Manure Transfer Cost-Share Program Claim Transport Date* MM slash DD slash YYYY Manure Hauler*Miles from manure storage to nearest field site*Eligible rate (see table below)* Distance of transfer Rate/hour Maximum < 4 miles $60 $5,000 4-8 miles $80 $5,000 >8 miles $100 $5,000 Number of Hours*Total Claim*Description of service*Payment InformationPlease fill out the information below and submit with a current W-9.Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Employer ID # OR Social Security #*W9*Accepted file types: jpg, png, pdf, Max. file size: 2 GB. Signature of Service Provider*The above service provider is requesting payment for manure transport and application services provided on the date listed above