FS-1500-19 Modification Form

Good Neighbor Agreements With State Cooperators

FS 1500-19 Modification

GOOD NEIGHBOR AGREEMENTS WITH STATE COOPERATORS

OMB: 0596-0239

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USDA Forest Service OMB 0596-0217

FS-1500-19


MODIFICATION OF GRANT OR AGREEMENT

PAGE OF PAGES

1

 

1. U.S. FOREST SERVICE GRANT/AGREEMENT NUMBER:

     

2. RECIPIENT/COOPERATOR GRANT or AGREEMENT NUMBER, IF ANY:

     

3. MODIFICATION NUMBER:

     

4. NAME/ADDRESS OF U.S. FOREST SERVICE UNIT ADMINISTERING GRANT/AGREEMENT (unit name, street, city, state, and zip + 4):

     

5. NAME/ADDRESS OF U.S. FOREST SERVICE UNIT ADMINISTERING PROJECT/ACTIVITY (unit name, street, city, state, and zip + 4):

     

6. NAME/ADDRESS OF RECIPIENT/COOPERATOR (street, city, state, and zip + 4, county):

     

7. RECIPIENT/COOPERATOR’S HHS SUB ACCOUNT NUMBER (For HHS payment use only):

     

8. PURPOSE OF MODIFICATION

CHECK ALL THAT APPLY:

This modification is issued pursuant to the modification provision in the grant/agreement referenced in item no. 1, above.

CHANGE IN PERFORMANCE PERIOD:      

CHANGE IN FUNDING:      

ADMINISTRATIVE CHANGES:      

OTHER (Specify type of modification):      

Except as provided herein, all terms and conditions of the Grant/Agreement referenced in 1, above, remain unchanged and in full force and effect.

9. ADDITIONAL SPACE FOR DESCRIPTION OF MODIFICATION (add additional pages as needed):

     

10. ATTACHED DOCUMENTATION (Check all that apply):

Revised Scope of Work

Revised Financial Plan

Other:      



11. SIGNATURES

Authorized Representative: By signature below, the signing parties certify that they are the official representatives of their respective parties and authorized to act in their respective areas for matters related to the above-referenced grant/agreement.

11.A.       SIGNATURE

11.B. DATE SIGNED


     

11.C. U.S. FOREST SERVICE SIGNATURE

11.D. DATE SIGNED

     

(Signature of Signatory Official)

(Signature of Signatory Official)

11.E. NAME (type or print):      

11.F. NAME (type or print):      

11.G. TITLE (type or print):      

11.H. TITLE (type or print):      

12. G&A REVIEW

12.A. The authority and format of this modification have been reviewed and approved for signature by:


______________________________________

     

U.S. Forest Service Grants Management Specialist

12.B. DATE SIGNED

     





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 0596-0217. 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, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (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 toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.




INSTRUCTIONS FOR FORM FS-1500-19

1. Enter the orginal U.S. Forest Service agreement number.


2. Enter the cooperator’s agreement number, if applicable.


3. Enter the number for this Modification, i.e. 01, 02, or 03. The first modification to an instrument is ‘01’, subsequent modifications receive a subsequent modification number (for example, the fourth modification is ’04’).


4. Enter the address of the G&A Specialist/Signatory Official responsible for this agreement.


5. Enter the address of the U.S. Forest Service Program/Project Manager or Lead Scientist responsible for this agreement.


6. Enter the cooperator’s address.


7. Enter the cooperator’s HHS Sub-Account numbers, if funding is provided on this modification (for example: G2412345003) (Only used by NA/S&PF and NRS)


8. Select all boxes that apply:


- Change in Performance = updated performance period agreed to.

- Change in Funding = obligation OR de-obligation amount and new totals.

- Administrative = change in pay address, administrator address, correcting typing errors, etc.

- Other = any other modification not described, such as update new objective to study plan, change the Principle Investigator, etc.


9. Insert changes such as updated provision, tasks, or any other data needed by the modification, add additional pages as needed.


10. Check all boxes that apply and ensure to attach these documents to the modification. Other attachments could include
SF-424 forms.



11. A – D, self explanatory.

11. E – H, Type or print the names of signatory officials.


12. G&A Specialist signs and dates before sending to the individuals in block 11, if all modification data are approved for signature.


File Typeapplication/msword
File TitleMODIFICATION OF GRANT OR AGREEMENT
AuthorJay Berg
Last Modified ByWoolley, Clark
File Modified2013-02-01
File Created2013-02-01

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