ND Department of Water Resources

Application for Drought Disaster Livestock Water Supply Assistance Program
Department of Water Resources
SFN 17810 (4-2021)

North Dakota Administrative Code 89-11-01-04 allows up to three projects per applicant.

If an applicant is requesting assistance for more than one project, please submit additional requests (one for each project).

Application Requirements

In order for this application to be considered complete, you will need to attach:

a map or aerial photo of the project site and the proposed works/project. Your county FSA office might be able to assist you with this information.

Do you certify that you receive more than 50% of your income from farming or ranching?

YesNo

Applicant Information

Name

Address

City
State
Zip Code

Telephone Number

Cell Number

E-Mail Address

Project Information and Location

Quarter (smallest) : Quarter : Section : Township : Range : County :

Are you the Property

Owner Operator Other

Describe your stock water shortages. (Be specific about the nature of the problem and the type of affected water source.)

Number of livestock affected by the problem:

Type of livestock affected by the problem:

Current water supply (well, dugout, stockdam, etc):

Proposed Solution

This Application is for Financial Assistance on:

Proposed Solution (Please include a detailed explanation including water supply source, pipelines, water tanks, power supply component, etc.):

New Well Information (Complete this section if your solution is a new well.)

Quarter (smallest) : Quarter : Section : Township : Range : County :

Driller's Name

Driller's Address

City

State

Zip Code

Estimated Cost (Your cost-share approval is based on this estimate!)

Rural Water (Complete this section if your solution is a connection to rural water.)

Rural Water System Name

Estimated Cost (Your cost-share approval is based on this estimate!)

Project Description

Pipeline Information (Complete this section if your solution is a pipeline.)

Water Supply Source

Estimated Cost (Your cost-share approval is based on this estimate!)

Project Description

Other Water Source or Works

Other Water Source

Estimated Cost (Your cost-share approval is based on this estimate!)

Project Description

The Applicant, by submitting this Form:

Understands that cost-share amounts are based upon projected cost estimates provided by the applicant. Reimbursements are based upon approved receipts.
Agrees to complete the project as described within 180 days of receipt of notice of approval of funding and to provide proof of work completed and proof of actual expenditures.
Grants to the Department of Water Resources (DWR) or anyone authorized by the DWR the right to enter upon the land, or view via drone, to inspect the completed water supply project after giving reasonable notice to the applicant.
Agrees to indemnify and hold harmless the State of North Dakota, DWR, and the Commission, its officers, agents, employees, and members, from all claims, suits, or actions of whatsoever nature resulting from or arising out of the activities of applicant or applicant’s agents or employees under this agreement.
Certifies that to the best of applicant’s knowledge and belief, the information in this application is true and correct and this problem is drought-related and not a result of lack of maintenance, a chronic long-term problem, or an expansion of applicant’s operation.
Certifies that the applicant is an existing “livestock producer;” meaning the applicant produces livestock or operates a dairy farm, devotes the major portion of applicant’s time to activities of farming or ranching, and normally receives not less than 50 percent of the applicant’s annual gross income from farming or ranching.
Certifies that the applicant has not, or will not, receive any other state or federal funds for the same project(s).
Understands that upon approval, the applicant must provide a completed IRS Form W-9 before receiving reimbursement.