Form FS-1500-100 Grant or Agreement Award Cover Sheet

FS-1500-100 (VER. XX/XX) OMB No. 0596-0217

Grant or Agreement Award Face Sheet

Federal Award Identification Number (FAIN):     	Title:     
Cooperator Instrument #:     	Instrument Type:      New: ☐ Modification:☐
Assistance Listing (CFDA) Number and Title:     	Authority:     
Cooperator Unique Entity Identifier (UEI/DUNS):     	Period of Performance Execution 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: No Funds ☐ Advance ☐ Reimbursable ☐
Cooperator Indirect Cost Rate (approved rate and rate charged to award): De minimis ☐ Supported ☐ NICRA ☐ Rate:     	Master ☐ Stand-Alone ☐ SPA ☐
Program Income/Revenue: No ☐ Yes☐	Master Agreement Number if SPA:      Master Agreement Expiration Date:      (SPA cannot exceed Master)
Reporting Requirements
Performance Report Frequency: Quarterly ☐ Semi-Annual ☐ Annual ☐ N/A or Other (Specific Cond)☐	Financial Report Frequency: Quarterly ☐ Semi-Annual ☐ Annual ☐ N/A or Other (Specific Cond)☐

ATTACHMENTS

The attachments listed below are hereby incorporated and made a part of this award.

REQUIRED FOR ALL INSTRUMENTS:

☐Provision Pages

☐Scope of Work Narrative

☐Budget/Financial Plan

REQUIRED DEPENDENT ON INSTRUMENT TYPE:

Statement of Mutual Benefit and Interest

Federal Financial Assistance Forms/Assurances

Good Neighbor/Stewardship

By signing this instrument, the signer certifies that they are vested with the authority to enter into this arrangement

Cooperator Signature Signature     

Name and Title      

Date      

This instrument, subject to the provisions above, is executed by	(U.S. Forest Service Authorized Signatory):
Signature     	U.S. Forest Service Signatory Official (SO) Name and Title      	Date      

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

Signature     

U.S. Forest Service G&A Specialist Name (if different than SO)      

Date      

^File Code: 1500 Page: ¹

Cooperator Program Manager Name:      Phone:       Email:     	Forest Service Program Manager Name:      Phone:       Email:      
Cooperator Program Manager Name:      Phone:       Email:     	Forest Service Program Manager Name:      Phone:       Email:      

By signing this instrument, the signer certifies that they are vested with the authority to enter into this arrangement

Cooperator Signature Signature     

Name and Title      

Date      

Cooperator Signature Signature     

Name and Title      

Date      

This instrument, subject to the provisions above, is executed by	(U.S. Forest Service Authorized Signatory):
Signature     	U.S. Forest Service Signatory Official (SO) Name and Title      	Date      

Signature     

U.S. Forest Service Signatory Official (SO) Name and Title      

Date      

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 3 hours 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.