A. Applicant[Applicant Name] (hereinafter "Applicant")

[Address and other Contact information]

Parcel No(s): __________________________

[Impact Site Name/Project Name]

B. Impact ProjectWatershed Service Area [? Chambers/Clover ? Nisqually]

Permitting Agency: __________________________

Permit Number(s): ___________________________

[Add additional agencies and permits as necessary]

Description of impacts: [Provide details of project impact]

Description of debits: [Wetland HGM class and category, impact acreage, also functions disturbed. Please list each class and category separately if more than one wetland unit.]

A.Credits Purchased. In exchange for the payment of mitigation fees, the Applicant receives [# credits is equal to # of debits] mitigation credits. These credits have been withdrawn from the [Advance Credit pool or released credit balance] in the [Service Area Name] service area.

PCILF Receiving site if known: [___________________]

B.Allocation to the PCILF Program Account. The mitigation fees will be deposited into the following funds within the Pierce County ILF Program Account (see Basic Agreement Article IV.D. and Appendix F of the Instrument):

Where the [year] price per credit is: $__________

Previously paid down payment secured through a Letter of Intent for 10 percent of necessary credits: $____________

Fees collected from Applicant for remaining 90 percent of credits: $_________

Total Mitigation Fees Collected from Applicant: $_________

(75% of these fees comprise the "credit fee" and 25% comprise the "land fee".)

Land Fee Account: $__________ (100% of land fee)

Program Admin. Account: $________ (15% of total credit fee)

Contingency Account: $________ (10% of total credit fee)

Long-Term Management Account: $________ (5% of total credit fee)

Individual Mitigation Projects Account: $________ (70% of total credit fee)

C. The Sponsor Agrees to Implement MitigationUpon acceptance of these fees from the Applicant, the Sponsor is agreeing to implement mitigation, and assume all associated obligations and liabilities according to terms of the final Program Instrument for the Pierce County ILF Program as certified on __________, _____.

A. Signed Statement of Sale Provided to ApplicantThe Sponsor will provide a signed copy of this form to the Applicant within 15 days after receipt of funds from the Applicant. The Applicant is responsible for submitting copies of the fully executed Statement of Sale to the appropriate regulatory agencies as proof of purchase of ILF mitigation credits.

B. Signed Statement of Sale Provided to the United States Corps of Army Engineers and the Washington State Department of EcologyThe Sponsor will provide a signed copy of this form to the above identified organizations within 15 days after receipt of funds from the Applicant.

C. Copies Available to the Interagency Review Team (IRT) MembersCopies of this Statement of Sale shall be made available to any member of the IRT upon the IRT member's request.

A. Allocation of FundsThe Sponsor will deposit the moneys listed above into the program account in the amounts listed in Article IV.B. of this Statement of Sale. Record of these funds will also be added to the Program Account Ledger.

B. Spending AuthorizationUpon initial receipt of credit fees, the Sponsor shall be authorized to spend up to 75 percent of funds allocated to Administrative Accounts according to Appendix F, Section 5.0 of the Program Instrument. The Co-chairs of the IRT (the District Engineer of the U.S. Army Corps of Engineers and the Department of Ecology), after consultation with the IRT, must authorize all additional expenditures from the program account pursuant to 33 CFR 332.8(i)(2) and pursuant to Article IV.B of the Basic Agreement.

C. Reporting Requirements UnaffectedThis agreement shall not affect reporting requirements outlined in the program instrument.

D. Effect of AgreementThis Agreement does not in any manner affect statutory authorities and responsibilities of the Sponsor. This Statement of Sale is not intended, nor may it be relied upon, to create any rights in third parties enforceable in litigation with the United States or the State of Washington. This Statement of Sale does not authorize, nor shall it be construed to permit, the establishment of any lien, encumbrance, or other claim with respect to the ILF program property, with the sole exception of the right on the part of the Corps to require the Sponsor to implement the provisions of Program Instrument, including recording conservation easements or similarly restrictive covenants, required as a condition of the issuance of permits for discharges of dredged and fill material into waters of the United States associated with construction and operation and maintenance of a Mitigation Site.

E. Attorneys' FeesIf any action at law or equity, including any action for declaratory relief, is brought to enforce or interpret the provisions of this Statement of Sale, each party to the litigation shall bear its own attorneys' fees and costs of litigation.

F. Headings and CaptionsAny paragraph heading or caption contained in this Statement of Sale shall be for convenience of reference only and shall not affect the construction or interpretation of any provision of this Statement of Sale.