Application for Withdrawal of Wetland Credits-Minnesota Wetla

Debit Date:

1. Applicant Information
Name: Organization (if applicable):
Street Address: Phone:
City, State, Zip: E-Mail Address:
2. Project Information
To be completed by the person or entity proposing the project. See instructions for completing this form.
Project Name: Bank Service Area: County:
Major Watershed #: Wetland Impact Size (ac.): Replacement Credits Required:
Project Purpose and Description:
Check and include the following attachments as applicable (at least one should include a legal description):
Site Location Map Plan Map showing existing and planned drainage features AD 1026 Form
Certified Wetland Determination and/or Wetland Delineation Report identifying wetland sizes in acres
Number of Wetland Credits to Use: Account Number: Account Owner:
County: Bank Service Area: Major Watershed #:
Attach Credit Purchase Agreement (written and signed agreement to purchase credits from identified seller).
By signature below I attest that I have the legal right to complete this project and the project is for agricultural purposes on agricultural land. I authorize the Natural Resource Conservation Service (NRCS) to share information with the Board of Water & Soil Resources (BWSR) that is pertinent to the required credit withdrawal.
Signature: Date:
3. Government Entity Approval/Authorization
By signature below, the LGU has approved this project and authorizes this wetland credit withdrawal.
WCA LGU: LGU Representative:
Signature: Date:

By signature below, I authorize this wetland credit withdrawal for the identified project.
NRCS Representative: E-mail address:
Signature: Date:

Minnesota Board of Water and Soil Resources Form - 12/31/12 Page 1 of 2

Application for Withdrawal of Wetland Credits-Minnesota Wetla

4. Withdrawal Information
To be completed by seller of credits. Account Number:
Credit Subgroup Letter / Plant Community Type / Number of Credits to be Withdrawn / Cost per Credit
TOTAL CREDITS
Fee Calculation (pick one method):
1)  Fee per credit (see Fee Schedule on BWSR website) X total credits = $
2)  Total Cost of Credits X .065 = $
Attach check payable to Minnesota Board of Water and Soil Resources.
By signature below I (seller) authorize the debiting of this account and attest that the credits have not been sold nor have I agreed to sell them to another user, and this debit will not result in a negative account balance. I also attest that the sale price reflected in the credit cost is accurate for fee purposes.
Signature: Date:

When this form is completed and all required signatures are obtained, send this form to:

Wetland Bank Coordinator

Minnesota Board of Water and Soil Resources

520 Lafayette Road North

Saint Paul, MN 55155

Minnesota Board of Water and Soil Resources Form - 12/31/12 Page 1 of 2