmental laws? If yes, describe the land use restrictions,
identify the party that issued the restrictions and the date. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
4.Are you aware of any compliance or enforcement notices relating to past or current violations of
environmental laws with respect to the property or any facility on the property? If yes, describe the violations
and the dates involved. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
5.Are you aware if any environmental site assessment, or other environmental investigations, of the property, or
any other property or site records ever indicated the presence of hazardous substances, petroleum products, or
other potential environmental problems on the property? If yes, describe the report and findings.
Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
6.Are you aware of any environmental site assessment, or other environmental investigations, of the property,
or any other property or site records that recommended further assessment of the property? If yes, identify the
report and indicate if the further assessment was done. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
7.Are you aware of any past, threatened, or pending lawsuits or administrative proceedings concerning a release
or threatened release of any hazardous substances or petroleum products on the real property? If yes, describe
the action and identify the party that is initiating the action. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
USDA - Natural Resources Conservation Services Landowner Hazmat Interview
9
E.Other
1.Are you aware any past or current occurrences of anomalous vegetation (e.g., stressed or dead) on the
property? If yes, indicate the locations and approximate dates. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
2.Are you aware of the presence of invasive or non-native plants on the property? If yes, please indicate the
locations and names (e.g., kudzu, Phragmites, cheatgrass), if known, and approximate area covered by the
plants. Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
a)If yes, has there been any attempt to remove or eradicate the invasive species? If yes, explain what
was attempted and if it was successful? Yes □ No □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
b)Have any vegetative control programs (e.g., along transmission lines, fence lines, rights-of-ways, or
pipelines) been done on the property? If yes, describe the program and types of activities.
Yes □ No □ Unknown □
_________________________________________________________________________________
_________________________________________________________________________________
3.If not mentioned above, is there anything else that could indicate the presence of hazardous substances,
petroleum products or other environmental conditions that may affect the property?
Yes □ No □ Unknown □
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
INTERVIEWEE SIGNATURE:
INTERVIEWEE SIGNATURE
INTERVIEWEE NAME DATE
INTERVIEWER SIGNATURE:
INTERVIEWER SIGNATURE OFFICIAL TITLE
INTERVIEWER NAME DATE
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
N.C. Department of Agriculture & Consumer Services
N.C. ADFP Trust Fund
Appraisal Checklist
Approved 6/2022 1
Certified Development Rights Appraisals ("Appraisals") will only be accepted and approved by
the Agricultural Development and Farmland Preservation Trust Fund (ADFPTF) if the following
qualifications are met and documentation of such is provided in the appraisal.
1. The acres used to determine the easement value in the appraisal must be equal to the
acres in the survey of the conservation easement area. A survey of the property must be
included in the appraisal.
2. A qualified appraisal and appraiser must meet the definitions of such set forth in U.S.
Public Law 109-280 (https://www.govinfo.gov/content/pkg/PLAW-
109publ280/html/PLAW-109publ280.htm). In addition, the appraiser must provide
documentation of completion of a valuation of conservation easements or eminent
domain appraisal course and be familiar with conducting appraisals of rural and
agricultural properties of the requested type.
3. The ADFPTF does not pay for property appraisals. The eligible entity (Grantee of the
ADFPTF easement) must order the appraisal and be identified as the client. The
landowner may not be the client but may be listed as an intended user.
4. Based on the funding partnerships, the following types of appraisals shall be used to
determine the effect of the conservation easement on the subject property:
a. ADFPTF as the sole funding source:
i. Uniform Standards of Professional Appraisal Practice (USPAP)
ii. Uniform Appraisal Standards for Federal Land Acquisitions (UASFLA or
"Yellow Book") appraisal
b. USDA NRCS partnership projects:
i. Uniform Standards of Professional Appraisal Practice (USPAP)
ii. Uniform Appraisal Standards for Federal Land Acquisitions (UASFLA or
"Yellow Book") appraisal
c. Military partnership projects:
i. Uniform Appraisal Standards for Federal Land Acquisitions (UASFLA or
"Yellow Book") appraisal
5. Final conservation easement values must be determined by a Certified Development
Rights Appraisal dated within the contract period and dated less than 365 days prior to
closing. Supplemental appraisals, updated opinion letters, or reaffirmation letters by the
appraiser for the original appraisal are acceptable if a closing occurs 365 days after
issuance of the Certified Development Rights Appraisal, provided the appraiser certifies
the land value with an updated effective date of valuation.
6. For the purposes of updating the values of the conservation easements for the federal
permanent conservation easement tax incentive, supplemental appraisals, updated opinion
letters, or reaffirmation letters by the appraiser for the original appraisal may be
submitted within 60 to 32 days before a potential closing date pending the approval of all
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 6/2022 2
funding partners. All other deliverables must be approved if submitting an update. No
appraisals, supplemental appraisals, updated opinion letters, or reaffirmation letters by
the appraiser for the original appraisal will be accepted 30 days before a potential closing
date or end of a contract. Please note: the N.C. Department of Agriculture and
Consumer Services does not provide tax or legal advice to entities or individuals.
Before considering a supplemental appraisal, updated opinion letter, or reaffirmation
letter by the appraiser for the original appraisal within 60 of the potential closing,
consult with your appraiser and tax or legal advisors.
7. The appraiser must prepare two opinions of the value of the subject property: one before
placement of the conservation easement and the second after placement of the
conservation easement. The after condition or second value will be based upon a
hypothetical condition that the conservation easement is in place and the effects on the
value that may be created. The difference in the two values is the proposed conservation
easement's effect on the property's value.
8. The property rights, such as mineral, water, timber, and hunting, must be owned in fee
simple terms by the current landowners. Surface rights, such as structures, barns, hay
sheds, fencing, orchards, or other plantings, and any irrigation water rights, including but
not limited to wells, ditches, ponds, and lakes that provide irrigation on the subject
property and are legally permitted, may be appraised. Crop base and allotments,
including other plantings on the subject property, may be appraised and included in any
valuations.
9. The highest and best use conclusion must be supported by market evidence. A
noneconomic highest and best use, such as "forever wild" or "natural lands," or any use
that requires the property to be withheld from economic production in perpetuity, is not a
valid use upon which to base an estimate of market value. Nearby transactions
comparable to the land under appraisement and reasonably current may provide the best
evidence of market value.
10. Every effort must be made to provide comparable conservation easement encumbered
sales. A sales adjustment chart that summarizes the adjustments, shows the final adjusted
sale price, and how the sales compare with the subject property is required. Market
evidence and supporting narrative shall be provided for each adjustment used.
11. The contract appraiser must be aware that all appraisal reports completed for ADFPTF
grants will be used by staff who will rely on the details in the report to understand the
property and market characteristics. The appraisal report must include the level of detail
necessary to thoroughly explain and support the property description, highest and best
use analysis, market characteristics, adjustment process, and all conclusions so that all
users have an adequate understanding of the statements, opinions, and conclusions
offered within the report.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Conservation Easement Content
Please visit our website to view and download the current version of the appropriate
conservation easement template for this project. Please ensure you use the most recent
version of the appropriate template.
1. Go to www.ncadfp.org
2. Click on the Downloads tab
3. Click on the appropriate template to download the most recent version
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
N.C. Department of Agriculture & Consumer Services
N.C. ADFP Trust Fund
Closing Agent Requirements for Easement Programs
Approved 11/2021
Grantees: The Closing Agent must complete the Closing Agent Requirements for Easement Programs
Form, State of North Carolina Substitute W-9 Form, and State of North Carolina Vendor Electronic
Payment Form.
If a Grantee does not have a Closing Agent at the time of grant award contract execution, the future
Closing Agent must complete the Closing Agent Requirements for Easement Programs Form, State of
North Carolina Substitute W-9 Form, and State of North Carolina Vendor Electronic Payment Form at
least 60 days prior to a tentative conservation easement closing date.
Due to the vendor registration requirements of the Office of State Controller, there are no exceptions to
this 60-day policy.
N.C. Agricultural Development and Farmland Preservation Trust Fund (NCADFPTF) Easement Program
(check only one):
NCADFPTF Easement
NCADFPTF and USDA-NRCS ALE Easement
NCADFPTF and US Air Force Easement
NCADFPTF and US Navy Easement
NCADFPTF, USDA-NRCS ALE, and US Air Force Easement
• For Agricultural Conservation Easement Program Agricultural Land Easements (ACEP-ALE)
transactions, these requirements and instructions are in addition to any closing instructions
provided by the United States Department of Agriculture (USDA) Natural Resource Conservation
Service (NRCS).
The Parties to this transaction are as follows:
State of North Carolina:
N.C. Dept. of Agriculture & Consumer Services
NC ADFP Trust Fund
2 West Edenton Street
Raleigh, NC 27601
Landowner/Grantor (name & address below):
_________________________________________
_________________________________________
______________, _____ _____
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
N.C. Department of Agriculture & Consumer Services
N.C. ADFP Trust Fund
Closing Agent Requirements for Easement Programs
Approved 11/2021
Eligible Entity/Grantee (name & address below):
_________________________________________
_________________________________________
______________, _____ _____
The closing agent must:
1. Acknowledge that he or she has up-to-date knowledge of the General Statutes of North Carolina
pertaining to conducting real estate transactions and obtaining title clearance.
2. Certify that he or she is an attorney duly licensed to practice law in the State of North Carolina.
3. Certify that the title insurance company issuing the title commitment and final policy of title
insurance is approved by the North Carolina Insurance Commissioner.
4. Provide all Parties evidence of liability insurance coverage or indemnification in an amount equal
to or greater than the easement purchase value paid from State Funds for each NCADFPTF
easement. Further, closing agent agrees to provide reimbursement to NCAD&CS for any loss of
State funds caused by errors, omissions, fraud, dishonest, negligence, or failure by the attorneys,
agents or closing agent employees to comply with written closing instructions.
a. The American Land Title Association (ALTA) closing protection letter revised 4/2/2014
is satisfactory to meet this condition of responsibility.
5. Certify that he or she will not close on an easement purchase for his or her spouse, children,
partners, or business associates, and that he or she does not have a financial interest in the real
estate to be covered by the proposed easement.
