Minnesota Department of Natural Resources
Division of Trails and Waterways
500 Lafayette Road, St. Paul, MN 55155

M.S. 84.780 [Effective 8/02/03 to 6/30/05]

Claim # _______________

IMPORTANT NOTE: M.S. 84.780 establishes specific conditions for successful claims on the Off-Highway Vehicle

Damage Account:

1. The damage must be caused by the unpermitted use of OHVs.

2. The damage must have happened after August 1, 2003.

3. Reasonable efforts must be taken to identify the responsible party and obtain payment from that

individual.

4. Reasonable efforts must be made to prevent the reoccurrence of damage.

Supporting documentation is REQUIRED for each condition. Claims will be DENIED if one or more of these

conditions are not met.

Governmental units interested in a grant agreement fill out Section 1 only and send the form to the local DNR

Division of Trails and Waterways Area Office for your jurisdiction. See Section 3 to find your DNR Area Office.

Name Telephone

Date Damage Occurred Date Damage Reported

Address

City, State, Zip County

Location of Damage

Section___Township___Range___County_________________

Please attach a map if available.

Contact Person (if not same) Telephone

When is it best to contact you by telephone? Day__

Different telephone number? Evening__

List:

Do you own the property in question? Yes__No__ If no, state relationship to Property Owner:

This section establishes whether the conditions necessary to approve a claim are satisfied. Supply all supporting documentation.

Absence of supporting documentation on any of these conditions means the claim will not be approved. Add additional

pages as necessary.

Is OHV use permitted where the damage is located? Yes__No__ If yes, describe:

Do you know who caused the damage? Yes__No__ If no, explain:

If yes, provide any of the following information: operator name and/or address, license plate, vehicle description

(yr./make/model/color), or other identifying features.

If yes, have you attempted to obtain payment from the responsible party? Yes__No__

If yes, have you negotiated an agreement on payment? Yes__No__ OR

If yes, has a case been submitted to conciliation court or district court? Yes__No__

Estimate the cost of repairing the damage. $_____________________

Have you tried to prevent reoccurrence of the damage? Yes__No__ If no, explain:

If yes, check all that are applicable:

Have posted no trespassing signs at:

__property corners __ingress-egress points __ 500-ft intervals (wooded) __1000-ft intervals (clear) When were the signs

posted? Date:_____________

Have installed maintained fence. Yes__No__

Any other measures? Please list:

Provide a general description of the damage. Include location, type(s), extent, and degree. Example: moderate rutting along

driveway for 50 feet.

Is damage present from other sources? Yes__No__ If yes, describe:

Is the damage causing direct or indirect impacts to a wetland, stream, or lake? Yes__No__ If yes, describe:

Civil or Criminal Citation. Has a law enforcement department been contacted? Yes__No__

If yes, provide the officer’s name, affiliation, and citation # (if available):

Citation #_____________ Issued by Agency:_________________ Name/Badge #:_____________________________________

Restitution. Has restitution been ordered to repair/restore the damage from either criminal or civil proceedings? Yes__No__ Has

restitution been negotiated with the responsible party? Yes__No__ If yes to either, has the restitution been collected and applied

to the damage? Yes__No__

Additional Comments and Supporting Documentation. Attach additional comments or information that documents the damage,

who caused it with attempts to obtain payment, and any steps taken to prevent reoccurrence. This can include photos of the

damage, photocopies of correspondence, or other information.

I hereby attest that the above information is true, complete, and accurate. I grant to the DNR or its authorized agent

a temporary, non-exclusive license to enter onto my property for the purpose of inspecting the damage to the

property listed in Section 1. I certify that I am aware of no hidden hazards or conditions that would be dangerous to

people on the property listed in Section 1 of this application.

Property Owner’s Signature Date

Signature of Preparer other than Property Owner Date

Do you wish to be present if a site visit is approved? Yes__No__ If yes, please be prepared to contact the DNR

Mail or deliver the completed application to the appropriate DNR Division of Trails and Waterways Office. Call (651) 297-1151 to locate the DNR office for the county where the damage occurred or visit < www.dnr.state.mn.us >.