Form FS-2700-3a Request for Revocation of a Special Use Authorization

FS-2700-3a (XX/202X) OMB No. 0596-0082

U.S. DEPARTMENT OF AGRICULTURE FOREST SERVICE

REQUEST FOR REVOCATION OF A SPECIAL USE AUTHORIZATION

I/We, the undersigned holder/s of a special use authorization dated , authorization ID _________ (hereinafter “authorization”), authorizing use and occupancy of National Forest System (NFS) lands

for (hereinafter “the use and occupancy”), are requesting revocation of the authorization because we are planning to:

Mark applicable box. If the box in Section 1 is marked, sign and date below that box. The form is then complete and may be submitted.

If the box in Section 1 is not marked, skip to Section 2 below.

Section 1

Discontinue the use and occupancy without any transfer of title to the authorized improvements or a change in ownership or control of the holder.

__

HOLDER SIGNATURE AND NAME 2^nd HOLDER SIGNATURE AND NAME (if applicable)

[name of person authorized to sign on behalf of holder, if holder is an entity]

Date: Date:

Section 2

Convey all my/our right, title, and interest in the improvements covered by the authorization (hereinafter “authorized improvements”) to the person/s identified below:

Enter into a contract for the sale of the authorized improvements and retain title to the authorized improvements until completion of payment under that contract with the individual/s or entity identified below:

Transfer ownership or control of the business entity that holds the authorization to the individual/s or entity identified below:

[Print name on line] [Print name on line]

Address: Address:

Telephone Number: ( ) - Telephone Number: ( ) -

Email: _________________________________ Email: ______________________________

I/We understand that the authorization terminates upon a change in ownership of the authorized improvements or upon a change in ownership or control of the business entity that holds the authorization, as provided in the authorization.

Accordingly, I/we have informed the prospective transferee/s or purchaser/s that (1) the authorization is not transferable; (2) the prospective transferee/s or purchaser/s must submit a special use application using form

SF-299 and obtain a new special use authorization for the use and occupancy; and (3) the prospective transferee/s or purchaser/s must coordinate with the authorized officer for the authorization (authorized officer) and apply for a new special use authorization for the use and occupancy sufficiently in advance of the transfer or contract execution to allow the authorized officer to process the application for a new special use authorization and, if the authorized officer grants the application, to issue a new special use authorization to the prospective transferee/s or purchaser/s concurrently with the transfer or contract execution.

I/We will coordinate the transfer or contract execution with the authorized officer to allow the authorized officer to process the application for a new special use authorization for the use and occupancy and, if the authorized officer grants the application, to issue a new special use authorization to the prospective transferee/s or purchaser concurrently with the transfer or contract execution. I/We will provide a copy of a bill of sale, deed, or other documentation of the transfer or contract execution upon completion.

HOLDER SIGNATURE AND NAME 2^nd HOLDER SIGNATURE AND NAME (if applicable)

[name of person authorized to sign on behalf of holder, if holder is an entity]

Date: Date:

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 Organic Administration Act, 16 U.S.C. 551. The time required to complete this information collection request is estimated to average 30 minutes 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 Organic Administration Act, 16 U.S.C. 551.

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]. 

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