PI-PGM-2 U.S. Department of Agriculture

FY2011 Natural Resources Conservation Service

IRRIGATION HISTORY SELF-CERTIFICATION

Operator/Farm Name ______

Water Source ______Tax Map Key(s) ______

I certify that I have physically irrigated the acres listed below at least two out of the last five years. I am attaching the following irrigation documentation to support my claim:

□  Irrigation records and/or other supporting documentation

□  Map and/or aerial photographs showing the field(s) with irrigation history

□  Records that show the amount of water pumped, diverted or delivered to the farm/field(s)

□  FSA records documenting that fields have been irrigated

Tract / Field / Method of Irrigation / Total Acres in Field / Amount of Water Applied / Acres Cropped in 2005 / Acres Cropped in 2006 / Acres Cropped in 2007 / Acres Cropped in 2008 / Acres Cropped in 2009

I understand it is my responsibility to provide NRCS with all records necessary to verify the irrigation history referenced in the table above. I also understand it is my responsibility to provide accurate and complete information and providing false information may subject me to criminal and/or civil penalties. I understand NRCS has the final decision regarding Irrigation History requirements of EQIP applicants.

My signature below indicates that I have read and understand, or had explained to me, all requirements referenced within this document.

______

Print Applicant Name Applicant Signature Date

Documentation verifying eligibility was reviewed by:

______

NRCS Employee Name NRCS Employee Signature Date

(10/2009)