Targeted Runoff Management Grant Program Economic Hardship Affidavit


State of Wisconsin
Targeted Runoff Management Grant Program
Department of Natural Resources
Economic Hardship Affidavit
PO Box 7921
Madison, Wisconsin 53707-7921
Form 3400-069B (9/03)
Notice: To document economic hardship eligibility under s. NR 154.03(3), Wis. Adm. Code, a landowner or land operator shall prepare
two original, signed and notarized copies of this affidavit.
• Provide one original with required financial records to an accredited financial institution or certified public accountant.
• Submit the other original with an application for economic hardship to the appropriate governmental unit (grantee).
Unless complete information is provided, the governmental unit will be unable to determine economic hardship cost-sharing status
under the Targeted Runoff Management Grant Program.
State of Wisconsin
) ss.
I, _______________________________________________ being first duly sworn, hereby certify that I have
provided to _______________________________________________, a full and true disclosure of my
financial condition, including a copy of my latest farm financial statement, if applicable.
Signature of Landowner/Operator
Signature of Landowner/Operator Spouse
Subscribed and sworn to before me this ___________
day of ____________________________, 20_______.
Signature of Notary Public
Notary Public, State of Wisconsin
My Commission (is permanent) (expires _______________________)
This document was drafted by the Wisconsin Department of Natural Resources.


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