FS-1500-100 Grant or Agreement Award Cover Sheet

UNITED STATES DEPARTMENT OF AGRICULTURE – FOREST SERVICE

Grant or Agreement Award Cover Sheet

FS-1500-100

OMB Control No. 0596-0217

EXP DATE:

GENERAL INFORMATION
FAIN:     		Title:     
Cooperator Instrument #:     		Instrument Type:     
Assistance Listing (CFDA) Number and Title:     		Authority:     
Cooperator Unique Entity Identifier (UEI/DUNS):     		Period of Performance Start date:     	Expiration date:     
Cooperator (Legal Name and Address – must match SAM) Name:      Address:      City:      State:      Zip:     		Forest Service Unit Address Name:      Address:      City:     State:      Zip:     
Cooperator Program Manager Name:      Phone:       Email:     		Forest Service Program Manager Name:      Phone:       Email:      
Cooperator Administrative Contact Name:      Phone:       Email:     		Forest Service G&A Specialist Name:      Phone:       Email:      
FINANCIAL INFORMATION
Cooperator Matching Funds:     		Federal Funding to Cooperator:     
Cooperator Match %:     		Payment Method: Advance & Reimbursement	Reimbursement Only
Cooperator Indirect Cost Rate (approved rate and rate charged to award): De minimis NICRA Rate:     
Program Income/Revenue: N	Y	Master Agreement Number:     

	REPORTING REQUIREMENTS
	Performance Report Frequency: Quarterly Semi-Annual Annual Other (Specific Conditions)		Financial Report Frequency: N/A Quarterly Semi-Annual Annual Other (Specific Cond.)
	ATTACHMENTS
	REQUIRED FOR ALL INSTRUMENTS: Scope of Work/Narrative Budget/Financial Plan Provisions		REQUIRED DEPENDENT ON INSTRUMENT TYPE: ☐ Statement of Mutual Interest/Benefit ☐ Federal Financial Assistance Forms ☐ Assurances ☐ Good Neighbor/Stewardship Attachments ☐ Conditional/Optional Provisions
	ACKNOWLEDGEMENTS:
This instrument, subject to the provisions above, is executed by:		Forest Service Authorized Representative:
Signature     		Forest Service Signatory Official (SO) Name and Title      		Federal Award Date      

The authority and format of this instrument has been reviewed and approved for signature.

Signature     

G&A Specialist Name (if different than SO)      

Date      

By signing this instrument, the signatory below certifies and attests, they are granted the authority to enter this binding contract on behalf of their respective parties.

Cooperator Signature      	Name and Title      	Date      
Cooperator Signature (Optional)      	Name and Title      	Date      

File Code: 1500

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 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. Responses to this collection of information are mandatory (2 C.F.R. §200). You may send comments regarding the USFS’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection techniques to the, USDA Forest Service Information Collections Officer, Business Operations, Directives & Regulations Branch, 1400 Independence Avenue SW, Washington, DC 20250-1108. Please include the OMB Control No. in any correspondence. Send only comments to this address. Page: ¹