6. Upon approval of the Grantee’s submission of a Request for Payment form and an Easement
Closing Check Request form, the NCADFPTF will submit the required documentation to the
Grants and Contracts office to transmit the NCADFPTF portion of the purchase price for the
acquisition (i.e.; State funds). The Request for Payment form, Easement Closing Check Request
form, and all required documents must be submitted in one complete package to the NCADFPTF
no later than 30 days before the proposed closing dates. The funds will be sent by electronic fund
transfer (EFT) to closing agent’s escrow account.
a. Errors in the Grantee’s forms and documents, or outdated State of North Carolina
Substitute W-9 Form and State of North Carolina Vendor Electronic Payment Form for
the Grantee or Closing Agent may cause delays in the EFT.
7. Agree to close the easement transaction within 30 calendar days of receipt of the State funds.
8. Acknowledge that costs to clear title defects are the responsibility of the landowner.
9. Return the easement funds and any accrued interest in accordance with NCADFPTF instructions
if the conservation easement is not closed within 30 calendar days of receipt of the State funds.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
N.C. Department of Agriculture & Consumer Services
N.C. ADFP Trust Fund
Closing Agent Requirements for Easement Programs
Approved 11/2021
10. Certify that he or she will:
a. Examine the real estate records and certify title for a period of at least sixty years.
b. Immediately prior to closing, examine the real estate records covering the time from the
effective date of the title commitment to the date of closing to determine that no new
encumbrances have been recorded against the subject property, no adverse change in title
has occurred and that there are not intervening matters affecting the title that might result
in a new title exception on the policy. Notify NCADFPTF of any such changes or matters
that are discovered, and delay the closing, the recording of the deed, and the
disbursement of funds pending consultation with NCDAFPTF.
c. Obtain the property executed conservation easement deed from the landowner and any
other required signatory parties.
d. Comply with any listed title commitment requirements.
e. Obtain and record as instructed the properly executed curative documents for any items
required to be removed, released, subordinated, waived, or otherwise handled as required
by the title commitment or proforma policy and closing instructions.
f. Secure the policy of title insurance referred to below.
g. Ensure all taxes, homeowners’ assessments, etc. are current as of the date the
conservation easement deed is recorded.
h. Record the conservation easement deed within 2 business days of execution.
i. Complete Internal Review Service (IRS) tax reporting Form 1099 for the full easement
compensation amount, as identified in the conservation easement deed.
11. Immediately following closing, issue policies of title insurance free and clear of any and all
encumbrances (exceptions) to the title except those that NCADFPTF, have determined to be
acceptable. See attached NCDAFPTF title requirements.
12. Certify that the following package will be delivered within five (5) business days of receipt of
recorded documents form the local land records office to NCADFPTF:
a. Policy of title insurance (original and one copy) on the appropriate form.
b. Recorder’s certified copy of the recorded conservation easement deed and a recording
receipt.
c. Recorder’s certified copies of any curative documents, including subordination
agreements.
d. Original and one copy of executed settlement statements.
e. Record of disbursement of funds to the landowner.
13. Acknowledge receipt and agree to comply with the terms of these requirements by promptly
signing and returning a signed copy of these closing agent requirements to NCADFPTF.
14. Provide a complete State of North Carolina Substitute W-9 Form and State of North Carolina
Vendor Electronic Payment Form with this document.
a. Per the Office of State Controller, the State of North Carolina Substitute W-9 Form and
State of North Carolina Vendor Electronic Payment Form must be dated within one year
prior to transmitting funds to the closing agent’s escrow account. Updated forms must be
submitted before requesting funds.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
N.C. Department of Agriculture & Consumer Services
N.C. ADFP Trust Fund
Closing Agent Requirements for Easement Programs
Approved 11/2021
By signing this “Closing Agent Requirements for Easement Programs”, I am certifying that I meet the
requirements set forth herein, which ensure that the State funds received for the purchase of the
subject easement are handled in a manner that protects the interest of the State of North Carolina.
__________________________________________ ________________
Signature of Closing Agent Date
Name of Closing Agent
By signing this “Closing Agent Requirements for Easement Programs”, I concur with the closing
agent’s qualifications.
__________________________________________ ________________
Signature of Grantee Representative Date
Name and Title of Grantee Representative
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
N.C. Department of Agriculture & Consumer Services
N.C. ADFP Trust Fund
Closing Agent Requirements for Easement Programs
Approved 11/2021
NCADFPTF Title Insurance Requirements
Landowner:
Contract No.:
Title Company:
Title Commitment No.:
Title Commitment Date:
1.All Requirements listed in Schedule B – Part I of the title commitment must be met.
2.All taxes, homeowner assessments, etc. must be paid to the date the Agricultural Land Easement
is recorded.
3. Exception 6 must be revised “Terms and conditions of those restrictions, conditions and
obligations as set forth in instrument recorded in Book __________, Page _________,
______________ County Registry that limit and/or restrict the rights of the Grantee.”
4. All other Exceptions listed in Schedule B – Part II are acceptable.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
NC Office of the
State Controller
(IRS Form W-9 will not be
accepted in lieu of this form)
*Denotes a Required Field
STATE OF NORTH CAROLINA
SUBSTITUTE W-9 FORM
Request for Taxpayer Identification Number
Please complete the “Modification to Existing Vendor Records” section below If there have been any changes to the following: Tax Identification Number (TIN),
Legal Name, Business Name, Remittance Address
Return to the NC State Agency from which you are requesting payment. Section 1– Taxpayer Identification Section 2 -Certification *1. Social Security Number (SSN),
OR
Employer Identification Number (EIN),
OR
Individual Taxpayer Identification Number (ITIN)
*2.
Please select the appropriate Taxpayer Identification Number (EIN, SSN,
or ITIN) type and enter your 9-digit ID number. The U.S. Taxpayer
Identification Number is being requested per U.S. Tax Law. Failure to
provide this information in a timely manner could prevent or delay
payment to you or require The State of NC to withhold 24% for backup
withholding tax.
*4. Legal Name (as shown on your income tax return):3. Dunn & Bradstreet Universal Numbering System (DUNS) (see
instructions)
5. Business Name/DBA/Disregarded Entity Name, if different from
Legal Name:
Contact Information
*6. Legal Address 7. Remittance Address (Location specifically used for payment that is
different from Legal Address, if applicable)
*Address Line 1: Address Line 1:
Address Line 2: Address Line 2:
*City *State *Zip (9 digit) City State Zip (9 digit)
*County County
*8. Contact Name:
*9. Phone Number:
10. Fax Number:
11. Email Address:
*12. Entity Type *13. Entity
Classification
14. Exemptions (see
instructions)
Individual/Sole Proprietor/Single-member LLC C-Corporation S-Corporation
Partnership Trust/Estate Other___________________________
Limited liability company. Enter the tax classification (C=C corporation,
S=S corporation, P=Partnership) ________
Note: Check the appropriate box in the line above for the tax classification of the single-
member owner. Do not check LLC if the LLC is classified as a single-member LLC that is
disregarded from the owner unless the owner of the LLC is another LLC that is not
disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC
that is disregarded from the owner should check the appropriate box for the tax classification
of its owner.
Exempt payee code (if any):
Exemption from FATCA
reporting code (if any):
Under penalties of perjury, I certify that:
1.The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service
(IRS) that I am subject to backup withholding because of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer
subject to backup withholding, and
3.I am a U.S. citizen or other U.S. person (defined later in general instructions), and
4.The FATCA code(s) entered on this form (if any) indicting that I am exempt from FATCA reporting is correct.
Certification instructions: Please refer to the IRS Form W-9 located on the IRS Website (https://www.irs.gov/):
*Printed Name: *Printed Title:
*Authorized U.S.
Signature:
* Date:
Medical Services
Legal/Attorney
Services
NC Local Govt
Federal Govt
NC State Agency
Other Govt
Other (specify)
X
56-6000327
Orange County, North Carolina
09-157-5191
Orange County Department of Finance
PO Box 8181
Hillsborough, NC 27278
Orange
Same as legal address
Gary Donaldson919-245-2453
gdonaldson@orangecountync.gov
Local Government
X
Gary Donaldson CFO
9/26/2022
REV 01/2019
(PRESS THE TAB KEY TO ENTER EACH NUMBER)
(PRESS THE TAB KEY TO ENTER EACH NUMBER)
(DO NOT TYPE OR WRITE IN THIS FIELD)
Gary Donaldson Digitally signed by Gary Donaldson
Date: 2022.09.26 17:52:02 -04'00'
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
NC Office of the
State Controller
*Denotes a Required Field
This form is to be
completed by the vendor.
STATE OF NORTH CAROLINA
SUBSTITUTE W-9 FORM
Modification to Existing Vendor Records
This form is to be completed by the vendor if one or more of the following have changed:
1.Change of remittance address.
2.Change of Social Security Number (SSN), or Employer Identification Number (EIN), or Individual Taxpayer
Identification Number (ITIN).
3.Change of Vendor Name.
Please complete the applicable sections below.
Section 1:
CHANGE FROM: Remittance Address CHANGE TO: Remittance Address
Section 2:
*CHANGE FROM: SSN, or EIN, or ITIN *CHANGE TO: SSN, or EIN, or ITIN
Section 3:
CHANGE FROM: Vendor Name CHANGE TO: Vendor Name
*Address Line 1:
Address Line 2:
*City *State *Zip (9 digit)
*County
*Address Line 1:
Address Line 2:
*City *State *Zip (9 digit)
*County
*Legal Name:*Legal Name:
Business Name/DBA/Disregarded Entity
Name, if different from Legal Name:
Business Name/DBA/Disregarded Entity
Name, if different from Legal Name:
*Printed Name:*Printed Title:
*Authorized U.S.
Signature:
*Date:
NOTE: If you would like to receive your payments electronically, please
complete the Vendor Electronic Payment Form
(PRESS THE TAB KEY TO ENTER EACH NUMBER) (PRESS THE TAB KEY TO ENTER EACH NUMBER)
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
NC Office of the State Controller Substitute W-9 Instructions Page 1
General Instructions
For General Instructions, please refer to the IRS Form W-9 located on the IRS Website (https://www.irs.gov/).
Specific Instructions
Section 1 -Taxpayer Identification
1.Taxpayer Identification Type. Check the type of identification number provided in box 2.
2.Taxpayer Identification Number (TIN). Enter taxpayer’s nine-digit Employer Identification Number (EIN), Social Security Number (SSN), or Individual Taxpayer
Identification Number (ITIN) without dashes.
