Form FS-2200-001 Refund Credit or Transfer Application

USDA Forest Service FS-2200-001 (V. 08/2012)

OMB No. 0596-0003 (Exp. 07/2012)

Refund, Credit, or Transfer Application

(Reference FSM 2230 and FSH 2209.13)

Permittee (Name & Mailing Address)      

Permit Number      

Date      

National Forest or Grassland      

Ranger District      

APPLICATION IS HEREBY MADE FOR: (Check One) Credit on next year’s fees for unused portion of       permitted use. (Year) Refund of fees for unused portion of       permitted use. (Year)

Transfer credit to the account of

     

PERMITTEE ACTION

FOREST SERVICE ACTION

allotment

cattle horses sheep

no. of head

period range not used

permitted head months not used

rate per head month

amount of credit

computed by

checked by

from

to

     

     

     

     

     

     

     

     

           

     

     

     

     

     

     

     

     

           

     

     

     

     

     

     

     

     

           

     

     

     

     

     

     

     

     

           

Total Credit or Refund

$     

REASON FOR LESS USE THAN PERMITTED:      

Signature of Permittee      

Title      

Date      

RECOMMENDATION: (Check One)

APPROVAL

DISAPPROVAL (Give reasons for either recommendation)

     

Signature of Recommending Officer      

Name (print)      

Title      

Date      

ACTION: (Check One)

APPROVAL

DISAPPROVAL (If disapproved, give reason(s))

     

Signature of Authorized Officer      

Name (print)      

Title      

Date      

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 0596-0003. The time required to complete this information collection is estimated to average 20 minutes per response, 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) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Previous versions of this form are obsolete Page 2 of 2