OREGON DEPARTMENT OF FISH AND WILDLIFE



|Oregon Department |

|of Fish and Wildlife |

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|Wildlife Division |

|4034 Fairview Industrial Dr. SE |

|Salem, OR 97302 |

|503-947-6300 |

|Fax: 503-947-6330 |

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|Bird Stamp Program |

|Grant Application |

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|Grant Applications may be submitted for habitat development and improvement projects, equipment, surveys and/or research. |

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|Grant applications are due by |

|March 1 and September 1 of each year. |

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|Applications must be submitted to the ODFW Game Bird Committee Representative for the watershed in which the project will take |

|place. (See page 10 for a list of committee members.) |

Instructions for Completing Application Forms

|You must complete Sections 1-7 as follows: |

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|Type in the information requested or reproduce the form on your computer. |

|Use 8 1/2” x 11” single-sided, unstapled pages with the spacing and layout provided. |

|Avoid color and detail that will not photocopy clearly. |

|Sign and date the Grant Application Submittal Form. |

|Submit the application to the appropriate Bird Stamp Committee Representative listed in Section 7 |

|If applicable, you may submit the following: |

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|Maps (if applicable): |

|Provide a general map highlighting the location. |

|On a USGS 7.5 min topo quad map, locate the extent of your project and site specific activities. |

|Please provide maps on 8 ½” x 11” pages and include a legend. |

|Avoid color and detail that will not photocopy clearly. |

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|Photographs (if applicable): |

|Provide photographs to aid in understanding the situation. |

|Please note that if your project is funded, pre-project photos will be required in the final report. |

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|Project Designs (if applicable): |

|Details should match the complexity of the proposed project. |

|These must show the project placement and provide sufficient detail to allow a reasonable evaluation of the effect of the project |

|on the site proposed. |

|The design should include reference to appropriate standards and guidelines. |

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|Provide 5 color copies of any maps, photos or project designs that you want ODFW reviewers to see in color. |

SECTION 1 (Do Not Exceed 2 pages)

BIRD STAMP PROGRAM APPLICANT INFORMATION

This box for ODFW use only

Application Number:________________________

Reviewed by ODFW Watershed Manager: _________________________ __________________

Signature Date

Watershed Manager Comment, if any:________________________________________________

_______________________________________________________________________________

Project Title: ____________________________________________________________________

Property Information (if applicable): Owned by: ___________________________________

Address: ______________________________________________________

___________________ ____________________

County Township Range Section(s) Longitude, Latitude (if applicable)

ODFW dollars requested: ________ Total cost of project: ___________

Applicant: ____________________ Phone: ___________________ Fax: _______________

Email: ______________________________________

Applicant Address: _______________________________________________________________

Street City Zip

Mailing Address (if different):_______________________________________________

Street City Zip

Applicant Affiliation (if any): ____________________________________________________

Technical Contact (if different): ____________________

Email: ______________________ Phone: _______________________Fax: _________________

Fiscal Officer (if any):___________ Phone: ______________________Fax: _________________

Email: __________________ Address: _________________ ___________ _________

Street City Zip

In 1-2 sentences briefly summarize for what purpose you are requesting funds:

1. Was this application submitted previously? ( Yes ( No

If yes, what was the application number?________ Briefly describe what changes have been made to the project proposal.

1a. Is this project a continuation of a previously ODFW funded project(s)? ( Yes ( No

If yes, what was the application(s) number? _________

2. If there is funding being received through cost share please list all agencies and organizations from which funding is anticipated for the proposed project.

Cost Share

Agency/Organization Cash In-Kind Secured Pending $Amount/Value

____________________ ( ( ( ( $ .00

____________________ ( ( ( ( $ .00

____________________ ( ( ( ( $ .00

____________________ ( ( ( ( $ .00

____________________ ( ( ( ( $ .00

____________________ ( ( ( ( $ .00

____________________ ( ( ( ( $ .00

____________________ ( ( ( ( $ .00

Total Estimated Project Costs: $ .00

2a. Briefly describe how each cost-share partner listed above is participating in the project.

