Certification of Title III Expenditures: Optional Form

OMB No. 0596-0220

Expires XX/XX/201X

Secure Rural Schools and Community Self-Determination Act of 2000

Certification of Title III expenditures by participating county

The Secure Rural Schools and Community Self-Determination Act of 2000 (the Act), reauthorized in Public Law 110-343 and Public Law 112-141, requires the appropriate official of a county that receives funds under title III of the Act to submit to the Secretary concerned (the Secretary of Agriculture, or the Secretary of the Interior, as appropriate) an annual certification that the funds expended have been used for the uses authorized under section 302(a) of the Act. The Secretary concerned also is requiring the appropriate official to certify the amount of title III funds received since October 2008 that have not been obligated as of September 30 of the previous year.

The appropriate official of each participating county may use this form (see page 2) to report information to meet the requirements of the Act. Certification must be made by February 1 following each year title III funds are expended. Certain counties in Oregon receive title III payments initiated by both the Department of Agriculture and the Department of the Interior. If the county received Secure Rural Schools Act title III payments from more than one agency, the county must certify separately to each Secretary regarding the separate payment initiated by that agency. Submit the certification to the appropriate address below for the respective agency.

All counties expending title III funds received from Forest Service payments are to submit the annual certification by one of the following methods:

Mail:	e-mail:	FAX:
Secretary of Agriculture c/o U.S. Forest Service Payments to States Coordinator Albuquerque Service Center, B&F SWAM/IAS/ASR 101B Sun Avenue NE Albuquerque, NM 87109	[email protected]	877-684-1422

Certain counties in western Oregon expending title III funds received from payments from the Department of Interior for lands administered by the Bureau of Land Management are to submit a separate annual certification about the separate title III funds by one of the following methods:

Mail:	e-mail:	FAX:
Secretary of the Interior c/o BLM Oregon State Office State Director Office (OR931) Attn: Secure Rural Schools Coordinator P.O. Box 2965 Portland, OR 97208	(none available)	503 808-6021

Secure Rural Schools and Community Self-Determination Act of 2000

County’s Certification of Title III Expenditures and Unobligated Funds.

Name of participating county and state:
Calendar year for which this report is submitted:

EXPENDITURES
Amount of title III funds expended this year to carry out authorized activities under the Firewise Communities program:	$
Amount of title III funds expended this year to reimburse the participating county for emergency services performed on Federal land, as defined in the Act, and paid for by the participating county:	$
Amount of title III funds expended this year to develop community wildfire protection plans in coordination with the appropriate Secretary:	$
Total amount of title III funds expended this year for authorized uses:	$

FUNDS NOT OBLIGATED
Amount of title III funds received since October 2008 not obligated by September 30 of the year for which this report is submitted.	$

CERTIFICATION
The expenditures reported above were for the uses authorized under section 302(a) of the Act. The proposed uses had a publication and comment period and were submitted to the appropriate Secure Rural Schools Act resource advisory committee(s) as required in Section 302(b) of the Act. The amounts reported as unobligated on September 30 are accurate and consistent with the county’s accounting practices. Signature of certifying official: _________________________________________________
Print or type name and title of certifying official:	Date of certification:

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 0596-0220. The time required to complete this information collection is estimated to average 24 hours annually 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.

Secure Rural Schools Act

Certification of Title III expenditures by participating county

Page 2 of 2