Form FS-2700-4h, Append FS-2700-4h, Append Special Use Permit for Campground and Related Granger-Th

Authorization ID: #AUTH_ID#                                                            FS-2700-4h, App. C (XX/202X)

Contact ID: #HOLDER_ID#                                                              OMB No. 0596-0082

Expiration Date:  #EXPIRATION_DATE#

U.S. DEPARTMENT OF AGRICULTURE

FOREST SERVICE

SPECIAL USE PERMIT FOR

CAMPGROUND AND RELATED GRANGER-THYE CONCESSIONS

APPENDIX C

GRANTER-THYE FEE OFFSET AGREEMENT

AUTHORITY:

Section 7 of the Granger-Thye Act, 16 U.S.C. 580d

<USER NOTES FOR FORM FS-2700-4h, APPENDIX C>

<A multi-year GT fee offset agreement may be used only if the annual land use fee is consolidated. If the annual land use fee is not consolidated, the GT fee offset agreement must be executed annually.>

1. The Parties. This Granger-Thye (GT) fee offset agreement (agreement) is entered into by #HOLDER_NAME# (the holder) and the U.S. Department of Agriculture, Forest Service, #NAME# National Forest (Forest Service), under section 7 of the GT Act, 16 U.S.C. 580d, and clause V.D of the special use permit for campground and related GT concessions issued to the holder on #DATE# (the permit).

2. Land Use Fee Offset. The holder’s total estimated annual land use fee for the permit is $#AMOUNT#. All or part of the holder’s annual land use fee may be offset in accordance with this agreement by the amount of allowable costs incurred by the holder for the Government maintenance, reconditioning, renovation, and improvement (MRRI) listed below. Examples of allowable costs include salaries, wages, materials, supplies, subcontracts that are direct costs of Government MRRI, and indirect costs based on an approved indirect cost rate.

3. Term and Reconciliation of Costs. This agreement covers [calendar year [year]/calendar years [years]]. If this agreement does not involve a consolidated land use fee, the estimated and actual costs of Government MRRI performed under this agreement shall not exceed the total annual land use fee. If this agreement involves a consolidated land use fee payment, the total estimated and actual costs of Government MRRI performed under this agreement shall not exceed the total amount of the consolidated land use fee payment, and estimated and actual costs of Government MRRI performed under the agreement must be reconciled annually against the consolidated land use fee payment and documented in the notes column of the table below.

<USER NOTES FOR PARAGRAPH 4>

<Include the following paragraph 4 if the Government MRRI will be performed by the holder. Delete the remaining paragraph 4.>

4. Holder-Performed Government MRRI. The holder shall perform the Government MRRI itemized below by the date specified and within the holder’s fiscal year for the year the annual land use fee is due or within the period payment of the annual land use fee is consolidated. The Forest Service may modify the Government MRRI and dates as necessary, after consultation with the holder. Upon a determination by the Forest Service that the Government MRRI has been satisfactorily completed by the holder, the holder shall submit to the Forest Service documentation of the actual costs of the Government MRRI and shall certify that the representations in that documentation are accurate and complete. The certification (form FS-2700-4h, Appendix H) shall be signed and dated, and shall state that failure to sign the certification shall vitiate the fee offset claim. The Forest Service shall verify that documentation before offsetting the holder’s land use fee and reserves the right not to offset the holder’s land use fee if any representations in the documentation are inaccurate or incomplete.

Table 1: Holder-Performed Government MRRI Calculation

Government MRRI	Calendar Year to be Initiated	Due Date	Estimated Costs	Completion Date	Actual Costs	Notes
[itemize projects]

Forest Service contractor. Delete the preceding paragraph 4.>

4. Forest Service-Performed Government MRRI. The Forest Service or a Forest Service contractor shall perform the Government MRRI itemized below by the date specified and within the year the holder’s annual land use fee is due or within the period payment of the annual land use fee is consolidated. The holder shall deposit land use fees annually within the holder’s fiscal year into a Forest Service account in accordance with a collection agreement executed by the authorized officer and the holder under section 5 of the GT Act, 16 U.S.C. 572. The Forest Service may modify the Government MRRI and due dates as necessary, after consultation with the holder. The Forest Service shall document the costs of the Government MRRI performed by the Forest Service or a Forest Service contractor.

Table 2:Forest Service-Performed Government MRRI Calculation

Government MRRI	Calendar Year to be Initiated	Due Date	Estimated Costs	Completion Date	Actual Costs	Notes
[itemize projects]

<USER NOTES FOR PARAGRAPH 5>

<Include paragraph 5 if the total estimated cost of Government MRRI to be performed under this agreement exceeds $2,000 and the holder is a private entity or a state or governmental entity that is contracting with a private entity to perform the Government MRRI, or a Forest Service contractor is performing the Government MRRI. Otherwise delete paragraph 5.>

5. Davis-Bacon Act Requirements. This agreement is subject to the Davis-Bacon Act, 40 U.S.C. 3141 et seq., and its implementing regulations at 29 CFR 5.5. These regulatory requirements are incorporated by reference into this agreement as if fully set forth in this agreement.

__________________________________________________________________________________

[NAME AND TITLE OF PERSON SIGNING ON BEHALF OF HOLDER, DATE

IF HOLDER IS AN ENTITY]

#HOLDER_NAME#

APPROVED:

___________________________________________________________________________________

#AUTHORIZED OFFICER NAME# DATE

#TITLE#

____________________ National Forest

USDA Forest Service

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 Section 7 of the Granger-Thye Act, 16 U.S.C. 580d. The time required to complete this information collection request is estimated to average 2 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 Section 7 of the Granger-Thye Act, 16 U.S.C. 580d.

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.

Page 1 of 5