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FIVE-STEP APPLICATION FOR FOUNDATION INCENTIVES TO REDUCE CONSUMPTIVE GROUNDWATER USE (This is NOT an interactive form. Please print it out and submit it to the Foundation office, or visit the office to obtain an application)

STEP 1.  Provide Your Personal Information

Name: ____________________________________________________________________________ Address: ___________________________________________________________________________ City, State, Zip ______________________________________________________________________ Phone: ________________________________

STEP 2.  Choose 1 or more of the following "Participation Options" (checkmark the red box) and complete requested Information for each chosen option.    (see "Operations" page for more detailed Option descriptions)

Retire Full Water Right Permanently: By contract with the Foundation, I am interested in permanently forfeiting and abandoning the designated water right in lieu of 10 equal annual payments that equal the bid price offered below. I understand the water right will be reverted back to the public domain and will not be available for any future use once forfeited.  I further agree to properly maintain or dispose of the subject well or wells, which can include converting the well to domestic use. Water Right #: ______________________________________ Legal Description of well(s): _____________________________________________________ Certified Acrefeet ____________________     Authorized Acres __________________ Bid Price: __________________________________ (Total Dollars required to retire water right) Land use & Well disposition plans: ___________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________  Retire a Partial Water Right Permanently: By contract with the Foundation, I am interested in permanently forfeiting and abandoning a portion of the designated water right and reducing said water right accordingly in lieu of 10 equal annual payments that equal the bid price offered below.  I understand the water rights (acrefeet) I reduce will be reverted back to the public domain and will not be available for any future use once forfeited. Water Right #: ______________________________________ Legal Description of well(s): _____________________________________________________ Bid Price: __________________________________ (Total Dollars required to retire partial water right) Certified Acrefeet ________________ Acrefeet Applying to Permanently Retire _______________ Land use plans: _________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________  Set Aside a Full Water Right from 5 - 10 Years: As a result of this incentive and by contract with the Foundation, I am interested in enrolling my full water right into the Kansas Water Rights Conservation Program (WRCP) for a designated period of time not less than 5 years and not more than 10 years in lieu of a series of equal annual payments that equal the bid price offered below and match the WRCP term of enrollment.  I understand this option also requires a separate contract with the division of water resources, Kansas Department of Agriculture, and will result in setting the entire water right aside for the designated contract period. Water Right #: ______________________________________ Legal Description of well(s): _____________________________________________________ Bid Price: __________________________________ (Total Dollars required to enroll water right in WRCP) Authorized Acres Under Water Right _________________________________________________________ Have you or will you receive any EQIP payments for enrolling in WRCP? _____________________________ Land & Well maintenance plans: _____________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________  Multi-Year Flex Account Enrollment: As a result of Foundation incentives and by contract with the Foundation, I am interested in converting my water right to a 5-year term permit per the state's established Multi-year Flex Account (MFA) Program (K.S.A. 82a-736) in lieu of 5 equal annual payments that equal the bid price offered below. Water Right #: ______________________________________ Legal Description of well(s): _____________________________________________________ Bid Price: __________________________________ (Total Dollars required to convert water right to a multi year flex account right) Percent of original water right to be set aside for 5 years: _______________ (must be at least 10%) STEP 3.  Applicant's Notarized Signature: ________________________________________ Signature of Applicant State of Kansas                     )                                              )    SS County of ____________     )     The foregoing instrument was acknowledged before me this ____ day of __________, 20___, by ______________________________________________________________________________. ________________________________________ Notary Public STEP 4.  Send or bring application to Foundation Office for Evaluation. NW Kansas Groundwater Conservation Foundation PO Box 905 1175 S. Range Colby, KS 67701-0905 STEP 5.  Sign Foundation Contract. If approved, enter into a Foundation Contract.  (Each approved applicant will be offered a Foundation/Applicant contract covering all the program details, payment schedules, enforcement issues, etc.  The applicant will have the final right to sign the contract and continue, or, NOT sign the contract and cancel the application process.) (FINAL NOTE:   The Foundation reserves the right to accept, reject, approve or deny any bid application based upon the Foundation's evaluation process.  Evaluations may take up to 60 days. Address:  PO Box 905, Colby, KS 67701-0905 Phone:  785.462.3915