ILF-Request-Fillable-Form-Feb2026

DMS ILF Mitigation Request Statement of Compliance with §143-214.11 & 143-214.20
(link to G.S. 143-214.11)
Prior to accessing the Division of Mitigation Services (DMS) In-Lieu Fee (ILF) program, all applicants
must demonstrate compliance with G.S. §143-214.11 and 143-214.20. All requests MUST include this
form signed and dated by the permit applicant or an authorized agent.
(link to DWR Bank list) (link to Ribits COE Bank List)
Compliance Statement:
I have read and understand G.S. § 143-214.11 and 143-214.20 and have, to the best of my knowledge,
complied with the requirements. I understand that participation in the DMS is voluntary and subject to
approval by permitting agencies.
Please check all that apply:
Applicant is a Federal or State Government Entity or a unit of local
government meeting the requirements set forth in G.S. 143-214.11 and is not
required to purchase credits from a mitigation bank.
Mitigation bank(s) in the hydrologic unit where the impacts will occur have
been contacted and credits are not currently available.
There are no listed mitigation banks located in the hydrologic unit where
this impact will take place that offer the credit type needed.
The DWR or the Corps of Engineers did not approve of the use of a
mitigation bank for the required compensatory mitigation for this project.
This is a renewal request and the permit application is under review. Bank
credits were not available at the time the application was submitted.
Enter date permit application was submitted for review: _____________
initial here
Signature of Applicant or Agent Printed Name
Date
Project Name Location
Print Form
I have read and agree to DMS's Refund Terms and Conditions for the satisfaction of
compensatory mitigation requirements (attached).
DIVISION OF MITIGATION SERVICES (DMS)
IN-LIEU FEE REQUEST FORM Feb2026 Update
Complete requested information, sign and date, email to [e-mail] . Attachments are acceptable for clarification
purposes (location map, address or lat long is required). Information submitted is subject to NC Public Records Law and may
be requested by third parties.
CONTACT INFORMATION APPLICANT’S AGENT APPLICANT
1. Business/Company Name
2. Contact Person
3. Street Address or P O Box
4. City, State, Zip
5. Telephone Number
6. E-Mail Address
PROJECT INFORMATION
7. Project Name
8. Project Location (nearest town, city)
9. Lat-Long Coordinates or attach a map
10. County
11. River Basin & Cataloging Unit (8-digit)
(See Note 1)
indicate owner type and
write in project type (e.g. school, church, retail,
residential, apartments, road, utilities, military,
Owner Type: Government Private
Project Type:
13. Riparian Wetland Impact (ac.) (e.g., 0.13)
14. Non-Riparian Wetland Impact (ac.)
15. Coastal Marsh Impact (ac.)
16. Stream Impact (ft.) (e.g. 1,234)Warm Cool Cold
17. Riparian Buffer Impact (sq. ft.)
Include subwatershed if Jordan or Falls Lake:Zone 1: Zone 2:
18.Regulatory Agency Staff Contacts
USACE:
NCDWR:
Other:
Check ( √) below if this request is for a:
revision to a current acceptance
renewal of an expired acceptance
extension of unexpired acceptance
Date:
Note 1: For help determining the Cataloging Unit, visit the DMS Website and use the search box to find your impact
location. For questions contact DMS ILF Staff [e-mail] or call the main phone at 919-707-8976.
By signing below, the applicant is confirming they have read and
agree to the Terms and Conditions of the DMS related to refunds
attached to this form.
Signature of Applicant or Authorized Agent:
Refunds of Fees Paid to DMS In-Lieu Fee Programs (rev. 12/9/2024)
Purpose: The purpose of these Terms and Conditions are to make clear the circumstances and
process under which a permittee can obtain a refund while simultaneously balancing customer
service and responsible business practices. These requirements apply to all refund requests.
Terms and Conditions: Under the Terms and Conditions, DMS allows for refunds under certain
conditions.
1.All refund requests must be made in writing to the DMS In-Lieu Fee Program
[e-mail].
2.All refund requests are subject to fund availability. DMS does not guarantee fund availability for
any request.
3.The request must either come from the entity that made the payment or from an authorized agent.
Third parties requesting refunds must provide written authorization from the entity that made the
payment specifying the name and address of the authorized refund recipient.
4.Refund requests related to unintended over-payments, typographical errors or incorrect invoices
should be brought the attention of the In-Lieu Fee Program Coordinator as soon as possible. Such
requests are typically remedied without delay.
5.Payments made under any incremental payment procedure are not eligible for refunds.
6.Refund requests made within nine months of payment to DMS will only be considered for
requests associated with projects that have been terminated or modified where the permittee’s
mitigation requirements have been reduced. Such requests must be accompanied by written
verification from the permitting agency that the project has been canceled, the permits have been
rescinded or have been modified, or the mitigation requirements have been reduced.
7.Refund requests made more than nine months from the payment date will only be considered for
permits that were terminated or modified to not require any mitigation. Such requests must be
accompanied by written verification from the permitting agency that the project has been canceled, the
permits have been rescinded and/or mitigation is no longer required.
8.Refund requests not meeting the criteria specified above are not eligible for a refund.
9.Refund requests that meet the criteria above will be elevated to DMS Senior Management for
review. The following considerations apply to all refund requests:
a.availability of funds after consideration of all existing project and regulatory obligations
b.the date the payment was made
c.the likelihood DMS can use the credit procured to satisfy the mitigation requirement to meet
other mitigation requirements
10.Once a refund has been approved, the refund recipient must provide a completed NC W-9 form to
the DMS In-Lieu fee staff within two weeks in order to process the refund though the State Controller's
Office.
11.All decisions shall be final.