Within District Cost-Share Application

Please do not staple receipts. Deadline for this year's applications is December 10 of the current year and are contingent on fund availability.

Print and complete this form, include a copy of the receipt for cost of herbicides and/or mowing, documentation (before and after pictures) of mowing/grazing if you performed treatment yourself and do not have a receipt, and mail to:

Larimer County Weed District, PO Box 1190, Fort Collins, CO 80522-1190.

Date: __________________

Applicant's Name:________________________________Phone No._______________________________

Senior Citizen (65 or older)? Yes_________ No_________

Parcel number (10 digits) ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___

Don't know your parcel number? Receipts will not be processed with out it!

Look here: http://www.larimer.org/assessor/query/search.cfm

Property address: _________________________________________________________________________

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Mailing address:___________________________________________________________________________

Treatment Locations. Example 100 feet west of eastern parcel boundry, 50 feet north of southern parcel boundary.

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Operator (chemical applicator) Name and Address: Same as above ( )

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Landowner Name and Address: Same as above ( )

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Canada thistle, leafy spurge, musk thistle, Russian knapweed, diffuse knapweed, spotted knapweed, tamarisk, Dalmatian toadflax, and yellow toadflax are the only species eligible for reimbursement.

Fill in the amount of area of and each species treated. Example: Canada thistle, acres, square feet, number of stalks etc.

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Applicant's signature:________________________________ Date:_____________

Account Code: 242-066500-57261