DATE STAMP DATE STAMP	Credit Request Form

Oregon Department	Oregon In-Lieu Fee Program

of State Lands

AGENCIES WILL ASSIGN NUMBERS
DSL Permit No.	Army Corps of Engineers Permit No.	180-day reservation ends:
In-Lieu Fee Project Name # of Credits Purchased Payment Amount	Project Number: $	PCA code(s) $ - PCA 13012-0218 (70%) $ - PCA 13013-0218 (30%)
SEND ONE SIGNED COPY OF YOUR MATERIALS TO
Oregon Department of State Lands, ATTN: In-Lieu Fee Mitigation Specialist, 775 Summer Street NE, Suite 100, Salem, OR, 97301, -OR- fax to (503) 378-4844 –OR- email to grey.wolf@state.or.us *Include an ORWAP functional assessment (if this was the method required) with your request if proposing purchase of wetland credits from the Half Mile Lane project.
Applicant information
Applicant Name and Address	Business Phone # Home Phone # Fax # Email
Authorized Agent Name and Address	Business Phone # Home Phone # Fax # Email
Check one
Consultant
Contractor
Project Location
Street, Road or Other Descriptive Location	Legal Description (attach tax lot map*)
Township	Range	Section	Quarter/Quarter
In or near (City or Town)	County	Tax Map #	Tax Lot #
Latitude (in DD.DDDD format)	Longitude (in DD.DDDD format)
Proposed Project Information
How many credits are needed? Credits	When will the credits be purchased by? / /

Wetland Impacts
Wetland Impact HGM Class/Subclass	Impact Cowardin System/Class	Acres Impacted	Do both the Corps and DSL require mitigation for these impacts?
Non-Wetland Impacts
Type and square feet of impact (e.g. 100 sq ft. of stream below ordinary high water).	Do both the Corps and DSL require mitigation for these impacts?
Yes	No	If yes, please describe:
Are you aware of any state or federally listed species on the project site?
Are there any impacts to tidal waters?
DSL requires a wetland delineation to be submitted prior to credit reservation for wetland impacts. Provide the DSL delineation ID number to the right.	WD #
If a Joint Permit Application for the proposed impact has been submitted to the Corps of Engineers and the Department of State Lands, provide the identification number assigned by the agencies:
Corps #	State of Oregon #
If a Joint Permit Application for the proposed impact has not yet been submitted, when will submittal occur?
(4) Application Verification
I certify that I am familiar with the information contained in the application, and that to the best of my knowledge and belief, such information is true, complete, and accurate. I understand that if credits are available from a DSL In-Lieu Fee project serving my project area and are determined to be a good match for the impact, the credits will be reserved for up to 180 days from the date this request is received. I understand that if I do not purchase the credits within that 180-day period, the credits will no longer be reserved for me. _________________________________________________________________ _________________________ Signature of Applicant or Authorized Agent Date

Send your completed form to:

Oregon Department of State Lands

ATTN: In-Lieu Fee Mitigation Specialist

775 Summer Street NE, Suite 100

Salem, OR, 97301

OR Fax to (503) 378-4844 ATTN: In-Lieu Fee Mitigation Specialist OR Email; grey.wolf@state.or.us

If purchasing credits from the Half Mile Lane Project and the Oregon Rapid Wetland Assessment Protocol (ORWAP) was the functional assessment method used to evaluate the impact site, include a copy of ORWAP with your reservation form. Half Mile Lane is a pilot project for the Willamette Partnership’s Counting on the Environment program and the number of credits required for mitigation will be based on the impact location and functions lost.

Important Notes about Credit Requests, Reservations, and Purchases

Staff will attempt to process the application within 5 business days of receiving a complete credit reservation application. The mitigation specialist will conduct a preliminary review to assess whether the in-lieu fee project will replace the type (e.g. wetland HGM and Cowardin class) of water resource that will be impacted and has a service area that includes the project site, and whether any private bank also serves the area. After processing the application, the mitigation specialist will notify the Applicant whether an in-lieu fee site is appropriate and has enough credits to service the request.

Credits will be reserved for the Applicant’s project for up to 180 calendar days from the date the request was received. If credits are not currently available, DSL will place the applicant on a waiting list based on the date the application was received.

If the 180-day period lapses and the credits have not been purchased, the credits will no longer be reserved for the Applicant and may be allocated to other customers that may be on the waiting list.

During the permit application completeness review, a DSL resource coordinator will determine whether the proposed credit purchase provisionally meets the compensatory mitigation requirements for the proposed impact. The results of that review will be included in the completeness review and communicated to the Applicant.

In some cases, DSL may not sell credits if there is also an approved mitigation bank with appropriate credits available. Once a permit application is deemed complete by the resource coordinator, the application is circulated for public review. The day that the public review period closes will be used to determine whether competition with a private mitigation bank exists. If there is competition, the applicant will be notified that use of in-lieu fee credits will not be acceptable and DSL will direct the applicant to purchase credits from the private supplier, even if credit costs are higher. If no competition exists, in-lieu fee credits may be used and this decision will hold even if bank credits become available at a later date (e.g. prior to permit issuance). The exception may be if the permit is modified and results in additional mitigation requirements.

Credits may be purchased at any time during the 180-day reservation period. However, it is highly recommended that the Applicant wait until immediately before permit issuance to complete the sale. (Credit purchase before final review is near completion is at the Applicant’s own risk. Applicants should coordinate with the Corps of Engineers to be sure that the credit purchase will also satisfy federal mitigation requirements). Please contact the DSL In-Lieu Fee Mitigation Specialist for a payment invoice when ready to purchase. Payments may be made by sending the form and a check payable to Oregon Department of State Lands and mailed to:

Oregon Department of State Lands

775 Summer Street NE, Suite 100

Salem, OR 97301-1279

Upon confirmation of purchase, DSL will provide a bill of sale to the Applicant, Authorized Agent, the DSL Resource Coordinator, and the U.S. Army Corps of Engineers as proof of mitigation credit purchase.