Targeted Runoff Management Grant Program Economic Hardship Affidavit printable pdf download

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.

__________________________County

)

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.

Targeted Runoff Management Grant Program Economic Hardship Affidavit