New Hanover_Agent_Authorization_v1ENG FORM 6295, JAN 2024
U.S. Army Corps of Engineers (USACE)
AUTHORIZATION TO ACT AS AN AGENT
For use of this form, see Section 404 of the Clean Water Act, Section 10 of the Rivers and Harbors Act of 1899,
and Section 103 of the Marine Protection, Research, and Sanctuaries Act, the proponent agency is CECW-COR.
Form Approved -
OMB No. 0710-0003
Expires XX-XX-XXXX
The Agency Disclosure Notice (ADN)
The Public reporting burden for this collection of information, 0710-003, is estimated to average 5 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at
whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no
person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
Purpose: This form is used by members of the public to authorize an agent (for example - a private consultant) to act on their behalf
in all matters relating to all dealings with the USACE regarding the project. This includes taking all necessary actions for the
application, processing, issuance, and/or acceptance of a Clean Water Act and/or Rivers and Rivers Act delineations,
determinations, and/or permits.
This form is a component in the Corps Regulatory Request System (RRS), which is an online permitting application portal for the Regulatory Program.
ITEMS 1 THRU 3 - FOR USACE USE ONLY
1. APPLICATION NO.2. FIELD OFFICE CODE 3. DATE RECEIVED
ITEMS 4 THRU 14 - COMPLETD BY THE PROPERTY OWNER
4. PROJECT NAME 5. PROJECT LOCATION
6. APPLICANT NAME (first, middle, last)7. AGENT NAME
Company (if applicable):
E-mail Address:
Company:
E-mail Address:
8. APPLICANT ADDRESS (if applicable)
Address
City:State:
9. AGENT ADDRESS (if applicable)
Address
City:State:
10. APPLICANT PHONE NUMBERS. w/AREA CODE 11. AGENT PHONE NUMBERS. w/AREA CODE
a. Residence b. Business c. Fax a. Residence b. Business c. Fax
12. APPLICANT/AGENT CERTIFICATION
By signing below, I hereby authorize the agent listed above, to act on my behalf in all matters relating to all dealings with the USACE
regarding the project and properties listed above, including taking all necessary actions for the application, processing, issuance, and/
or acceptance of a Clean Water Act and/or Rivers and Rivers Act delineations, determinations, and/or permits. Any and all acts
carried out by my agent on my behalf as it relates to this project and property shall have the same effect as acts of my own.
I agree to review all information submitted to the USACE on my behalf by my agent and certify that any information submitted on my
behalf is true and correct.
14. DATE13. SIGNATURE OF APPLICANT
18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of the United States knowingly and
willfully falsifies, conceals, or covers up any trick, scheme, or disguises a material fact or makes any false, fictitious or fraudulent statements or
representations or makes or uses any false writing or document knowing same to contain any false, fictitious or fraudulent statements or entry, shall be
fined not more than $10,000 or imprisoned not more than five years or both.