Note: If an LLC has one owner, the LLC's default tax status is "disregarded entity". If an LLC has two owners, the LLC's default tax status is "partnership". If an LLC has
elected to be taxed as a corporation, it must file IRS Form 2553 (S Corporation) or IRS Form 8832 (C Corporation).
3.Dunn and Bradstreet Universal Numbering System (DUNS). Vendors are requested to enter their DUNS number, if applicable.
4.Legal Name. Enter the legal name as registered with the IRS or Social Security Administration. In general, enter the name shown on your income tax return. Do
not enter a Disregarded Entity Name on this line.
5.Business Name. Business, Disregarded Entity, trade, or DBA ("doing business as") name.
Contact Information
6.Enter your Legal Address.
7.Enter your Remittance Address, if applicable. A Remittance Address is the location in which you or your entity receives business payments.
8.Enter the Contact Name.
9.Enter your Business Phone Number.
10.Enter your Fax Number, if applicable.
11.Enter your Email Address, if applicable.
For clarification on IRS Guidelines, see www.irs.gov.
12.Entity Type. Select the appropriate entity type.
13.Entity Classification. Select the appropriate classification type.
Exemptions
If you are exempt from backup withholding and/or FATCA reporting, enter in the Exemptions box, any code(s) that may apply to you. See Exempt payee code and
Exemption from FATCA reporting code below.
14.Exempt payee code. Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends. Corporations are not exempt from backup withholding for payments made in settlement of
payment card or third party network transactions.
Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding.
The following codes identify payees that are exempt from backup withholding:
1 - An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section
401(f)(2)
2 - The United States or any of its agencies or instrumentalities
3 - A state, the District of Columbia, a possession of the United States, or any of their political subdivisions, or instrumentalities
4 - A foreign government or any of its political subdivisions, agencies, or instrumentalities
5 - A corporation
6 - A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States
7 - A futures commission merchant registered with the Commodity Futures Trading Commission
8 - A real estate investment trust
9 - An entity registered at all times during the tax year under the Investment Company Act of 1940
10- A common trust fund operated by a bank under section 584(a)
11 - A financial institution
12 - A middleman known in the investment community as a nominee or custodian
13 - A trust exempt from tax under section 664 or described in section 4947.
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NC Office of the State Controller Substitute W-9 Instructions Page 2
The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.
If the payment is for… THEN the payment is exempt for…
Interest and dividend payments All exempt payees except for 7
Broker transactions Exempt payees 1 through 4 and 6 through
11 and all C corporations. S corporations
must not enter an exempt payee code
because they are exempt only for sales of
noncovered securities acquired prior to
2012.
Barter exchange transactions and patronage
dividends
Exempt payees 1 through 4
Payments over $600 required to be reported and
direct sales over $5,000¹
Generally, exempt payees 1 through 5²
Payments made in settlement of payment card
or third party network transactions
Exempt payees 1 through 4
¹ See Form 1099-MISC, Miscellaneous Income, and its instructions.
² However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care
payments, attorneys' fees, gross proceeds paid to an attorney, and payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting
this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account
you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to
these requirements.
A - An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)
B - The United States or any of its agencies or instrumentalities
C - A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities
D - A corporation the stock of which is regularly traded on one or more established securities markets, as described in Reg. section 1.1472- 1(c)(1)(i)
E - A corporation that is a member of the same expanded affiliated group as a corporation described in Reg. section 1.1472-1(c)(1)(i)
F - A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as
such under the laws of the United States or any state
G - A real estate investment trust
H - A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940
I - A common trust fund as defined in section 584(a)
J - A bank as defined in section 581
K - A broker
L - A trust exempt from tax under section 664 or described in section 4947(a)(1)
M - A tax exempt trust under a section 403(b) plan or section 457(g) plan
Section 2 - Certification
To establish to the paying agency that your TIN is correct, you are not subject to backup withholding, or you are a U.S. person, or resident alien, sign the certification
on NC Substitute Form W-9. You are being requested to sign by the State of North Carolina.
For additional information please refer to the IRS Form W-9 located on the IRS Website (https://www.irs.gov/).
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Revised February 2020
Office of the State Controller
Return to: OSC Support Services Center
Address: 1410 Mail Service Center
Raleigh, NC 27699-1410
Email: osc.support.services@osc.nc.gov
Telephone: 919-707-0795
Vendor Electronic Payment Form
New Add Request
Change/Update Existing Account
Inactivate Existing Account
*Denotes a required field
The State of North Carolina offers payees the opportunity to receive payments electronically through U.S. based banks. In addition to
having the funds deposited electronically, you will also receive remittance information by e-mail.
We require you to submit a copy of a voided check, bank statement, or a bank authorization letter on bank letterhead
signed by a bank representative for account verification.
*TAX ID # or SSN
*PAYEE NAME
*REMITTANCE ADDRESS
(AS PRINTED ON STREET SUITE/ROOM #
YOUR INVOICE)
CITY STATE ZIP CODE
*CONTACT
NAME & TITLE PHONE NUMBER
NEW FINANCIAL INFORMATION
*FINANCIAL INSTITUTION NAME:
*NAME ON ACCOUNT:
*NEW ROUTING NUMBER:
*NEW ACCOUNT NUMBER:
*ACCT TYPE: Checking Savings
*REMIT E-MAIL ADDRESS
New add requests MUST include contact information for the state agency with which you are doing business.
*North Carolina Agency Name:*North Carolina Agency Contact Name:
*North Carolina Agency Contact Email Address:*North Carolina Agency Contact Phone Number:
PRIOR FINANCIAL INFORMATION (only required for updates)
FINANCIAL INSTITUTION NAME:
NAME ON ACCOUNT:
ROUTING NUMBER:
ACCOUNT NUMBER:
ACCT TYPE: Checking Savings
REMIT E-MAIL ADDRESS
* ALL BOXES BELOW MUST BE REVIEWED AND CHECKED
I acknowledge that electronic payments to the designated account must comply with the provisions of U.S. law, and the requirements of
the Office of Foreign Assets Control (OFAC). I affirm the entire amount of the payment will not be transferred to a foreign bank account.
I authorize the Office of the State Controller to initiate ACH payments, and if necessary, adjustments for any ACH payments in error, to
the financial institution and account identified on the attached certification document. This authority will remain in effect until I, the vendor,
cancel it in writing or the authority is terminated by the NC Office of the State Controller.
I have attached a copy of a current voided check, current bank statement, or a bank authorization letter on bank letterhead signed by a bank representative.
*PRINT NAME:*DATE:
*SIGNATURE:*PHONE NUMBER:
6-6000327
Orange County, North Carolina
PO Box 8181
Hillsborough NC 27278
Gary Donaldson/CFO
No change to Financial Information
5
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
9/28/2022Gary Donaldson
Revised February 2020
Instructions * Denotes a required field on the form
1.*Check the appropriate box at the top of the form:
▪New Add Request – Vendor would like to begin receiving payments via ACH.
▪Change/Update Existing Account – Vendor’s account number, routing number, or remittance email address
has changed.
▪Inactivate Existing Account – Vendor no longer wants to receive payments via ACH.
2.*Enter the vendor’s Tax Identification Number or Social Security Number.
3.*Enter the Payee Name – The name of the person or business receiving payment.
4.*Enter the vendor’s remittance address. The remittance address is the address printed on your invoice where
payments should be sent.
5.*Enter the vendor’s contact name, title, and phone number.
6.*Enter the vendor’s financial information:
▪Financial Institution Name – Name of the financial institution.
▪Name on Account – The account owner’s name.
▪Routing Number – Nine-digit number identifying the financial institution.
▪Account Number – The bank account number where the funds should be deposited.
▪Account Type – Is this a checking or savings account? Check the appropriate box.
▪Remit E-mail address - Enter the email address to which the remittance advices should be sent.
7.*For a new add request only, provide the following:
▪North Carolina State Agency Name – The state agency the vendor is doing business with.
▪North Carolina State Agency Contact Name – The vendor’s contact person name at the state agency.
▪North Carolina State Agency Contact Email Address – The contact person’s email address at the state agency.
▪North Carolina State Agency Contact Phone Number – The contact person’s phone number at the state agency.
NOTE: New add requests MUST include contact information for the state agency with
which you are doing business.
8.Prior Financial Information – this is required if the vendor’s bank account, routing number, or remittance email
address has changed.
▪Financial Institution Name – Name of the prior financial institution.
▪Name on Account – The account owner’s name.
▪Routing Number – Nine-digit number identifying the prior financial institution.
▪Account Number – The bank account number where the funds were being deposited.
▪Account Type – Is this a checking or savings account? Check the appropriate box.
▪Remit E-mail address - Enter the email address to which the remittance advices were being sent.
9.*Review all the information in the 3 attestation boxes located above the signature area. All 3 boxes must be
checked – otherwise the form will not be processed.
10.*Print Name – Print the name of the authorized signee on the form.
*Date – Date of signature.
*Signature – The authorized signee’s signature.
*Phone Number – The authorized signee’s phone number.
Return to: OSC Support Services Center
Address:
1410 Mail Service Center
Raleigh, NC 27699-1410
Email: osc.support.services@osc.nc.gov
Please allow up to 30 days for processing.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 09/20
N.C. Department of Agriculture & Consumer Services
N.C. ADFP Trust Fund
Conservation Easement Monitoring Policy and Guidelines
I. Purpose
The N.C. Agricultural Development and Farmland Preservation (ADFP) Trust Fund, administered by the
Farmland Preservation Division of the N.C. Department of Agriculture & Consumer Services, provides
grants for agricultural conservation easements on family farms throughout the state of North Carolina.
The ADFP Trust Fund will “hold grantees accountable for the expenditure of State funds by performing
monitoring and oversight functions,” in accordance with Administrative Code 09 NCAC 03M “Uniform
Administration of State Grants” and Subsection .0400, pursuant to N.C.G.S. 143C-6-22 & 23. The ADFP
Trust Fund will work with the grantee to ensure compliance with the terms and conditions of the
easement. Monitoring is necessary to make certain the easements are maintained while ensuring a
productive relationship between the funding source (ADFP Trust Fund), grantee (counties or private
nonprofit conservation organizations, according to N.C.G.S. 106-744), and landowner.
