FS-2700-3a Holder-Initiated Revocation of Existing Authorization an

FS-2700-3a (03/06)

OMB No. 0596-0082

USDA FOREST SERVICE

HOLDER INITIATED REVOCATION OF EXISTING AUTHORIZATION

REQUEST FOR A

SPECIAL-USE PERMIT OR TERM SPECIAL-USE PERMIT

PART I - REQUEST FOR REVOCATION (Completed by current permit holder)

I (We), the undersigned holder(s) of a special-use authorization, dated       authorizing me (us) to occupy and use National Forest System lands for       have

(Mark one box with "X")

conveyed all my (our) right, title, and interest in and to the improvements located on the parcel covered by said permit to:

entered into a contract for the sale of the improvements located on the parcel covered by said permit but have retained title to said improvements until completion of payment under said contract with:

New Owner (1):       Address:      

(Please Print)

New Owner (2):       Address:      

(Please Print)

Phone: (   )    -    

Accordingly, I (we) request that the special-use authorization identified above be revoked. I (we) have informed the new owner(s) that (1) the current authorization is not transferable; (2) they must apply for and obtain a new authorization; (3) there are terms and conditions for the use of National Forest System lands; (4) and they must contact the Forest Service prior to acquisition of improvements. The remaining balance of any fees previously paid should be credited to the new owner(s) named above, if an authorization is issued.

Holder (1):       Holder (2):      

(Please Print) (Please Print)

Signature:       Signature:      

Date:       (mm/dd/yyyy)

PART II - REQUEST FOR A NEW PERMIT OR TERM PERMIT (Completed by new owner - Requester)

Request is made for a special use authorization to cover the same parcel of land or use covered by the authorization referred to above, and for the same purpose, subject, however, to such new conditions and stipulations as the circumstances may warrant. I (We) acknowledge that this is a request only, and that the use and occupancy of National Forest System lands is not authorized until an authorization is signed and issued by an authorized officer. I (We) also understand that an administrative fee may be charged by the Forest Service to process this request for a new authorization to use or occupy National Forest System lands.

Requester (1):       Phone: (   )    -    

(Please Print) E - Mail:      

FAX: (   )    -    

Signature:       Date:       (mm/dd/yyyy)

Requester (2):       Phone: (   )    -    

(Please Print) E - Mail:      

FAX: (   )    -    

Signature:       Date:       (mm/dd/yyyy)

18 U.S.C. § 1001 makes it a crime for any person knowingly and willfully to make to any department or agency of the United States any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction. Anyone who knowingly or willfully makes or uses any false writing shall be fined not more than $10,000 or imprisoned not more than five years, or both.

PLEASE ATTACH BILL OF SALE, DEED, OR OTHER DOCUMENTATION VERIFYING PURCHASE OF IMPROVEMENTS

PART III - REQUEST CHECKLIST (Completed by Administrator/Case Manager)

1. Does the current use and occupancy of National Forest System lands and facilities comply with all federal, state, and local laws, regulations, orders, and policies? If not, what must be done to make the use and occupancy comply?      

Yes

No

2. Is the current use and occupancy of National Forest System lands and facilities being conducted in a manner that is consistent with established standards and guidelines in the Forest Land and Resource Management Plan? If not, can it be made to be consistent?       How?      

Yes

No

3. What was the date of last inspection? What is the condition of the authorized area and facilities? (Describe undesirable or unacceptable conditions that need to be corrected.)      

Yes

No

4. Does the requester(s) owe any fees to the Forest Service from a prior or existing special-use authorization? If yes, identify fees owed.      

Yes

No

5. Is the requester(s) qualified to hold an authorization for the subject use and occupancy? If not, why?      

Yes

No

6. Can the requester(s) demonstrate technical and financial capability to undertake the proposed use and occupancy, and fully comply with all the terms and conditions of the authorization?      

Yes

No

7. Is there someone authorized by the requester(s) to sign an authorization, and there is someone willing to accept the responsibility of the terms and conditions of the authorization?      

Yes

No

Remarks:      

Signature of Administrator /Case Manager:			     			Date:		      (mm/dd/yyyy)
PART IV – AUTHORIZED OFFICER
	The request and/or requester do not meet the criteria identified in Part III of this form. Therefore, I will not approve this request to issue an authorization to use or occupy National Forest System lands for the use(s) described in Part I of this form.
	The request and the requester meet the criteria identified in Part III of this form. Therefore, I approve this request to issue an authorization to use or occupy National Forest System lands for the use(s) described in Part I of this form.
Signature:		     	Title:	     	Date:		      (mm/dd/yyyy)

Burden Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0082. The time required to complete this information collection is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 975-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer. The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 552) govern the confidentiality to be provided for information received by the Forest Service.

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