AD-1159 Notice of Intent To Continue

U.S. Department of Agriculture

OMB NO. 0578-0018

NOTICE OF INTENT TO CONTINUE
2. Date:

1. To be completed by NRCS; check appropriate box:

3. Contract Number:

This transaction is for CCC
This transaction is for NRCS

4. Name of District Conservationist or Field Office:
5. Address of District Conservationist or Field Office:

Dear Natural Resources Conservation Service,
Re: (Landowner or Landowners):
6 a.

6 b.
(Name of Entity if Applicable)

(Landowner name)

7 a.

7 b.
(Name of Entity if Applicable)

(Landowner name)

8 a.

8 b.
(Landowner name)

(Name of Entity if Applicable)

9. NOTE: (Check only ONE box, sign, date and return to the Field office address above)
YES, I wish to continue in the easement program. I understand that indicating my intention to continue in the Program does not bind
me to file an easement. However, it authorizes NRCS to commence easement acquisition activities.
NO, I no longer wish to enroll in the easement program. Please remove my application from consideration.
Landowner(s) signatures:
10 a. Signature:

10 b. Date:

11 a. Signature:

11 b. Date:

12 a. Signature:

12 b. Date:

OMB DISCLOSURE STATEMENT
According to the Paper work Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0578- 0013. The time required to complete this information collection is estimated
to average 26 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information.
PRIVACY ACT STATEMENT
The above statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a). Furnishing this information is voluntary; however, failure to furnish correct, complete
information will result in the withholding or withdrawal of such technical or financial assistance. The information may be furnished to other USDA agencies, the Internal
Revenue Service, the Department of Justice, or other State or Federal Law enforcement agencies, or in response to orders of a court, magistrate, or administrative tribunal.
NONDISCRIMINATION STATEMENT
The United States Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age,
disability, political beliefs, sexual orientation, or marital or family status. (Not all prohibited bases apply to all programs.). Persons with disabilities who require alternative means
for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint
of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (202)
720-5964.

AD-1159
Former CCC-1257, NRCS-LTP-24

U.S. DEDEPARTMENT OF AGRICULTURE

OMB NO. 0578-0013
AD-1159

NOTICE OF INTENT TO CONTINUE

OMB BURDEN STATEMENT
Federal Agencies may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. Public reporting burden for this collection of information is estimated to average 26 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to Department of Agriculture, Clearance Officer, OIRM (OMB NO. 0578-0013), Stop 7630, Washington, D.C. 20250-7630.