II. Definition of Agricultural Conservation Easements
According to N.C.G.S. 106-744, an “agricultural conservation easement” means a negative easement in
gross restricting residential, commercial, and industrial development of land for the purpose of
maintaining its agricultural production capability. Agricultural conservation easements may be perpetual
or term-limited in duration. The agricultural conservation easement may permit the creation of not more
than three lots that meet applicable county zoning and subdivision regulations, provided it is allowed in
the original recorded easement.
III. Involved Parties
The ADFP Trust Fund, administered by the Commissioner of Agriculture, is the funding source for
purchasing conservation easements. The ADFP Trust Fund has full-time staff administratively located in
Raleigh, North Carolina. Part-time field staff members are located remotely throughout the state. The
ADFP Trust Fund Document Specialist is the monitoring program manager, unless otherwise designated
by the Farmland Preservation Division Director. Field staff members will conduct on-site monitoring,
unless otherwise directed by the Document Specialist.
The ADFP Trust Fund Advisory Committee is administratively located within the N.C. Department of
Agriculture and Consumer Services. The Advisory Committee will advise the Commissioner on the
prioritization and allocation of funds, the development of criteria for awarding funds, guidelines for
monitoring easements and projects, program planning, and other areas where monies from the ADFP
Trust Fund can be used to promote the growth and development of family farms in North Carolina.
Grantees are counties or private nonprofit conservation organizations. Grantees are the first point of
contact for monitoring conservation easements and discussing potential violations of contracts and/or
recorded easements. Grantees are required to monitor the easement at least once a year and
complete annual monitoring reports for the length of the term of the easement.
Landowners will work with grantees to ensure compliance with the terms and conditions of conservation
easements and will be notified of site visits by the grantee.
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Approved 09/20
IV.ADFP Trust Fund Monitoring Roles and Responsibilities
The ADFP Trust Fund monitoring methods include but are not limited to:
-Site visit: ADFP Trust Fund staff will make every effort to coordinate site visits with the grantee’s
monitoring schedule. ADFP Trust Fund staff will physically visit the easement. ADFP Trust Fund
staff will notify grantee and seek permission from landowner. The use of unmanned aerial
vehicles (UAVs), or drones, can supplement, but not replace in-person site visits.
-In-office: ADFP Trust Fund staff will review grantee monitoring reports and verify information.
Site visit protocol for ADFP Trust Fund staff:
-Contact grantee about site visit. Site visits will be coordinated to the extent possible with the
grantee’s annual monitoring visit schedule.
-Review completed “Grantee Monitoring Report – Perpetual or Term Easement.”
-Ensure landowner has been notified of site visit.
-Site visit can be conducted on foot or by vehicle.
-Compile documentation, including, but not limited to, photographs and data.
-Complete “ADFP Trust Fund Staff Monitoring Report – Perpetual or Term Easement.”
-Complete “ADFP Trust Fund Staff Incident Report – Perpetual or Term Easement” if necessary.
-Site visit will occur every three (3) years, unless otherwise directed.
In-office monitoring protocol for ADFP Trust Fund staff:
-Review completed “Grantee Monitoring Report – Perpetual or Term Easement.”
-Review the most current aerial photography data available (e.g. GIS via Multi-Hazard Threat
Database (MHTD), Google Earth, etc.).
-Complete “ADFP Trust Fund Staff In-Office Monitoring Report – Perpetual or Term Easement.”
-Complete “ADFP Trust Fund Staff Incident Report – Perpetual or Term Easement” if necessary.
-In-office monitoring will be completed in the years when site visits do not occur.
Incident report protocol for ADFP Trust Fund staff:
-The “ADFP Trust Fund Staff Incident Report – Perpetual or Term Easement” must be filed if a
grantee reports a violation or if ADFP Trust Fund staff discovers a violation during a site visit or
in-office monitoring.
-The completed “ADFP Trust Fund Staff Incident Report – Perpetual or Term Easement” will be
submitted to the Program Director for review, investigation, and/or corrective action.
-If necessary, the Program Director will meet with funding partners to discuss the findings of the
“ADFP Trust Fund Staff Incident Report – Perpetual or Term Easement.”
-If corrective action is warranted by the grantee, a conference call or meeting will be scheduled to
discuss the “ADFP Trust Fund Staff Incident Report – Perpetual or Term Easement” and results
of the initial review by the Program Director.
-If a violation has occurred, the grantee shall submit a Plan of Corrective Action to the ADFP Trust
Fund Staff within 30 days of the conference call or meeting. The Plan of Corrective Action must
be a comprehensive plan detailing the corrective action that will be taken to remedy all
violations and bring the project back in compliance. The ADFP Trust Fund staff will work with
grantee for correction.
-The appropriate NCDA&CS staff will formally notify grantee in writing of violation or potential
violation.
-If it is determined that a violation has occurred, a site visit will occur the subsequent year. The
monitoring schedule (site visit, in-office, site visit) will be reset each time a violation occurs.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 09/20
V. Grantee Monitoring Responsibilities and Expectations
After the approval of final budget and progress reports and the closeout of the contract, Grantees will
complete and submit the online “Grantee Monitoring Report – Perpetual or Term Easement” to ADFP
Trust Fund office annually on or before December 31. The “Grantee Monitoring Report – Perpetual or
Term Easement” is accessed through NC ADFP Trust Fund’s website. Grantees should navigate to
https://ncadfp.org/, then click on the “Downloads” tab. The portal is at the bottom of the “Downloads”
tab and is labeled “Grantees: Click Here to Access the ADFP Trust Fund Grantee Monitoring Report
Submission Portal.” Grantees will be required to create a Formsite account to access the report portal.
Grantees should follow the prompts in the online portal to complete and submit their report.
Failure to file annual monitoring reports on or before December 31 of each year shall constitute a
violation of the easement and the grant contract.
In January, ADFP Trust Fund staff will coordinate to the extent possible with the grantee’s annual
monitoring visit schedule for easements due for a site visit. Grantees are encouraged to submit tentative
site visit schedule to ADFP Trust Fund office ninety (90) days prior to first scheduled site visit. As
subsequent site visits are scheduled throughout the year by the grantee, the ADFP Trust Fund office will
be notified in a timely manner of site visits due for that calendar year.
VI. Additional Guidance and Reference – Dispute Resolutions
For issues in dispute, the ADFP Trust Fund Staff will report such differences to the Farmland
Preservation Director. If the Farmland Preservation Director is unable to find a resolution, the Director
will review with the appropriate NCDA&CS management for assistance and instruction, e.g. Office of the
General Counsel, Chief Deputy Commissioner, and Commissioner of Agriculture. See chart below.
ADFP Trust Fund Staff are to follow appropriate approved ADFP Trust Fund Policies and Guidelines as
directed by the ADFP Trust Fund Advisory Committee and the Commissioner of Agriculture, i.e. ADFP
Trust Fund Grantee Eligibility Classification.
VII. Monitoring Documents
The following documents will be used for the monitoring of conservation easements:
-Grantee Monitoring Report – Perpetual or Term Easement
-ADFP Trust Fund Staff Monitoring Report – Perpetual or Term Easement
-ADFP Trust Fund Staff In-Office Monitoring Report – Perpetual or Term Easement
-ADFP Trust Fund Staff Incident Report – Perpetual or Term Easement
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Approved 09/20
VIII.Document Filing, Retention, and Disposal
All completed reports, including maps from GIS and supplemental documentation from grantees, will be
scanned for electronic storage and printed for paper files. The North Carolina State Property Office, Land
Asset Maintenance database (http://www.ncspo.com/fis/dbLandAsset.aspx) lists all ADFP Trust Fund
funded easements. Electronic copies of monitoring documents will be stored on the ADFP Trust Fund
server and SharePoint page.
All monitoring documents will be filed, retained, and disposed pursuant to the ADFP Trust Fund records
retention schedule.
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06/15/2022
2022-2023 Annual Contract Attachment Completion Instructions -Governmental
You are receiving this packet because your entity has an active contract(s) or is being offered a
contract(s) with the Agricultural Development and Farmland Preservation (ADFP) Trust Fund. In order to
receive payments from the ADFP Trust Fund, each form in this packet must be completed and signed
every 12 months. Please follow the instructions below for completing and signing the forms. Contact
the ADFP Trust Fund Document Specialist, Sarah Weavil, at sarah.weavil@ncagr.gov or 919-707-3072
with questions.
Please complete, sign in blue or black ink, and return each of the included forms. A scanned/electronic
copy is acceptable and can be emailed to ADFP. All forms need to be dated at the time of signing.
Below are the portions of the contract that require completion..
1.Complete and sign the Certifications and Assurances in Attachment C. Place of performance
is your office’s physical address.
2.Complete NC OpenBook Supplemental Information in Attachment D.
3.Complete and sign Signature Card in Attachment E (Authorized Governmental Official and
Chief Fiscal Officer signatures).
4.Complete and sign Substitute W-9 form in Attachment F. This form must be dated at the
time of signing.
5.Attach a copy of a voided check or a letter from your bank, complete, and sign the Vendor
Electronic Payment Form in Attachment G. f there has been no change to your entity’s
information, the form still needs to be completed, signed, and attached with a voided check
or letter. This form must be dated at the time of signing
Please email the completed packet to Sarah Weavil at sarah.weavil@ncagr.gov.
If you are sending original copies, please return the completed packet via FedEX or UPS (not USPS) with
a tracking number to:
Veronica Jamison, Office Manager
N.C. Department of Agriculture & Consumer Services, Farmland Preservation
2 W. Edenton Street, Raleigh, NC 27601
Please return the completed packet within 10 working days (see policy below). If you are unable to
meet the deadline, please email Sarah within 10 working days of original receipt with the reason for the
delay.
If a selected grant recipient fails to return a completed grant contract by the stipulated deadline, ADFP
Trust Fund will notify the selected grant recipient in writing as a warning. The selected grant recipient
will be allowed a grace period of 10 working days from the date of correspondence to return the
completed contract. After the stipulated grace period, the offer will be rescinded and the grant funding
reallocated. (Approved by the ADFP Trust Fund Advisory Committee 12/09/08)
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
PUBLIC SECTOR CONTRACTS (Including Local Governments)
NCDA&CS - General Terms and Conditions – Public - Local Governmental Entities
Eff. 07/14;4/15;1/17 Page 1 of 4
General Terms and Conditions
DEFINITIONS
Unless indicated otherwise from the context, the
following terms shall have the following meanings in
this Contract. All definitions are from 9 NCAC
3M.0102 unless otherwise noted. If the rule or
statute that is the source of the definition is changed
by the adopting authority, the change shall be
incorporated herein:
(1) "Agency" (as used in the context of the
definitions below) shall mean and include
every public office, public officer or official
(State or local, elected or appointed),
institution, board, commission, bureau,
council, department, authority or other unit of
government of the State or of any county,
unit, special district or other political
subagency of government. For other
purposes in this Contract, “Agency” shall
mean the entity identified as one of the
parties hereto.