_______________________________________________________________________________

_______________________________________________________________________________

3. Have any conditions been placed on other funds that may affect project completion?

( Yes ( No If yes, explain: ________________________________________________________

4. Are there additional partners (agencies, landowners, volunteers)? ( Yes ( No

If yes, what will they do? __________________________________________________________

_______________________________________________________________________________

5. What do you expect will be the public benefits of the project?___________________________

_______________________________________________________________________________

6. How will you promote public awareness about Bird Stamp benefits of the project locally?

______________________________________________________________________________________________________________________________________________________________

7. What is the proposed schedule for the project? (Include start date, critical element dates, completion date, and monitoring schedule):

______________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________

SECTION 2

BIRD STAMP PROGRAM

SPECIFIC FUNDING ACTIVITY

Please answer the following questions that apply to the funding proposal. If there are multiple locations for habitat projects, be specific for each site. (USE 8½" x 11" SINGLE-SIDED PAGES)

1. What are you proposing to do? Supply specific and sufficient detail to match the funding proposal’s complexity and technical difficulty so that its viability can be evaluated. Include who will do the project design, and whether other alternatives were considered and why this particular methodology was selected from among the alternatives considered.

2. What are the funding proposal objectives? Provide a bulleted list of measurable indicators.

3. What will be the anticipated condition of the site(s) upon project completion, and in 10 years? Be site specific.

Upon completion:

After 10 years:

4. Are there potential adverse impacts to other properties or resources as a result of this project? If yes, what are they and how have they been addressed in the project plans?

5. How will success be determined, i.e., what elements will be monitored/evaluated - by whom, how often, and for how long? How will project effectiveness be assessed? Be sure to link this to the objectives identified in # 2 above. List:

Agency/Organization Address Activity & Frequency Signature

6. Who will inspect and sign off on the completed work? Who will submit required project reports? Please provide contact information.

Agency/Organization Address Activity & Frequency Signature

7.

8. Who will maintain the project/equipment and for how long? List:

Agency/Organization Address Activity & Frequency Signature

9. Which elements of the proposal will ODFW funds be used for? This should correspond to elements in the “ODFW Funds” column on the budget sheet.

SECTION 3

BIRD STAMP PROGRAM BUDGET

Attach additional pages if necessary

|Itemized projected costs under each |Unit Number (i.e. |Unit Cost |In-Kind |Cash Match* |ODFW Stamp |Total Costs |

|applicable category: |hours, feet) | |Match* | |Funds Requested| |

|IMPLEMENTATION COSTS (Design, permits, engineering, baseline monitoring, etc) |

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|PERSONNEL (Position title, wages, benefits, etc.) |

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|TRAVEL (Mileage, per diem, lodging, etc.) |

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|CONTRACTED SERVICES (Non-employee cost for labor for: fencing, instream work, tree planting, technical consultation, project management, |

|etc.) |

| Blue Mountain Asphalt Co | |  | |  | |  |

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|SUPPLIES/MATERIALS (Fertilizer, seed, fencing, boulders, logs, plants, etc.) |

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|OUTREACH COSTS (Video production, printing, direct mail, tours, workshops, etc.) |

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|EQUIPMENT (Items usable beyond end of the project with a value greater than $100, i.e. rain gage, thermograph, etc.) |

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|SUB-TOTALS |

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|MONITORING*** (Component to be monitored, cost per year, number of years, and total cost) |

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|TOTALS: |  |  |  |  |

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SECTION 5

BIRD STAMP

LAND USE INFORMATION SHEET

Some habitat projects may require approval by appropriate land use regulatory agencies. This form must be submitted prior to ODFW releasing project funds for habitat related projects. ODFW will only release project funds if the project either is not regulated by, or is compatible with, the local comprehensive plan and zoning ordinance. ODFW will void grant agreements for projects the county determines to be incompatible with the local comprehensive plan and zoning ordinance. If the county requires additional local approvals, ODFW will not release project funds until these conditions are satisfied.

