FS-2700-14c Claim for In-Kind C0osideration Cost

Authorization ID       FS-2700-14c (09/2020)

Contact ID       OMB 0596-0082

Expiration Date      

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U.S. DEPARTMENT OF AGRICULTURE

Forest Service

LEASE FOR FOREST SERVICE ADMINISTRATIVE SITES

APPENDIX: F [current 4 digit fiscal year]

claim for In-Kind CONSIDERATION COSTS

AUTHORITY:

Section 8623 of the Agriculture Improvement Act of 2018,

Pub. L. No. 115-334, 132 Stat. 4853, 16 U.S.C. 580d note

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      NATIONAL FOREST

      RANGER DISTRICT

In-Kind Consideration:       Lessee’s Fiscal Year:      

This Claim for In-Kind Consideration Costs (claim) corresponds to the In-Kind Consideration Agreement (agreement) executed by [lessee name] (the lessee) and the U.S. Department of Agriculture, United States Forest Service, [forest name] National Forest (the Forest Service), on [date agreement is fully executed], under section 8623 of the Agriculture Improvement Act of 2018, Pub. L. No. 115-334, 132 Stat. 4853, 16 U.S.C. 580d note, and clauses IV.C.2 and VI.E of the Lease for Forest Service Administrative Sites executed on [date lease is fully executed] (lease).

All or part of the rent for the lease may be paid in-kind for approved costs incurred by the lessee, in accordance with the agreement and clauses VI.C.2 and VI.E of the lease, for the construction of new facilities or improvements in the lease area; Government maintenance, repair, improvement, or restoration of facilities or improvements in the lease area; and services relating to activities that occur in the lease area. Costs submitted under this claim shall be documented and determined by the Forest Service to be reasonable, allocable, and allowable, in accordance with the terms of the lease and the agreement.

Approval of this claim is subject to all the provisions in the agreement.

Salaries and Wages $      

Materials and Supplies $      

Subcontracts $      

Other (please specify)       $      

TOTAL COSTS CLAIMED AS IN-KIND CONSIDERATION $      

Itemize claimed costs by category, and attach schedules showing the cost breakdown by category.

Subject to the penalties prescribed in the False Statements Act, 18 U.S.C. 1001, the lessee certifies to the best of its knowledge that the representations in this claim and its supporting documentation are accurate and complete. The Forest Service reserves the right not to grant this claim if it contains any inaccurate or incomplete representations. Failure to sign the certification below shall vitiate this claim.

Signed:       Date:      

Lessee Name, Preceded by Name and Title of

Person Signing on Behalf of Lessee, if Lessee is an Entity

According to the Paperwork Reduction Act of 1995, no persons are 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. Public reporting burden for collection of information, if requested, is estimated to average 1 hour per response, including the time for reviewing instructions, searching data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to United States Department of Agriculture, Clearance Officer, OCIO, AG Box 7630, Washington D.C. 20250, and to the Office of Management and Budget, Paperwork Reduction Project (OMB #0596-0082), Washington, D.C. 20503.

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.

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