AD-1160 Compatible Use Authorization

OMB NO. 0578-0013

U.S. Department of Agriculture

COMPATIBLE USE AUTHORIZATION
2. County:

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

3. Contract NO.:

This transaction is for CCC

4. Agreement NO.:

This transaction is for NRCS EWP

5. Expiration Date:

A. Person Responsible for Agreement Activities (Name and Address):
A 1. Person Responsible for Agreement
(Telephone Number):
B. Purpose:

C. Location Description (Attach a copy of map showing approximate area of compatible use.):

D. Beginning Condition of Site:

E. Statement of Affect and Compatibility:

F. Special Conditions, Specifications and Other Details Including Information From Consultation with FWS, CD and State Wildlife
Agency:

NRCS retains the right to modify or cancel this compatible use authorization at any time if the NRCS determines that such activities
do not further the protection and enhancement objectives of the easement, or that the landowner has failed to comply with specified
terms and conditions. The landowner engages in such activities at his or her own risk. This authorization does not vest any right of
any kind in the Landowner. This authorization is null and void after the expiration date specified above. By signing this document,
the landowner agrees to the terms described above and on referenced documents.
G. Recommended (NRCS Signature):

G 1. Date:

G 2. Title:
H. Landowner or Representative (Signature):

H 1. Date:

I. Approved (NRCS Signature):

I 1. Date:

I 2. Title:
The signature by the NRCS representative signifies a CCC-NRCS transaction as indicated above.

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AD-1160
rev.

OMB NO. 0578-0013

COMPATIBLE USE AUTHORIZATION

OMB DISCLOSURE STATEMENT
According to the Paperwork 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 40 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.
NONDISCRIMINATION STATEMENT
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its program and activities on the basis of race, color,
national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation,
genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived from any public assistance
program. (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 to USDA, Director, Office of Civil Rights, 1400
Independence Avenue, SW., Washington, DC 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an
equal opportunity provider and employer.
PRIVACY ACT STATEMENT
The above statements are made in accordance with the Privacy Act of 1974 (5 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.

AD-1160
rev.

2

U.S. DEDEPARTMENT OF AGRICULTURE

OMB NO. 0578-0013
AD-1160

COMPATIBLE USE AUTHORIZATION

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 40 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.