(2) "Audit" means an examination of records or
financial accounts to verify their accuracy.
(3) "Certification of Compliance" means a report
provided by the Agency to the Office of the
State Auditor that states that the Grantee has
met the reporting requirements established
by this Subchapter and included a statement
of certification by the Agency and copies of
the submitted grantee reporting package.
(4) "Compliance Supplement" refers to the North
Carolina State Compliance Supplement,
maintained by the State and Local
Government Finance Agency within the
North Carolina Department of State
Treasurer that has been developed in
cooperation with agencies to assist the local
auditor in identifying program compliance
requirements and audit procedures for
testing those requirements.
(5) "Contract" means a legal instrument that is
used to reflect a relationship between the
agency, grantee, and subgrantee.
(6) "Fiscal Year" means the annual operating
year of the non-State entity.
(7) "Financial Assistance" means assistance that
non-State entities receive or administer in the
form of grants, loans, loan guarantees,
property (including donated surplus
property), cooperative agreements, interest
subsidies, insurance, food commodities,
direct appropriations, and other assistance.
Financial assistance does not include
amounts received as reimbursement for
services rendered to individuals for Medicare
and Medicaid patient services.
(8) "Financial Statement" means a report
providing financial statistics relative to a
given part of an organization's operations or
status.
(9) "Grant" means financial assistance provided
by an agency, grantee, or subgrantee to
carry out activities whereby the grantor
anticipates no programmatic involvement
with the grantee or subgrantee during the
performance of the grant.
(10) "Grantee" has the meaning in G.S. 143C-6-
23(a)(2): a non-State entity that receives a
grant of State funds from a State agency,
department, or institution but does not
include any non-State entity subject to the
audit and other reporting requirements of the
Local Government Commission. For other
purposes in this Contract, “Grantee” shall
mean the entity identified as one of the
parties hereto.
(11) "Grantor" means an entity that provides
resources, generally financial, to another
entity in order to achieve a specified goal or
objective.
(12) "Non-State Entity" has the meaning in
N.C.G.S. 143C-1-1(d)(18): Any of the
following that is not a State agency: an
individual, a firm, a partnership, an
association, a county, a corporation, or any
other organization acting as a unit. The term
includes a unit of local government and
public authority.
(13) "Public Authority" has the meaning in
N.C.G.S. 143C-1-1(d)(22): A municipal
corporation that is not a unit of local
government or a local governmental
authority, board, commission, council, or
agency that (i) is not a municipal corporation
and (ii) operates on an area, regional, or
multiunit basis, and the budgeting and
accounting systems of which are not fully a
part of the budgeting and accounting
systems of a unit of local government.
(14) "Single Audit" means an audit that includes
an examination of an organization's financial
statements, internal controls, and compliance
with the requirements of federal or State
awards.
(15) "Special Appropriation" means a legislative
act authorizing the expenditure of a
designated amount of public funds for a
specific purpose.
(16) "State Funds" means any funds
appropriated by the North Carolina General
Assembly or collected by the State of North
Carolina. State funds include federal
Attachment A
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
PUBLIC SECTOR CONTRACTS (Including Local Governments)
NCDA&CS - General Terms and Conditions – Public - Local Governmental Entities
Eff. 07/14;4/15;1/17 Page 2 of 4
financial assistance received by the State
and transferred or disbursed to non-State
entities. Both federal and State funds
maintain their identity as they are subgranted
to other organizations. Pursuant to N.C.G.S.
143C-6-23(a)(1), the terms "State grant
funds" and "State grants" do not include any
payment made by the Medicaid program, the
Teachers' and State Employees'
Comprehensive Major Medical Plan, or other
similar medical programs.
(17) "Subgrantee" has the meaning in G.S.
143C-6-23(a)(3): a non-State entity that
receives a grant of State funds from a
grantee or from another subgrantee but does
not include any non-State entity subject to
the audit and other reporting requirements of
the Local Government Commission.
(18) "Unit of Local Government has the meaning
in G.S. 143C-1-1(d)(29): A municipal
corporation that has the power to levy taxes,
including a consolidated city-county as
defined by G.S. 160B-2(1), and all boards,
agencies, commissions, authorities, and
institutions thereof that are not municipal
corporations.
Relationships of the Parties
Independent Contractor: The Grantee is and shall
be deemed to be an independent Contractor in the
performance of this Contract and as such shall be
wholly responsible for the work to be performed and
for the supervision of its employees. The Grantee
represents that it has, or shall secure at its own
expense, all personnel required in performing the
services under this agreement. Such employees shall
not be employees of, or have any individual
contractual relationship with, the Agency.
Subcontracting: The Grantee shall not subcontract
any of the work contemplated under this Contract
without prior written approval from the Agency. Any
approved subcontract shall be subject to all
conditions of this Contract. Only the subcontractors
or subgrantees specified in the Contract documents
are to be considered approved upon award of the
Contract. The Agency shall not be obligated to pay
for any work performed by any unapproved
subcontractor or subgrantee. The Grantee shall be
responsible for the performance of all of its
subgrantees and shall not be relieved of any of the
duties and responsibilities of this Contract.
Subgrantees: The Grantee has the responsibility to
ensure that all subgrantees, if any, provide all
information necessary to permit the Grantee to
comply with the standards set forth in this Contract.
Assignment: No assignment of the Grantee's
obligations or the Grantee's right to receive payment
hereunder shall be permitted. However, upon written
request approved by the issuing purchasing authority,
the State may:
(a) Forward the Grantee's payment check(s)
directly to any person or entity designated by
the Grantee, or
(b) Include any person or entity designated by
Grantee as a joint payee on the Grantee's
payment check(s).
In no event shall such approval and action obligate
the State to anyone other than the Grantee and the
Grantee shall remain responsible for fulfillment of all
Contract obligations.
Beneficiaries: Except as herein specifically
provided otherwise, this Contract shall inure to the
benefit of and be binding upon the parties hereto and
their respective successors. It is expressly
understood and agreed that the enforcement of the
terms and conditions of this Contract, and all rights of
action relating to such enforcement, shall be strictly
reserved to the Agency and the named Grantee.
Nothing contained in this document shall give or
allow any claim or right of action whatsoever by any
other third person. It is the express intention of the
Agency and Grantee that any such person or entity,
other than the Agency or the Grantee, receiving
services or benefits under this Contract shall be
deemed an incidental beneficiary only.
Indemnity
Indemnification: The Grantee agrees to indemnify
and hold harmless the Agency, including any of its
Divisions, and any of its officers, agents and
employees, from liability of any kind, and from any
claims of third parties arising out of any act or
omission of the Contractor in connection with the
performance of this Contract to the extent permitted
by law.
Default and Termination
Termination by Mutual Consent: The Parties may
terminate this Contract by mutual consent with 60
days notice to the other party, or as otherwise
provided by law.
Termination for Cause: If, through any cause, the
Grantee shall fail to fulfill its obligations under this
Contract in a timely and proper manner, the Agency
shall have the right to terminate this Contract by
giving written notice to the Grantee and specifying
the effective date thereof.
In that event, all finished or unfinished deliverable
items prepared by the Grantee under this Contract
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shall, at the option of the Agency, become its
property and the Grantee shall be entitled to receive
just and equitable compensation for any satisfactory
work completed on such materials, minus any
payment or compensation previously made.
Notwithstanding the foregoing provision, the Grantee
shall not be relieved of liability to the Agency for
damages sustained by the Agency by virtue of the
Grantee’s breach of this agreement, and the Agency
may withhold any payment due the Grantee for the
purpose of setoff until such time as the exact amount
of damages due the Agency from such breach can be
determined. The filing of a petition for bankruptcy by
the Grantee shall be an act of default under this
Contract.
Waiver of Default: Waiver by the Agency of any
default or breach in compliance with the terms of this
Contract by the Grantee shall not be deemed a
waiver of any subsequent default or breach and shall
not be construed to be modification of the terms of
this Contract unless stated to be such in writing,
signed by an authorized representative of the Agency
and the Grantee and attached to the Contract.
Availability of Funds: The parties to this Contract
agree and understand that the payment of the sums
specified in this Contract is dependent and contingent
upon and subject to the appropriation, allocation, and
availability of funds for this purpose to the Agency.
Force Majeure: Neither party shall be deemed to be
in default of its obligations hereunder if and so long
as it is prevented from performing such obligations by
any act of war, hostile foreign action, nuclear
explosion, riot, strikes, civil insurrection, earthquake,
hurricane, tornado, or other catastrophic natural
event or act of God.
Survival of Promises: All promises, requirements,
terms, conditions, provisions, representations,
guarantees, and warranties contained herein shall
survive the Contract expiration or termination date
unless specifically provided otherwise herein, or
unless superseded by applicable federal or State
statutes of limitation.
Intellectual Property Rights
Copyrights and Ownership of Deliverables: All
deliverable items produced pursuant to this Contract
are the exclusive property of the Agency. The
Grantee shall not assert a claim of copyright or other
property interest in such deliverables.
Compliance with Applicable Laws
Compliance with Laws: The Grantee shall comply
with all laws, ordinances, codes, rules, regulations,
and licensing requirements that are applicable to the
conduct of its business, including those of federal,
State, and local agencies having jurisdiction and/or
authority.
Equal Employment Opportunity: The Grantee
shall take affirmative action in complying with all
federal and State statutes and all applicable
requirements concerning fair employment of people
with disabilities, and concerning the treatment of all
employees without regard to discrimination by reason
of race, color, religion, sex, national origin or
disability. For additional information see Title VI of the
Civil Rights Act of 1964 (42 U.S.C., 2000d, 2000e-
16), Title XI of the Education amendments of 1972,
as amended (20 U.S.C. 1681-1683 and 1685-1686),
and section 504 of the Rehabilitation Act of 1973 as
amended (29 U.S.C. 794).
