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1 , . <br /> REQUEST FOR PAYMENT <br /> It is requested that the State of Minnesota make payment of $ <br /> • (amount) <br /> to <br /> at <br /> (name of payee) (address) <br /> I do hereby certify that the following stated trees, claimed as basis for <br /> Payment <br /> under the agreement by and`between the Department of Agriculture and <br /> (parties name) <br /> entered into on the _ of 197,1 <br /> (day) (month)— <br /> do <br /> month)do comply with the eligibility criteria as set forth in the Department of Agriculture's <br /> Regulation Agr 107. <br /> Signature of Authorized Agent (date) <br /> SUMMARY SHEET OF CERTIFIED REMOVALS/DISPOSALS <br /> Name of Property Owner Date of Noti- Date of Charge for Local State Cost to <br /> Address fication of Removal Removal - Subsidy Subsidy Property <br /> Telephone # Removal Disposal <br /> Location of Removed Tree Owner <br /> i <br /> i <br /> I <br /> i <br /> I <br /> I <br />