20220267 Ver 1_Form_DMS In-Lieu Fee Request Form_20220214

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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), 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. Please refer to DENR's Implementation Policy for more details.
Compliance Statement:
I have read and understand G.S. § 143-214.11 and 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.
❑ There are no listed mitigation banks with the credit type I need located in the
hydrologic unit where this impact will take place (link to DWR list)
▪ Mitigation bank(s) in the hydrologic unit where the impacts will occur have been
contacted and credits are not currently available.
▪ 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:
Note: It is the applicant's responsibility to document any inquiries made to private mitigation
banks regarding credit availability.
I have read and understand the DMS refund policies (attached)
initial here
Signature of Applicant or Agent Printed Name
Date
Project Name Location

DIVISION OF MITIGATION SERVICES (DMS)
IN -LIEU FEE REQUEST FORM Revised 4/23/2015
Complete requested information, sign and date, email to kelly.williams©ncdenr.gov . 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. Review meetings are held on Tuesday afternoons.
CONTACT INFORMATION APPLICANT'S AGENT APPLICANT
•
1. Business/Company Name
2. Contact Person
3. Street Address or P 0 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)
12. Project Type **indicate owner type and
write in project type (e.g. school, church, retail,
residential, apartments, road, utilities, military,
etc.)**
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)
17. Riparian Buffer Impact (sq. ft.)
Include subwatershed if Jordan or Falls Lake:
18. Regulatory Agency Staff Contacts
USACE:
Check (4) below if this request is for a:
revision to a current acceptance
renewal of an expired acceptance
extension of unexpired acceptance
Owner Type: O Government O Private
Project Type:
Warm
Cool Cold
Zone 1: 1 Zone 2:
NCDWR:
Other:
By signing below, the applicant is confirming they have
read and understand the DMS refund policy posted at
nceep.net and attached to this form.
Signature of Applicant or Authorized Agent:
Date:
Note 1: For help in determining the Cataloging Unit, visit:www.nceep.net or contact DMS
Direct questions to Kelly Williams at 919-707-8915 or [e-mail] or to the front desk at 919-707-8976

Refund Policy for Fees Paid to DMS In -Lieu Fee Programs (9/21/2009)
Purpose: The purpose of this policy is to make clear the circumstances and process under which a
permittee can obtain a refund while simultaneously balancing customer service and responsible
business practices. This policy applies to all refund requests made on or after the publication date of
this policy.
Policy Statement: The policy of DMS is to allow for refunds under certain conditions.
1. All refund requests must be made in writing to the DMS In -Lieu Fee Program Coordinator at
[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 overpayments, 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 approved without delay.
5. Payments made under the 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 cancelled, 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 cancelled, 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 mitigation procured using the payment to meet other
mitigation requirements
10. Once a refund has been approved, the refund recipient must provide a completed W-9 form to the
DMS In -Lieu fee Program Coordinator within two weeks in order to process the refund though the
State Controller's Office.
11. All decisions shall be final.