FS-1500-34 Grant Equipment Justification and Certification Statemen

USDA Forest Service OMB 0596-0217

FS-1500-34

GRANT EQUIPMENT JUSTIFICATION AND CERTIFICATION STATEMENT

Project Title:

Grant Program:

Grant Number:

Equipment Description

Type: (i.e., Dozer, Engine, Pick up, Pump, Map Grade GPS, etc.)

Model: (i.e., Ford F-350 4x4, John Deere 750J, Honda GX340, Trimble Juno, etc.)

Specialized/Custom/Technical Requirements: (i.e., Briefly describe any special or customized modifications to the equipment required for use in project implementation. Include performance and/or safety items. For Example: screens, shields, manual fuel shut-off valves, etc. that is not standard.)

Quantity:

Cost

Cost Per Unit:

Total Cost:

Equipment Need and Added Value To Grant Declaration

Briefly describe how this equipment is necessary to accomplishment the grant project/program objectives.

Briefly describe how this equipment is unique (i.e., safety, efficiency, innovative, etc.) in its ability to accomplish the grant task(s) described above (6A) compared to other potential options (i.e., other equipment types, contracting, etc.):

Time equipment will be used for this grant project/program:

Months :

Days:

Will equipment be used to support another federal grant? (Note: Equipment cannot be included as a cost or used to meet cost sharing requirements of any other federal award.)

YES: ☐ NO: ☐

Grantee Certification Statement

This equipment purchase adheres to State Statutes and approved State purchasing/acquisition guidelines. State will maintain purchase and usage documentation to support grant accounting.

Certified by:

Title:

USDA Forest Service Grant Program Manager Review and Approval

Approved by:

Program Manager

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 25 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.

Revised 11-25-2013