FS-2700-3a Holder Initiated Revocation of Existing Authorization, R

FS-2700-3a (05/2020)

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:

(Please Print)

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:       

Signature:

FAX: (   )    -    

Requester(2):       

(Please Print)

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

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.  Response to this collection of information is mandatory. The authority to collect the information is the Organic Administration Act,16 U.S.C. 551.  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.

   

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs).  Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible agency or USDA’s TARGET Center at (202) 720-2600 (voice and TYY) or contact USDA through the Federal Relay Service at (800) 877-8339.  Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form.  To request a copy of the complaint form, call (866) 632-9992.  Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. 

USDA is an equal opportunity provider, employer, and lender.

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.

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

Yes comply?      

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

Yes not, can it be made to be consistent? How?      

No

3. What was the date of last inspection? What is the condition of the authorized area and facilities? (Describe

Yes undesirable or unacceptable conditions that need to be corrected.)      

No

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

Yes yes, identify fees owed.       

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

Yes occupancy, and fully comply with all the terms and conditions of the authorization?      

No

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

Yes the responsibility of the terms and conditions of the authorization?      

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)