SAMPLE APPLICATION FORM PERMIT TO CUT AND BALE HAY ALONG INTERSTATE RIGHTS-OF-WAY IN TENNESSEE I, ______________________________________ , _________________________________ , _____________ NAME ADDRESS ZIP _________________________________ , being a resident of the State of Tennessee and deriving a significant PHONE NO. portion of my annual income from farming, petition the Tennessee Department of Transportation for permission to cut and bale hay on a certain portion of the Interstate Rights-of-Way as described below. I certify by this petition that all hay derived from the Interstate Rights-of-Way will be used for personal farming purposes and will not be sold. DESCRITPION INTERSTATE I- ______________________________ COUNTY ______________________________ MILE MARKER _________________________ TO MILE MARKER ___________________________ MEDIAN ____________R-O-W RIGHT SIDE ______________R-O-W LEFT SIDE ________________ AVERAGE WIDTH ______________________________ LENGTH ______________________________ I certify that I will adhere to the required rules and regulations at all times during this operation. I certify that if this application is approved, I will defend and hold the Department of Transportation, its officers, or employees harmless from any claims or actions brought by any person against the Department of Transportation, its officers or employees as a result of my hay harvesting operation. APPLICANT ___________________________ SIGNATURE ___________________________ (STREET, RFD) ___________________________ CITY STATE ZIP

Authority: T.C.A. §54-585. Administrative History: Original rule filed June 30, 1980; effective August 14, 1980. Rule has been assigned a new control number from 1680-2-5-.05 filed and effective February 1, 2003.