Executive Order 24: In accordance with Executive
Order 24, issued by Governor Perdue, and N.C.G.S.§
133-32, a vendor or contractor (i.e. architect, bidder,
contractor, construction manager, design
professional, engineer, landlord, offeror, seller,
subcontractor, supplier, vendor, or grantee), is
prohibited from making gifts or giving favors to any
employee of the Agency of Agriculture and Consumer
Services. This prohibition covers those vendors ,
contractors, and/or grantees who:
(a) have a Contract with a governmental
Agency; or
(b) have performed under such a Contract within
the past year; or
(c) anticipate bidding on such a Contract in the
future.
For additional information regarding the specific
requirements and exemptions, vendors, contractors,
and/or grantees are encouraged to review Executive
Order 24 and N.C.G.S. § 133-32.
Confidentiality
Confidentiality: Any information, data, instruments,
documents, studies or reports given to or prepared or
assembled by the Grantee under this agreement
shall be kept as confidential and not divulged or
made available to any individual or organization
without the prior written approval of the Agency. The
Grantee acknowledges that in receiving, storing,
processing or otherwise dealing with any confidential
information it will safeguard and not further disclose
the information except as otherwise provided in this
Contract.
Oversight
Access to Persons and Records: The State Auditor
and the using agency’s internal auditors shall have
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PUBLIC SECTOR CONTRACTS (Including Local Governments)
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access to persons and records as a result of all
Contracts or grants entered into by State agencies or
political subdivisions in accordance with General
Statute 147-64.7 and Session Law 2010-194, Section
21 (i.e., the State Auditors and internal auditors may
audit the records of the contractor during the term of
the Contract to verify accounts and data affecting
fees or performance).
Record Retention: Records shall not be destroyed,
purged or disposed of without the express written
consent of the Agency. State basic records retention
policy requires all grant records to be retained for a
minimum of five years or until all audit exceptions
have been resolved, whichever is longer. If the
Contract is subject to federal policy and regulations,
record retention may be longer than five years since
records must be retained for a period of three years
following submission of the final Federal Financial
Status Report, if applicable, or three years following
the submission of a revised final Federal F inancial
Status Report. Also, if any litigation, claim,
negotiation, audit, disallowance action, or other
action involving this Contract has been started before
expiration of the five-year retention period described
above, the records must be retained until completion
of the action and resolution of all issues which arise
from it, or until the end of the regular five-year period
described above, whichever is later.
Miscellaneous
Choice of Law: The validity of this Contract and any
of its terms or provisions, as well as the rights and
duties of the parties to this Contract, are governed by
the laws of North Carolina. The Grantee, by signing
this Contract, agrees and submits, solely for matters
concerning this Contract, to the exclusive jurisdiction
of the courts of North Carolina and agrees, solely for
such purpose, that the exclusive venue for any legal
proceedings shall be Wake County, North Carolina.
The place of this Contract and all transactions and
agreements relating to it, and their situs and forum,
shall be Wake County, North Carolina, where all
matters whether sounding in Contract or tort, relating
to the validity, construction, interpretation, and
enforcement shall be determined.
Headings: The Section and Paragraph headings in
these General Terms and Conditions are not material
parts of the agreement and should not be used to
construe the meaning thereof.
Time of the Essence: Time is of the essence in the
performance of this Contract.
Care of Property: The Grantee agrees that it shall
be responsible for the proper custody and care of any
property furnished to it for use in connection with the
performance of this Contract and will reimburse the
Agency for loss of, or damage to, such property. At
the termination of this Contract, the Grantee shall
contact the Agency for instructions as to the
disposition of such property and shall comply with
these instructions.
Amendment: This Contract may not be amended
orally or by performance. Any amendment must be
made in written form and executed by duly authorized
representatives of the Agency and the Grantee.
Severability: In the event that a court of competent
jurisdiction holds that a provision or requirement of
this Contract violates any applicable law, each such
provision or requirement shall continue to be
enforced to the extent it is not in violation of law or is
not otherwise unenforceable and all other provisions
and requirements of this Contract shall remain in full
force and effect.
Travel Expenses: Reimbursement to the Grantee
for travel mileage, meals, lodging and other travel
expenses incurred in the performance of this
Contract shall be reasonable and supported by
documentation. State rates shall be used.
International travel shall not be reimbursed under this
Contract.
Sales/Use Tax Refunds: If eligible, the Grantee and
all subgrantees shall: (a) ask the North Carolina
Department of Revenue for a refund of all sales and
use taxes paid by them in the performance of this
Contract, pursuant to G.S. 105-164.14; and (b)
exclude all refundable sales and use taxes from all
reportable expenditures before the expenses are
entered in their reimbursement reports.
Advertising: The Grantee shall not use the award of
this Contract as a part of any news release or
commercial advertising.
Indirect Costs Policy: The Agency has adopted a
“Zero” policy that indirect costs are unallowable
expenditures in all State funded grant applications
and/or grant guidance, informational or directional
documents.
Allowable Uses of State Funds: Expenditures of
State funds by any grantee shall be in accordance
with the Cost Principles outlined in the Office of
Management and Budget (OMB) CFR Title 2, Part
200 Uniform Administrative Requirements, as
applicable. If the grant funding includes federal
sources, the grantee shall ensure adherence to the
cost principles established by the Federal Office of
Management and Budget. [09 NCAC 03M.020]
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Certifications and Assurances
NCDA&CS Certifications & Assurances Page 1 of 3
Rev 9/12, 10/12, 11/13;1/17
CERTIFICATIONS REGARDING LOBBYING, NONPROCUREMENT, DEBARMENT,
SUSPENSION AND DRUG-FREE WORKPLACE
Applicants should refer to the regulations cited below to determine the certification to which they are
required to attest. Signature of this form provides for compliance with certification requirements under 2
CFR, Subtitle B, Chapter IV, Part 417, "Nonprocurement Debarment and Suspension," Part 418, "New
Restrictions on Lobbying,” and Part 421, “Requirements for Drug-Free Workplace (Financial Assistance),"
and 2 CFR Part 180. The certifications shall be treated as a material representation of fact upon which
reliance will be placed when the Department of Agriculture & Consumer Services determines to award the
covered transaction, grant, or cooperative agreement.
1. LOBBYING
As required by authority: 31 U.S.C. 1352 and U.S.C. 301 and implemented at 2 CFR Part 180, for persons
entering into a grant or cooperative agreement over $100,000, as defined at 2 CFR Section 418.110, the
applicant certifies that to the best of their knowledge and belief, that:
1)No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned,
to any person for influencing or attempting to influence an officer or employee of an agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with the awarding of any Federal contract, the making of any Federal
contract, the making of any Federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan,
or cooperative agreement.
2)If any funds other than Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in
connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall
complete and submit Standard Form -LLL, “Disclosure Form to Report Lobbying” in accordance
with its instructions.
3)The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly.
This certification is a material representation of fact upon which r eliance was placed when this transaction
was made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required
certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for
each such failure.
2.NONPROCUREMENT DEBARMENT AND SUSPENSION
As required by Executive Order 12549, Debarment and Suspension, and implemented at 2 CFR Part 180
and 2CFR Part 417, for prospective participants in primary covered transactions, as defined at 2 CFR
180.435 and Subpart C, 417.332, the applicant certifies that it and its principals:
a)Are not presently debarred, suspended, proposed for debarment, declared ineligible, or v oluntarily
excluded from covered transactions by any Federal department or agency;
b)Have not within a three-year period preceding this application been convicted of or had a civil
judgment rendered against them for commission of fraud or a criminal offense in connection with
obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or
contract under a public transaction; violation of Federal or State antitrust statutes or commission of
embezzlement, theft, forgery, briber y, falsification or destruction of records, making false
statements, or receiving stolen property;
Attachment C
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c)Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity
(Federal, State, or local) with commission of any of the offenses enumerated in paragraph 2. (a)
(b) of this certification.
d)Have not within a three-year period preceding this application had o ne or more public transaction
(Federal, State, or local) terminated for cause or default.
e)Agree to include a term or condition in lower tier covered transactions requiring lower tier
participants to comply with subpart C of the OMB guidance in 2 CFR part 180, as supplemen ted by
subpart C of Part 417.
Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach
an explanation to this certification.
3.DRUG-FREE WORKPLACE (GRANTEES OTHER THAN INDIVIDUALS)
As required by the Drug-Free Workplace Act of 1988, and implemented at 2 CFR Part 182, Subparts B,
and C, for grantees:
The applicant certifies that it will:
a)Make a good faith effort, on a continuing basis, to maintain a drug -free workplace. You must
agree to do so as a condition for receiving any award covered by this part.
b)Publish a drug-free workplace statement and establish a drug-free awareness program for your
employees (see Sections 182.205 through 182.220); and
c)Take actions concerning employees who are convicted of violating drug statutes in the w orkplace
(see Section 182.225), including notification to any Fe deral agency on whose award the convicted
employee was working and within 30 days take appropriate personnel action against the
employee, up to and including termination, consistent with the requirements of the Rehabilitation
Act of 1973 (29 U.S.C. 794), as amended; or require the employee to participate satisfactorily in a
drug abuse assistance or rehabilitation program approved for these purposes by a Federal, State
or local health, law enforcement, or other appropriate agency.
d)You must identify all known workplaces under your Federal awards (see Section 182.230).
The grantee must provide the location site(s) for the performance of work done in connection with t he
specific grant.
Place(s) of Performance (Street address, city, county, state, zip code)
DRUG-FREE WORKPLACE (GRANTEES WHO ARE INDIVIDUALS)
As required by the Drug-Free Workplace Act of 1988, and implemented at 2 CFR Part 182:
A.As a condition of the grant, I certify that I will comply with drug-free workplace requirements in
Subpart B (or Subpart C, if the recipient is an individual) of part 421, which adopts the Government -
wide implementation (2 CFR part 182) of sec. 5152-5158 of the Drug Free Workplace Act of 1988
(Pub.L100-690, Title V, Subtitle D; 41 U.S.C. 701-707).
Bonnie B Davis Agricultural and Environment Building
1020 US 70 West
Hillsborough, NC 27278
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B. I agree to notify the agency as required by 2 CFR 182.300(b) of any conviction for a criminal drug
offense within ten days.
Notice shall include the identification number(s) of each affected grant.
