FS-6500-235 De-obligation and Closeout Request Form

USDA Forest Service FS-6500-235 (Rev. 6/2008)

De-Obligation and/or Closeout Request Form

I-WEB, Grants & Agreements

(One request per package)

Contact Information
1. Transmitting Unit		     						Phone	     
2. Project/Program Manager		     						E-mail	     
Type of Request
3. Type of Instrument (Choose one)				interagency agreement	federal financial assistance			other type of FSM 1580 obligating instrument			MOU
4. Action Required				de-obligation	closeout			de-obligation and closeout
5. Agreement or Grant Number:				     
6. Obligation Document # (i.e. MO):				     
7. Amount to de-obligate, if any:				     
Attachments and Comments
8. Attachments (Check all that are applicable)
final progress report	final financial report					other substantive documentation				none
9. Comments:      
Acknowledgements
Program Manager acknowledges (Please check one) Substantial documentation is attached for a fund-obligating instrument. Do not proceed to Item #11, below. No substantial documentation is attached for a fund-obligating instrument. Completion of Item #11, below, is required. FS Program Manager Signature is not required for #10. No substantial documentation is required, since the instrument is a MOU. Do not proceed to Item #11, below.
FS Program Manager
Signature:							Date:      
Type/Print Name:      							Title:      
Phone Number:      			Fax Number:      				E-mail Address:      

Acknowledgements (Continued)
NOTE: Signatures from both the Forest Service Signatory Official and Cooperator are required below. Release information: All applicable administrative actions and all required work as described in the instrument listed above have been completed, minus this request for de-obligation and/or closeout activity(ies). All invoices, including the final invoice, have been provided to the Forest Service, and, if applicable, the Forest Service has either paid the cooperator for all monies owed, or the Forest Service has collected all over payments made to the cooperator. Authorized Representative: By signature below, the signing parties certify that they are the official representatives of their respective parties and authorized to act in their respective areas for matters related to the above referenced instrument.
FS Signatory Official (or Designee)
Signature:		Date:      
Type/Print Name:      		Title:      
Phone Number:      	Fax Number:      	E-mail Address:      
Cooperator (or Designee)
Signature:		Date:      
Type/Print Name:      		Title:      
Phone Number:      	Fax Number:      	E-mail Address:      
Grants & Agreements Specialist acknowledges: (Please check) All documentation (if required) is attached, and all required signatures have been provided on this form.
FS Grants and Agreements Specialist
Signature:		Date:      
Type/Print Name:      		Title:      
Phone Number:      	Fax Number:      	E-mail Address:      

• Send the original of this form and the supporting documentation to your assigned G&A Technician or Specialist via overnight or USPS mail, inter-agency shuttle or hand-delivery. Retain copies for your program records. If pieces of substantive documentation are already attached in IWeb, then list those items on a separate sheet of paper and attach the list to this form. There is no need to duplicate scanned files already in IWeb.

INSTRUCTIONS

The following instruction is for I-Web Grants and Agreements instruments.

1. Transmitting Unit – Enter requesting unit name

2. Name of Requestor – Enter name of program official or designee authorizing that the grant or agreement is ready to either de-obligate remaining funds, closeout the instrument, or both.

3. Type of instrument – Select type of instrument.

   1. Interagency Agreement

   2. Federal Financial Assistance, i.e. grants or cooperative agreement (non-HHS payment type only)

   3. Other type of FSM 1580 obligating instrument, e.g. Participating, Challenge Cost-Share, Joint Venture, and Cost Reimbursable

   4. MOU (Memorandum of Understanding)

NOTE: This form does not apply to Intra Agency, HHS-Paid Federal Financial Assistance awards or Collection agreements.

4. Action Required

   1. De-obligation -Select to de-obligate the balance of an open obligation.

   2. Closeout – Select to closeout the instrument with a zero balance, i.e. there is not a remaining balance on the instrument.

   3. De-obligation/Closeout – Select to both de-obligate the balance of an open obligation and to closeout the instrument.

5. Agreement or grant number - Enter the grant or agreement number, a.k.a. Federal Identifier Number.

6. Obligation Document Number - If de-obligating an existing obligation, then enter the obligation number, e.g. MO G13690270 (Note: an MO is the same as “FFIS Document Number”).

7. Amount to de-obligate, if any – If applicable, enter the balance of the open obligation (ULO).

8. Attachments (Describe)

Select the type of attachments that will be provided to closeout the agreement. Select the appropriate boxes as follows:

1. Substantive Documentation for Interagency Agreements: Documentation shall include:

• A signed statement or email from the Cooperator’s responsible fiscal representative that shows the aggregate amount invoiced, through the applicable federal billing system, the amount of the total Forest Service obligation (including all modifications), the outstanding ULO amount, the MO#, if available, and a statement that the final invoice has been sent to the Forest Service (if applicable) and final payment has been received through the applicable federal billing system.

2. Final Progress/Accomplishments/Technical Report: Reports shall contain the following:

• a comparison of actual accomplishments with the goals and objectives established for the period;

• where project output can be quantified, a computation of the cost per unit of output;

• reason why goals and objectives were not met, if appropriate; and

• Other pertinent information including, when appropriate, analysis and explanation of cost overruns or high unit costs

3. Final Financial Report

• SF-269 (Federal Financial Assistance)

• SF-272 (Federal Financial Assistance)

• Detailed transaction report

• Other Cooperator format

d. Other Substantive Documentation, such as:

• Correspondence letter to or from the Cooperator documenting closeout and/or de-obligation of any remaining award funding (i.e., clear, documented indication of the vendor’s informed knowledge)

• Confirmation e-mail regarding the final invoice or final report submission

• Final invoice with cumulative expenditures

• Billing history

• Completion of activity confirmation, i.e., training certification, email on training attendance

e. None – Select this box when you do not have any attachments to provide to closeout the grant or agreement.

9. Comments - Please provide a justification for not providing any or all required documents according to the terms or conditions described in the instrument.

10. Release - Forest Service signatory official or designee is required to sign the form. Bilateral signatures are required when the terms or conditions are not met in the instrument, or when substantive documentation is not provided.

4