1. TO BE COMPLETED BY THE GRANTEE

Applicant Name: ___________

Project Title: ________

2. TO BE COMPLETED BY CITY/COUNTY OR TRIBAL PLANNING OFFICIAL

Complete this section only after Section 1, above, has been completed. Check the box below that applies:

( This project is not regulated by the local comprehensive plan and zoning ordinance.

( This project has been reviewed and is compatible with the local comprehensive plan and zoning ordinance.

( This project has been reviewed and is not compatible with the local comprehensive plan and zoning ordinance.

( Compatibility of this project with the local planning ordinance cannot be determined until the following local approvals are obtained:

______ Conditional Use Permit ______ Development Permit

______ Plan Amendment ______ Zone Change

______ Other

An application has ___ has not __ been made for the local approvals checked above.

* Signature of Local Official: ________________________________________________

Title: ___________________________________ Date:____________________

*Must be authorized signature from your local City/County or Tribal Planning

Department regardless of which box is checked.

SECTION 6

BIRD STAMP APPLICATION SUBMITTAL

AUTHORIZATION

I/we,___________________________of ______________________________, Oregon, hereby make application for financial assistance under the terms and conditions of this Grant Application in the amount of $__________. The total cost of the project is $______________, as shown under Section 1.

I/we understand that if this proposal is funded, I/we will be required to:

• Sign a Grant Agreement containing the terms and conditions upon which funds

will be released, including submission of other necessary permits and documents,

a certification to comply with state, federal and local regulations, and a release of

liability for the State of Oregon;

• Obtain landowner, monitoring, and maintenance agreements (as applicable);

• Certify that the project complies with state, federal and local regulations;

• Submit written evidence that all applicable permits and licenses from local, state

or federal agencies or governing bodies have been obtained or are not needed;

• Submit a report at the completion of the project, and subsequent periodic reports

required, to ODFW;

• Agree that educational products resulting from projects are public domain.

• Use of the pictured pre-made signs for habitat projects or decals for equipment purchases is strongly encouraged. Please request from the game birds program if funding is granted.

Signed: ___________________________________ Date: _____________________

Title: ________________________________________________________________

SECTION 7

BIRD STAMP COMMITTEE REPRESENTATIVE REVIEW FORM

Please submit this application, for initial review, to the appropriate Bird Stamp Committee Representative from the watershed in which your project would occur. The representative will then forward the application to the appropriate ODFW Watershed Manager for review and signature. A list of representatives is below. If you need help determining the correct representative please contact Dave Budeau at (503) 947-6323 or David.A.Budeau@state.or.us

This box for ODFW use only

Game Bird Committee Representative: _________________________________

Date Received by Committee Rep: ____________________________

Date

Representative’s comments, if any: __________________________________________________

______________________________________________________________________________

ODFW Game Bird Committee Members

North Coast Watershed Rep

Dave Nuzum

North Coast Watershed District Office

4907 Third Street

Tillamook, OR 97141

North Willamette Watershed Rep

Mark Nebeker

Sauvie Island Wildlife Area

18330 NW Sauvie Island Rd.

Portland, OR 97231

South Willamette Watershed Rep

Wayne Morrow

Fern Ridge Wildlife Area

26969 Cantrell Road

Eugene, OR 97402

Umpqua Watershed Rep

Stuart Love

Umpqua Watershed District Office

63538 Boat Basin Drive

Charleston, OR 97420

Rogue Watershed Rep

Vince Oredson

Rogue Watershed District Office

1795 East Gregory Road

Central Point, OR 97502

Deschutes Watershed Rep

Jeremy Thompson

The Dalles Field Office

3701 West 13th Street

The Dalles, OR 97058

John Day Watershed Rep

Kevin Blakely

John Day Watershed District Office

73471 Mytinger Lane

Pendleton, OR 97801

Grande Ronde Watershed Rep

Dave Larson

Ladd Marsh Wildlife Area

59116 Pierce Road

La Grande, OR 97850

Klamath Watershed Rep

Marty St. Louis

Summer Lake Wildlife Area

53447 Hwy 31

Summer Lake, OR 97640

Malheur Watershed Rep

Autumn Larkins

Hines District Office

Po Box 8; 237 S Hines Blvd

Hines, OR 97738

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