As the duly authorized representative of the Grantee, I hereby certify and state to the best of my
knowledge and belief, that the Grantee will comply with the above certifications.
Grantee Organization Name
Signature of Authorized Representative Date
Printed Name of Authorized Representative Title
Orange County, a local body politic
Bonnie B. Hammersley County Manager
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
9/28/2022
NC OpenBook Supplemental Information
Page 1 of 1 NCDA&CS NC OpenBook Supplemental
Information Rev 07/14; 4/17; 5/22
Instructions: Complete the information below and return it to the Contract Administrator identified in your
original contract. This information must be submitted as part of your contract. If you have questions,
please contact the Contract Administrator or the Alternate Contact as reflected in your contract.
Grantee Name:
County of Residence: District Number (MUST BE FILLED IN):
Tax Id Number:
UEI Number**: I have started the UEI process but not received a UEI number.
*Due to the SAM.gov migration from DU& Bradstreet, obtaining a UEI number has created unforeseen issues with the SAM.gov website search engines and portals. Due to the
massive backlog in validation ticket issues, we are not requiring the UEI numbers at this time; however, if you have started the process, please let us know OR if you UEI number
please provide it.
Fiscal Year End:
(MM/DD) Format
Grantee’s Website:
Current project timeline: Begin date End Date
Attachment D
Expected outcomes and specific deliverables: Expected outcome is intended result of your grant
program. The specific deliverables are the accomplishments that will be achieved with the grant. EXAMPLE: Funding for the Farmers Produce Box
program will allow an additional 150 boxes to be created this year. This will allow approximately 37 additional families to receive these the boxes 4
times a week to help resolve their food insecurity. MAX CHARACTERS: 300
**If your answer is Regional, list all Counties that are receiving
benefit:
Project Location Benefit Information: (Location(s) in which funding will be spent and/or
food commodities will be received.)
Single County
Regional**
Mountains
Piedmont
Inner Coastal Plain
Tidewater
Statewide
GRANTEE INFORMATION:
PROJECT INFORMATION:
Brief Description and Background/History of your Organization: Be sure to include the number of years in existence,
number of employees, mission and goals of your organization. MAX CHARACTERS: 250
Orange County
Orange County
566000327
GFFMCW9XDA53
06/30 https://www.orangecountync.gov/
Lands Legacy Program of Orange County, 22 years. Two employees, one FT, one PT. A comprehensive program for the
acquisition of protection of highly important natural and cultural resource lands in Orange County.
This project will encourage the preservation of qualifying farmland and foster the growth, development, and
sustainability of family farms in North Carolina.
July 1, 2022 June 30, 2023
4
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Signature Card
Page 1 of 1 NCDA&CS - Signature Card – NGO & Governmental
Rev 7/14; 1/17;11/17
CONTRACT & FINANCIAL DOCUMENTS
INSTRUCTIONS: Please read and fill in the required information to the right of each field where applicable. Signatures
must match the Contract signatures. In the event the affixed signature(s) are no longer valid, a revised form must
be submitted prior to processing any contractual documents or submitting “Request for Payments” or any other
financial documents. If more than two people will sign for the organization, this form may be duplicated.
SECTION I.
Date:
Legal Applicant Organization/Agency Name:
Federal Tax Identification Number:
SECTION II.
Certification:
By affixing my signature below, I certify that person(s) identified are designated having legal authorization to sign on
behalf of the organization named in Section I., above, for purposes of executing contractual documents and preparing,
approving and executing all financial documents; including “Requests for Payments.” I understand the legal implications
of any and all misrepresentation, which include but are not limited to defrauding the State of North Carolina, and certify
that the person signing below has full authority to execute this Agreement on behalf of the named organization.
NON-GOVERNMENTAL ORGANIZATIONS ONLY (Must match Contract signature)
Board Chair, Executive Director, etc. Financial Representative, Treasurer, etc.
Print Name & Title: Print Name & Title:
Signature: Signature:
GOVERNMENTAL ENTITIES (Must match Contract signature)
Authorized Governmental Official Chief Fiscal Officer
Print Name & Title: Print Name & Title:
Signature: Signature:
Attachment E
Orange County
566000327
Bonnie Hammersley, County Manager Gary Donaldson, Chief Financial Officer
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
NC Office of the
State Controller
(IRS Form W-9 will not be
accepted in lieu of this form)
*Denotes a Required Field
STATE OF NORTH CAROLINA
SUBSTITUTE W-9 FORM
Request for Taxpayer Identification Number
Please complete the “Modification to Existing Vendor Records” section below If there have been any changes to the following: Tax Identification Number (TIN),
Legal Name, Business Name, Remittance Address
Return to the NC State Agency from which you are requesting payment. Section 1– Taxpayer Identification Section 2 -Certification *1. Social Security Number (SSN),
OR
Employer Identification Number (EIN),
OR
Individual Taxpayer Identification Number (ITIN)
*2.
Please select the appropriate Taxpayer Identification Number (EIN, SSN,
or ITIN) type and enter your 9-digit ID number. The U.S. Taxpayer
Identification Number is being requested per U.S. Tax Law. Failure to
provide this information in a timely manner could prevent or delay
payment to you or require The State of NC to withhold 24% for backup
withholding tax.
*4. Legal Name (as shown on your income tax return):3. Dunn & Bradstreet Universal Numbering System (DUNS) (see
instructions)
5. Business Name/DBA/Disregarded Entity Name, if different from
Legal Name:
Contact Information
*6. Legal Address 7. Remittance Address (Location specifically used for payment that is
different from Legal Address, if applicable)
*Address Line 1: Address Line 1:
Address Line 2: Address Line 2:
*City *State *Zip (9 digit) City State Zip (9 digit)
*County County
*8. Contact Name:
*9. Phone Number:
10. Fax Number:
11. Email Address:
*12. Entity Type *13. Entity
Classification
14. Exemptions (see
instructions)
Individual/Sole Proprietor/Single-member LLC C-Corporation S-Corporation
Partnership Trust/Estate Other___________________________
Limited liability company. Enter the tax classification (C=C corporation,
S=S corporation, P=Partnership) ________
Note: Check the appropriate box in the line above for the tax classification of the single-
member owner. Do not check LLC if the LLC is classified as a single-member LLC that is
disregarded from the owner unless the owner of the LLC is another LLC that is not
disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC
that is disregarded from the owner should check the appropriate box for the tax classification
of its owner.
Exempt payee code (if any):
Exemption from FATCA
reporting code (if any):
Under penalties of perjury, I certify that:
1.The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service
(IRS) that I am subject to backup withholding because of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer
subject to backup withholding, and
3.I am a U.S. citizen or other U.S. person (defined later in general instructions), and
4.The FATCA code(s) entered on this form (if any) indicting that I am exempt from FATCA reporting is correct.
Certification instructions: Please refer to the IRS Form W-9 located on the IRS Website (https://www.irs.gov/):
*Printed Name: *Printed Title:
*Authorized U.S.
Signature:
* Date:
Medical Services
Legal/Attorney
Services
NC Local Govt
Federal Govt
NC State Agency
Other Govt
Other (specify)
N/A
Attachment FREV 01/2019
(PRESS THE TAB KEY TO ENTER EACH NUMBER)
(DO NOT TYPE OR WRITE IN THIS FIELD)
5 6 6 0 0 0 3 2 7
Orange County
P.O. Box 8181
Hillsborough NC 27278
Orange
Gary Donaldson
919-245-2453
gdonaldson@orangecountync.gov
local governmentn
n
n
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
9/28/2022
Gary Donaldson Chief Financial Officer
NC Office of the
State Controller
*Denotes a Required Field
This form is to be
completed by the vendor.
STATE OF NORTH CAROLINA
SUBSTITUTE W-9 FORM
Modification to Existing Vendor Records
This form is to be completed by the vendor if one or more of the following have changed:
1.Change of remittance address.
2.Change of Social Security Number (SSN), or Employer Identification Number (EIN), or Individual Taxpayer
Identification Number (ITIN).
3.Change of Vendor Name.
Please complete the applicable sections below.
Section 1:
CHANGE FROM: Remittance Address CHANGE TO: Remittance Address
Section 2:
*CHANGE FROM: SSN, or EIN, or ITIN *CHANGE TO: SSN, or EIN, or ITIN
Section 3:
CHANGE FROM: Vendor Name CHANGE TO: Vendor Name
*Address Line 1:
Address Line 2:
*City *State *Zip (9 digit)
*County
*Address Line 1:
Address Line 2:
*City *State *Zip (9 digit)
*County
*Legal Name:*Legal Name:
Business Name/DBA/Disregarded Entity
Name, if different from Legal Name:
Business Name/DBA/Disregarded Entity
Name, if different from Legal Name:
*Printed Name:*Printed Title:
*Authorized U.S.
Signature:
*Date:
NOTE: If you would like to receive your payments electronically, please
complete the Vendor Electronic Payment Form
(PRESS THE TAB KEY TO ENTER EACH NUMBER) (PRESS THE TAB KEY TO ENTER EACH NUMBER)
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
NC Office of the State Controller Substitute W-9 Instructions Page 1
General Instructions
For General Instructions, please refer to the IRS Form W-9 located on the IRS Website (https://www.irs.gov/).
Specific Instructions
Section 1 -Taxpayer Identification
1. Taxpayer Identification Type. Check the type of identification number provided in box 2.
2. Taxpayer Identification Number (TIN). Enter taxpayer’s nine-digit Employer Identification Number (EIN), Social Security Number (SSN), or Individual Taxpayer
Identification Number (ITIN) without dashes.
Note: If an LLC has one owner, the LLC's default tax status is "disregarded entity". If an LLC has two owners, the LLC's default tax status is "partnership". If an LLC has
elected to be taxed as a corporation, it must file IRS Form 2553 (S Corporation) or IRS Form 8832 (C Corporation).
3. Dunn and Bradstreet Universal Numbering System (DUNS). Vendors are requested to enter their DUNS number, if applicable.
4. Legal Name. Enter the legal name as registered with the IRS or Social Security Administration. In general, enter the name shown on your income tax return. Do
not enter a Disregarded Entity Name on this line.
5. Business Name. Business, Disregarded Entity, trade, or DBA ("doing business as") name.
Contact Information
6. Enter your Legal Address.
7. Enter your Remittance Address, if applicable. A Remittance Address is the location in which you or your entity receives business payments.
