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Project Date Rec d Bicentennial Nature Trust Application Form I. PROJECT NAME II. DESCRIPTION OF PROPOSED PROJECT Include acreage and special features. All property must be open to the public* III. PROJECT TYPE A. PROJECT CATEGORIES Check all that apply Wetlands Public Access River Buffer Upland Forest Savanna/Prairie Greenways Other Threatened/Endangered Species B. ACQUISITION TYPE Inholding New property Addition to existing conservation area Conservation Easement C. PROPOSED PROPERTY OWNERSHIP AND MANAGEMENT DNR will own the property Yes No If answer is NO who will own the property DNR will manage the property D. COUNTY/COUNTIES County E* LOCATION S Section Township Range Township Name Rural Road name or number F* PROPERTY ZONING AND ADJACENT LAND USE G* LANDOWNERS List property owners with addresses and phone numbers. H. ENVIRONMENTAL ASSESSMENTS STUDIES APPRAISALS BOUNDARY SURVEYS OR EVALUATIONS OF THE PROPERTY List or attach if available I. HAZARDS Are there any known environmental hazards on the property If yes please provide documentation* J* STRUCTURES List any structures on the property. Indicate if any structures are within a floodway K. OTHER Indicate if any dams active or abandoned water wells or natural gas wells are present on the property. IV. MAPS Attach an 8 1/2 x 11 Map s that includes the project site. Please outline and cross-hatch the project area* V. FUNDING/COST OF ACQUISITION A. Proposed Bicentennial Nature Trust Fund SHARE B. MATCHING FUNDS OR VALUES A portion of the project review and rating will be based upon the ratio of outside matching funds. A match ratio of at least 1 to 1 is encouraged List sources and amounts of matching funds available for your project. Attach letter s of intent from the person s or organizations s providing match if possible. 1. Monetary 2. Non-Monetary Subtotal Non-BNT Funds C. ESTIMATED TOTAL PROJECT Acquisition COST 0. 00 VI. ANNUAL PROPERTY TAXES VII. CONTACTS FOR FURTHER INFORMATION Name/Title Address City Telephone State Zip Code Fax E-mail required. All property must be open to the public* III. PROJECT TYPE A. PROJECT CATEGORIES Check all that apply Wetlands Public Access River Buffer Upland Forest Savanna/Prairie Greenways Other Threatened/Endangered Species B. ACQUISITION TYPE Inholding New property Addition to existing conservation area Conservation Easement C. ACQUISITION TYPE Inholding New property Addition to existing conservation area Conservation Easement C. PROPOSED PROPERTY OWNERSHIP AND MANAGEMENT DNR will own the property Yes No If answer is NO who will own the property DNR will manage the property D. PROPOSED PROPERTY OWNERSHIP AND MANAGEMENT DNR will own the property Yes No If answer is NO who will own the property DNR will manage the property D. COUNTY/COUNTIES County E* LOCATION S Section Township Range Township Name Rural Road name or number F* PROPERTY ZONING AND ADJACENT LAND USE G* LANDOWNERS List property owners with addresses and phone numbers. COUNTY/COUNTIES County E* LOCATION S Section Township Range Township Name Rural Road name or number F* PROPERTY ZONING AND ADJACENT LAND USE G* LANDOWNERS List property owners with addresses and phone numbers. H. ENVIRONMENTAL ASSESSMENTS STUDIES APPRAISALS BOUNDARY SURVEYS OR EVALUATIONS OF THE PROPERTY List or attach if available I. .

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