FS-1500-34 Grant Equipment Justification and Certification Statemen

FS-1500-34 (VER. XX/XX) OMB No. 0596-0217

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.)

Make & 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 Cooperator’s purchasing/acquisition guidelines and State Statutes (as applicable) Cooperator will maintain purchase and usage documentation to support grant accounting. Use of grant funded equipment for incident work: Only actual costs of operation may be reimbursed, but no replacement or acquisition costs may be included. See associated provision in the award document.

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 Response to this collection of information is Mandatory (Title VIII of IIJA). The time required to complete this information collection is estimated to average 25 minutes per response, including the time for reviewing the 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 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, S.W., Washington, DC 20250-9410, or call toll free at (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.

The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 522) govern the confidentiality to be provided for information received by the Forest Service.

Revised 11-25-2013