U.S. Department of Agriculture
Natural Resources Conservation Service
NRCS-CPA-1257
June 2023
Landowner Concurrence Form to Install Structural or Vegetative Activities This form is used for the applicant to obtain written documentation of landowner concurrence for the purpose of installing structural or vegetative conservation activities on land they lease. Structural and vegetative conservation activities are those activities with a lifespan greater than one year.
Applicant Name: Landowner Name: Date Prepared:
Application No. Farm Name (opt):
Conservation Activity: Farm No. & Tract No. Field Nos.
1. 2.
3. 4.
5. 6.
7. Landowner Concurrence
permission to install and maintain conservation activities on the land identified. I understand that I am not a party to any contract between NRCS and the applicant to install or maintain the above listed activities.
Landowner Signature: Print Name: Date:
Non- Discrimination Statement
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.
By signing this form, I, the landowner, hereby agree that the above-named applicant, if awarded a contract with the USDA Natural Resources Conservation Service (NRCS) has Clear Form
Attachment B