Form FS-2700-4i, Append FS-2700-4i, Append Special Use Permit for Outfitting and Guiding, Appendix

Contact Name: #AUTH_ID# Expiration Date: #EXPIRATION_DATE#	FS-2700-4i (XX/XXXX) OMB No. 0596-0082 FS-2700-4i, Appendix I
U.S. DEPARTMENT OF AGRICULTURE FOREST SERVICE SPECIAL USE PERMIT FOR OUTFITTING AND GUIDING APPENDIX I STEWARDSHIP ACT FEE OFFSET CLAIM AUTHORITY: Section 7 of the National Forest System Trails Stewardship Act, 16 U.S.C. 583k-5
________________________________[name of] NATIONAL FOREST NATIONAL FOREST ________________________________[name of] Ranger District RANGER DISTRICT Project Name:_____________________________________________Holder's Fiscal Year:_______ Total allowable costs may be offset under an annual Stewardship Act fee offset agreement to the extent they do not exceed the total annual land use fee for this permit. Costs submitted under this claim shall be documented and determined by the Forest Service to be reasonable, allocable, and allowable, in accordance with the terms of this permit and the annual Stewardship Act fee offset agreement for this permit. Approval of this fee offset claim is subject to all provisions in the annual Stewardship Act fee offset agreement (FS-2700-4i, Appendix H) executed by the U.S. Department of Agriculture, U.S. Forest Service, ______________________[name of] NATIONAL FOREST National Forest, and #HOLDER_NAME# of #HOLDER_ADD_LINE_1#, on ____________[date of annual Stewardship Act fee offset agreement]. COSTS Salaries and Wages________________________________$ Materials and Supplies______________________________$ Subcontracts______________________________________$ Other (specify)_____________________________________$ TOTAL COSTS CLAIMED FOR FEE OFFSET PROJECT _______$ Itemize claimed costs by category, and attach schedules showing the cost breakdown by category. 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 the documents supporting its claim for land use fee offset are accurate and complete. The Forest Service reserves the right not to grant the land use fee offset claim if it contains any inaccurate or incomplete representations. Failure to sign the certification shall vitiate the land use fee offset claim. Signed: __________________________________________________________________________________________________ HOLDER NAME, PRECEDED BY NAME AND TITLE           SIGNATURE           DATE OF PERSON SIGNING ON BEHALF OF HOLDER, IF HOLDER IS AN ENTITY

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 National Forest System Trails Stewardship Act, 16 U.S.C. 583k-5. 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 National Forest System Trails Stewardship Act, 16 U.S.C. 583k-5.

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.