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. H (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 H

GRANGER-THYE FEE OFFSET CLAIM

AUTHORITY:

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

______________________NATIONAL FOREST

______________________RANGER DISTRICT

AUTHORIZATION ID: #AUTH_ID#

Description of Government MRRI:____________________ Holder’s Fiscal Year (FY): ________

This Granger-Thye (GT) fee offset claim (fee offset claim) is submitted by #HOLDER_NAME# (the holder) under section 7 of the GT Act, 16 U.S.C. 580d, clause V.D of the special use permit for campground and related GT concessions issued to the holder on #DATE# (the permit), and the GT fee offset agreement executed by the holder and the Forest Service on #DATE# (GT fee offset agreement).

All or part of the holder’s annual land use fee under the permit may be offset in accordance with the GT fee offset agreement by the amount of allowable costs incurred by the holder for Government maintenance, reconditioning, renovation, and improvement (MRRI) listed in the GT fee offset agreement. Total allowable costs of Government MRRI included in this GT fee offset claim are the sum of direct costs and indirect costs allocable to the Government MRRI listed in the GT fee offset agreement. Costs submitted under this GT fee offset claim shall be documented by the holder as provided below and shall be determined by the Forest Service to be actual, reasonable, allocable, and allowable, in accordance with the terms of the permit, the GT fee offset agreement, and applicable Forest Service directives.

The holder shall itemize direct costs of Government MRRI performed by the holder under the GT fee offset agreement and attach documentation for all itemized direct costs.

Indirect costs of Government MRRI shall be computed using the Forest Service-approved indirect cost rate. The Forest Service-approved indirect cost rate for FY [ ] is attached.

Approval of this GT fee offset claim is subject to the terms of the permit and GT fee offset agreement.

DIRECT COSTS

Salaries and Wages $      

Materials and Supplies $      

Other (specify) $      

Total of Direct Costs Without Subcontracts $      

Subcontracts $      

Total of Direct Costs With Subcontracts $      

<USER NOTES>

<Generally, apply the indirect cost rate to the total of direct costs without subcontracts. The indirect cost rate may be applied to the total of direct costs with subcontracts only if approved by the authorized officer in accordance with FSH 2709.14, Chapter 40.>

INDIRECT COSTS (#AMOUNT#% x direct costs) $      

TOTAL GT FEE OFFSET CLAIM $      

Subject to the penalties prescribed in the False Statements Act, 18 U.S.C. 1001, the holder certifies to the best of its knowledge that the representations in this GT fee offset claim and its supporting documents are accurate and complete. The Forest Service reserves the right not to grant this GT fee offset claim if any representations in this GT fee offset claim are inaccurate or incomplete. Failure to sign this GT fee offset claim shall vitiate the claim.

___________________________________________________________________________________

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

IF HOLDER IS AN ENTITY]

#HOLDER_NAME#

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.

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