8. Enter the Contact Name.
9. Enter your Business Phone Number.
10. Enter your Fax Number, if applicable.
11. Enter your Email Address, if applicable.
For clarification on IRS Guidelines, see www.irs.gov.
12. Entity Type. Select the appropriate entity type.
13. Entity Classification. Select the appropriate classification type.
Exemptions
If you are exempt from backup withholding and/or FATCA reporting, enter in the Exemptions box, any code(s) that may apply to you. See Exempt payee code and
Exemption from FATCA reporting code below.
14. Exempt payee code. Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends. Corporations are not exempt from backup withholding for payments made in settlement of
payment card or third party network transactions.
Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding.
The following codes identify payees that are exempt from backup withholding:
1 - An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section
401(f)(2)
2 - The United States or any of its agencies or instrumentalities
3 - A state, the District of Columbia, a possession of the United States, or any of their political subdivisions, or instrumentalities
4 - A foreign government or any of its political subdivisions, agencies, or instrumentalities
5 - A corporation
6 - A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States
7 - A futures commission merchant registered with the Commodity Futures Trading Commission
8 - A real estate investment trust
9 - An entity registered at all times during the tax year under the Investment Company Act of 1940
10- A common trust fund operated by a bank under section 584(a)
11 - A financial institution
12 - A middleman known in the investment community as a nominee or custodian
13 - A trust exempt from tax under section 664 or described in section 4947.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
NC Office of the State Controller Substitute W-9 Instructions Page 2
The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.
If the payment is for… THEN the payment is exempt for…
Interest and dividend payments All exempt payees except for 7
Broker transactions Exempt payees 1 through 4 and 6 through
11 and all C corporations. S corporations
must not enter an exempt payee code
because they are exempt only for sales of
noncovered securities acquired prior to
2012.
Barter exchange transactions and patronage
dividends
Exempt payees 1 through 4
Payments over $600 required to be reported and
direct sales over $5,000¹
Generally, exempt payees 1 through 5²
Payments made in settlement of payment card
or third party network transactions
Exempt payees 1 through 4
¹ See Form 1099-MISC, Miscellaneous Income, and its instructions.
² However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care
payments, attorneys' fees, gross proceeds paid to an attorney, and payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting
this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account
you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to
these requirements.
A - An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)
B - The United States or any of its agencies or instrumentalities
C - A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities
D - A corporation the stock of which is regularly traded on one or more established securities markets, as described in Reg. section 1.1472- 1(c)(1)(i)
E - A corporation that is a member of the same expanded affiliated group as a corporation described in Reg. section 1.1472-1(c)(1)(i)
F - A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as
such under the laws of the United States or any state
G - A real estate investment trust
H - A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940
I - A common trust fund as defined in section 584(a)
J - A bank as defined in section 581
K - A broker
L - A trust exempt from tax under section 664 or described in section 4947(a)(1)
M - A tax exempt trust under a section 403(b) plan or section 457(g) plan
Section 2 - Certification
To establish to the paying agency that your TIN is correct, you are not subject to backup withholding, or you are a U.S. person, or resident alien, sign the certification
on NC Substitute Form W-9. You are being requested to sign by the State of North Carolina.
For additional information please refer to the IRS Form W-9 located on the IRS Website (https://www.irs.gov/).
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Revised May 2018
Office of the State Controller
Return to: OSC Support Services Center
Address: 1410 Mail Service Center
Raleigh, NC 27699-1410
Email: osc.support.services@osc.nc.gov
Telephone: 919-707-0795
Vendor Electronic Payment Form
New Add Request
Change/Update Existing Account
Inactivate Existing Account
*Denotes a required field
The State of North Carolina offers payees the opportunity to receive payments electronically through U.S. based banks. In addition to
having the funds deposited electronically, you will also receive remittance information by e-mail.
We require you to submit a copy of a voided check, bank statement, or a letter from your bank for account verification.
*TAX ID # or SSN
*PAYEE NAME
*REMITTANCE ADDRESS
(AS PRINTED ON STREET SUITE/ROOM #
YOUR INVOICE)
CITY STATE ZIP CODE
*CONTACT
NAME & TITLE PHONE NUMBER
NEW FINANCIAL INFORMATION
*FINANCIAL INSTITUTION NAME:
*NAME ON ACCOUNT:
*NEW ROUTING NUMBER:
*NEW ACCOUNT NUMBER:
*ACCT TYPE: Checking Savings
*REMIT E-MAIL ADDRESS
New add requests MUST include contact information for the state agency with which you are doing business.
*Agency Name:*Agency Contact Name:
*Agency Contact Email Address:*Agency Contact Phone Number:
PRIOR FINANCIAL INFORMATION (only required for updates)
FINANCIAL INSTITUTION NAME:
NAME ON ACCOUNT:
ROUTING NUMBER:
ACCOUNT NUMBER:
ACCT TYPE: Checking Savings
REMIT E-MAIL ADDRESS
* ALL BOXES BELOW MUST BE REVIEWED AND CHECKED
I acknowledge that electronic payments to the designated account must comply with the provisions of U.S. law, and the requirements of
the Office of Foreign Assets Control (OFAC). I affirm the entire amount of the payment will not be transferred to a foreign bank account.
I authorize the Office of the State Controller to initiate ACH payments, and if necessary, adjustments for any ACH payments in error, to
the financial institution and account identified on the attached certification document. This authority will remain in effect until I, the vendor,
cancel it in writing or the authority is terminated by the NC Office of the State Controller.
I have attached a copy of a current voided check, current bank statement or included a bank letter on bank letterhead.
*PRINT NAME:*DATE:
*SIGNATURE:*PHONE NUMBER:
No change
(Or current information if no changes)
Attachment G
6-6000327
Truist Bank
Orange County, North Carolina
Same 401036167
Same 061000104
Gary Donaldson 9/28/2022
919-245-2453
XXX
XX
XX
, North Carolina
/CFO
5
Orange County
PO Box 8181
Hillsborough NC 27278
Gary Donaldson 919-245-2453
n
NC Dept of Agriculture and Consumer Services Allison Rodriguez
allison.rodriguez@ncagr.gov 919-707-3073
n
Gary Donaldson Digitally signed by Gary Donaldson
Date: 2022.09.28 09:28:21 -04'00'
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Revised May 2018
Instructions * Denotes a required field on the form
1.*Check the appropriate box at the top of the form:
▪New Add Request – Vendor would like to begin receiving payments via ACH.
▪Change/Update Existing Account – Vendor’s account number, routing number, or remittance email address
has changed.
▪Inactivate Existing Account – Vendor no longer wants to receive pa yments via ACH.
2.*Enter the vendor’s Tax Identification Number or Social Security Number.
3.*Enter the Payee Name – The name of the person or business receiving payment.
4.*Enter the vendor’s remittance address. The remittance address is the address printed on your invoice where
payments should be sent.
5.*Enter the vendor’s contact name, title, and phone number.
6.*Enter the vendor’s financial information:
▪Financial Institution Name – Name of the financial institution.
▪Name on Account – The account owner’s name.
▪Routing Number – Nine-digit number identifying the financial institution.
▪Account Number – The bank account number where the funds should be deposited.
▪Account Type – Is this a checking or savings account? Check the appropriate box.
▪Remit E-mail address - Enter the email address to which the remittance advices should be sent.
7.*For a new add request only, provide the following:
▪Agency Name – The state agency the vendor is doing business with.
▪Agency Contact Name – The vendor’s contact person name at the state agency.
▪Agency Contact Email Address – The contact person’s email address at the state agency.
▪Agency Contact Phone Number – The contact person’s phone number at the state agency.
NOTE: New add requests MUST include contact information for the state agency with
which you are doing business.
8.Prior Financial Information – this is required if the vendor’s bank account, routing number, or remittance email
address has changed.
▪Financial Institution Name – Name of the financial institution.
▪Name on Account – The account owner’s name.
▪Routing Number – Nine-digit number identifying the financial institution.
▪Account Number – The bank account number where the funds should be deposited.
▪Account Type – Is this a checking or savings account? Check the appropriate box.
▪Remit E-mail address - Enter the email address to which the remittance advices should be sent.
9.*Review all the information in the 3 attestation boxes located above the signature area. All 3 boxes must be
checked – otherwise the form will not be processed.
10.*Print Name – Print the name of the authorized signee on the form.
*Date – Date of signature.
*Signature – The authorized signee’s signature.
*Phone Number – The authorized signee’s phone number.
Return to: OSC Support Services Center
Address:
1410 Mail Service Center
Raleigh, NC 27699-1410
Email: osc.support.services@osc.nc.gov
Please allow up to 30 days for processing.
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
Revised 06/21
ORANGE COUNTY—DEPARTMENT USE ONLY
______________________________________________________________________________
Party/Vendor Name: North Carolina Department of Agriculture and Consumer Services Party/Vendor Contact
Person: N. David Smith Contact Phone: 919-707-3033 Party/Vendor Address: 1001 Mail Service Center City
Raleigh State: NC Zip: 27699 Department: DEAPR Amount: $189,645.15 Purpose: Approval of NCADFP Grant
Contract for matched funds in acquisition of Conservation Easement of Poteat Family Farms Budget Code(s):
61370035-899950-20006 Vendor # 25374 (N/A if new vendor) Vendor is a BOCC consultant? Yes No
Contract Type: (Check one) New Renewal Amendment Effective Date 10/01/2022 Approved by Board
Yes No Agenda Date: 09/20/2022 --- For Section XIV. c. contracts only, Approved by Board in Current FY
Budget Yes No
This agreement is approved as to technical form and content and I as Department Director affirmatively state work on
this project has not been initiated prior to execution of the agreement:
Department Director’s Signature ________________________________________ Date: ________
Agreements for emergency services or repair are not subject to the above affirmation. If services related to this
agreement have already begun or been completed please briefly describe the nature of the emergency condition that
was addressed:
Information Technologies
(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is
approved as to information technology content and specifications:
Office of the Chief Information Officer___________________________________ Date: ________
Risk Management
This agreement is approved for sufficiency of insurance standards, specifications, and requirements:
Office of the Risk Management Officer___________________________________ Date: _________
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer ____________________________________ Date: _________
Legal Services
This agreement is approved as to legal form and sufficiency:
Office of the County Attorney __________________________________________Date: ________
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board __________________________________________Date:_________
DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2
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