Form FS-2700-6b Recreation Residence Self-Inspection Report

USDA Forest Service FS-2700-6b (XX/202X)

OMB No. 0596-0082

RECREATION RESIDENCE SELF-INSPECTION REPORT

Permit Holder to complete and send to Forest Service

RANGER DISTRICT

ATTN:

ADDRESS

ADDRESS

FAX

PART I - TERMS AND CONDITIONS

Permit Holder/Primary & Mailing Address/Telephone/email					Tract: Lot #:
Yes No	1. Have you built or modified your structures during the past year? (Clause II-A) If yes, explain.
Yes No	2. Do you plan to construct or modify structures on the lot during the next year? (Clause II-B) If yes, explain.
Yes No		3. Do your structures meet state and local regulations and have you had an annual inspection if required by these entities? (Clause I-H and IV-I) If no, explain.
Yes No		4. Have you or do you plan to cut down any trees, altered the vegetation, or caused disturbance to the soil on the lot? (Clause III-G) If yes, explain.
Yes No			5. Have your kept your structures and access road in good repair, and maintained a neat appearance on the lot? (Clause III-C) If no, explain.
Yes No				6. Have you removed dangerous trees, limbs, or other hazardous conditions that could pose a risk of injury? (Clause III-D) If no, explain what hazards exist.
Yes No				7. Have you paid your annual cabin user special use permit fees for the current year? (Clause VI) If no, explain.
Yes No N/A				8. Have you received written approval for renting or subleasing your structures? (Clause VII-A) If no, explain.
Yes No				9. Are you planning to sell your structures in the next year? (Clauses IV-E, VII - C and D; IX-B) If yes, request a FS-2700-3a form and complete.
Yes No				10. Are you living at the recreation residence full-time, to the exclusion of a home elsewhere? (Clause III-B) If yes, explain.

Comments/Explainations/Input for Forest Service consideration:

Attach photos (with descriptions) and any additional sheets if necessary

Please sign, date, and return this form to your local Ranger District by: ____________________________________

PART II - OPERATION AND MAINTENANCE PLAN STANDARDS

!**USE THIS SECTION AS NEEDED TO LIST STANDARDS FROM APPROVED OPERATION & MAINTENANCE PLANS (Clause III-A)**!

Item Inspected Meets Standard Action Required/Due Date

	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No

I certify that I have inspected the structures and permitted area, and the above information is accurate and true. I understand that any modifications to the structures and lot require prior written approval by the authorized officer.

___________________________________________ _________________________

Signature of Permit Holder Date

____________________________________

Print Name

18 U.S.C. Section 1001 makes it a crime for any person knowingly and willfully to make to any department or agency of the United State any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.

PAPERWORK REDUCTION ACT STATEMENT

According to the Paperwork Reduction Act of 1995, a Federal agency may not conduct or sponsor, and a person is not required to respond to, an information collection request unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection request is 0596-0082. Response to this information collection request is required to obtain or retain benefits, specifically, a special use authorization. The authority for this information collection request is the Act of March 4, 1915, 16 U.S.C. 497. The time required to complete this information collection request is estimated to average 2.5 hours per response, including the time for reviewing instructions, searching existing data sources, collecting and maintaining the data needed, and completing and reviewing the information collection request. Send comments regarding this burden estimate or any other aspect of this information collection request, including suggestions for reducing the burden, to Forest Service Information Collections Officer, [email protected], with OMB control number 0596-0082 in the subject line.

PRIVACY ACT STATEMENT

Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act statement serves to inform you of the following concerning the collection of the information on this form.

Purpose:  The Privacy Act of 1974 requires that the Director of Recreation, Heritage, and Volunteer Resources staff and the Director of Lands, Minerals, and Geology Management staff provide the following statements to individuals from whom they request information.

Authority:  Collection of this information solicited on this form is authorized by the Act of March 4, 1915, 16 U.S.C. 497.

Routine Uses:  The information collected will be used by Forest Service officials to ensure that your use of National Forest System lands is administered in accordance with applicable statutes, regulations, and directives. The information collected from you is retained in the Special Uses Data System (SUDS) and is retrieved by the Forest Service create reports for the Agency’s Special Uses Program, generate bills for collection of land use fees for your authorization, monitor compliance with your special use authorization, and other matters pertaining to administration of your special use authorization. SUDS is a component of the Forest Service’s Natural Resources Manager database (NRM). A complete list of the routine uses of NRM can be found in the system of records notice associated with this form, FS-24.

Disclosure:  The submission of this information is required to obtain or retain benefits, specifically, a special use authorization.

NONDISCRIMINATION STATEMENT

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs).  Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible agency or USDA’s TARGET Center at (202) 720-2600 (voice and TYY) or contact USDA through the Federal Relay Service at (800) 877-8339.  Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all the information requested in the form.  To request a copy of the complaint form, call (866) 632-9992.  Submit the completed form or letter to USDA by (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. 

USDA is an equal opportunity provider, employer, and lender.

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