FS-2200-001 Refund, Credit, or Transfer Application

USDA Forest Service FS-2200-001 (v08-2018)

OMB No. 0596-0003 (Exp. 9/30/2018)

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 any overpaid portion of      permitted use. (Year)

Transfer credit (rarely used) to the account of

     

PERMITTEE ACTION

FOREST SERVICE ACTION

allotment

cattle horses sheep

no. of head

period rangeland 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.

Instructions for Completion of Form FS-2200-001, Refund, Credit, or Transfer Application

(Reference FSM 2230 and FSH 2209.13)

1. Permittee – Enter Name and Mailing address of permit holder who is applying for Refund, Credit or Transfer.

2. Permit Number – Enter the identifying number of the active permit for which the Refund, Credit, or Transfer is being applied for.

3. Date – Enter the date the application is being submitted.

4. National Forest or Grassland – Enter the name of National Forest of which the active grazing permit is administered.

5. Ranger District – Enter the name of the Ranger District of which the active grazing permit is administered.

6. Application Hereby Made For: (check one) - Select by placing a check in the appropriate block to identify which process (Refund, Credit, or Transfer) is being applied for. For either Refund or Credit, enter the appropriate Grazing Year in the blank provided to identify permitted use. If Transfer is selected, then enter the complete entire name of the account that the credit will be applied to.

7. Permittee Action

   1. Allotment – Enter the complete name of the allotment which the permitted use occurs on.

   2. Cattle/Horses/Sheep – Enter the appropriate livestock kind.

   3. No. of Head – Enter the number of animals

   4. Period Range Not Used. (From/To) – Enter dates (mm/dd) of the period for which the refund, credit, or transfer is being applied for.

8. Forest Service Action

   1. Permitted Head Months Not Used – Enter the calculated permitted head months not used

   2. Rate Per Head Month – Enter the grazing fee for the appropriate year applied.

   3. Amount of Credit – Enter the calculated amount of credit (permitted head months not used times rate per head month).

   4. Computed by – Enter the initials of the person who computed the credit amount.

   5. Checked by – Enter the initials of the person who checked the computed calculation.

   6. Total Credit or Refund – Enter the total sum of the all the lines of Refund or Credit.

9. Reason for less use than Permitted – Narratively describe what contributed to need for refund, credit, or transfer.

10. Signature of Permittee – Enter the complete full name of the permit holder applying for the Refund, Credit, or Transfer.

11. Title – Enter the title of the person applying for Refund, Credit, or Transfer.

12. Date – Enter the date of signature.

13. Recommendation – Select by placing a check mark in the appropriate field identifying whether or not the application is recommended for Approval, or Disapproval.

14. Signature of Recommending Officer – Enter the official signature of the Recommending official

15. Name (Print) – Print the name of the recommending official.

16. Title – Enter the official Title of the recommending official

17. Date – Enter the date that the recommendation was submitted.

18. Action - Select by placing a check mark in the appropriate field identifying whether or not the application is Approved, or Disapproved.

19. Signature of Authorized Officer – Enter the official signature of the approving officer.

20. Name (Print) – Print the name of the approving officer.

21. Title – Enter the Official Title of the approving officer.

22. Date – Enter the date the approving officer signed the document.

Previous versions of this form are obsolete Page 4 of 4