Appendix 14 FS-2700-4h App H_GT Fee Offset Certification 092020.pdf
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- Chequamegon-Nicolet National Forest Prospectus for Campground and Related Granger-Thye Concessions
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Department of Agriculture Forest Service
About this file
This document is Appendix H of a U.S. Department of Agriculture Forest Service Special Use Permit for Campground and Related Granger-Thye Concessions, specifically a Granger-Thye Fee Offset Claim form (FS-2700-4h, Appendix H, 09/2020).
The form is used by permit holders to claim cost offsets against their annual permit fees under the Granger-Thye Act (16 U.S.C. 580d). Total allowable costs may be offset to the extent they do not exceed the total annual fee for the permit. Allowable costs consist of direct Granger-Thye project costs and indirect costs allocable to the project, all of which must be documented, reasonable, and allocable in accordance with permit terms, the applicable fee offset agreement, and Forest Service directives. Direct costs are organized into four categories: Salaries and Wages, Materials and Supplies, Subcontracts, and Other (with specification required). Indirect costs are calculated by applying a Forest Service-approved indirect cost rate to the sum of direct costs; the approved rate for the fiscal year must be attached to the claim. The claim requires supporting documentation and detailed cost breakdowns by cost element. Approval is subject to all provisions in the Annual Granger-Thye Fee Offset Agreement executed between the Forest Service, the specified National Forest, and the permit holder. The holder must certify under penalty of the False Statements Act (18 U.S.C. 1001) that all representations supporting the claim are accurate and complete; failure to sign the certification voids the claim. The form includes standard federal notices regarding the Paperwork Reduction Act, USDA civil rights regulations, Privacy Act, and Freedom of Information Act compliance.
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Text version
Authorization ID: #AUTH_ID# FS-2700-4h, App. H (09/2020) 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
PERMIT ID NUMBER
Project Name Holder’s Fiscal Year (FY)
Total allowable costs may be offset under a Granger-Thye (GT) fee offset agreement to the extent they do not exceed the total annual fee for this permit. Total allowable costs of a GT project included in this GT claim are the sum of the direct GT project costs and indirect costs allocable to this GT project. Costs submitted under this GT claim shall be documented and determined by the Forest Service to be reasonable, allocable, and determined to be allowable, in accordance with the terms of this permit, the applicable GT fee offset agreement, and applicable Forest Service directives.
Direct GT Costs: Provide claimed GT costs by cost element and attach schedules to show the cost breakdown by cost element. Provide supporting documentation for the cost claim.
Indirect Costs: Indirect costs must be computed based on Forest Service-approved indirect cost rate and may be added to the total direct GT costs. Attach the approved indirect cost rate for FY [ ].
Approval of the fee offset claim is subject to all provisions in the Annual Granger-Thye Fee Offset Agreement (FS-2700-4h, Appendix B) executed by the U.S. Department of Agriculture, Forest Service, [name] National Forest, and [holder name] on [date of GT fee offset agreement].
DIRECT GT COSTS
Salaries and Wages $ Materials and Supplies $ Subcontracts $ Other (specify) $ Sum of Direct GT Costs $
INDIRECT COSTS ([ ]% x Direct GT costs) $
TOTAL GT COST CLAIM FOR PROJECT $
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 fee offset are accurate and complete. The Forest Service reserves the right not to grant the fee offset claim if any of these representations is inaccurate or incomplete. Failure to sign the certification shall vitiate the fee offset claim.
[NAME AND TITLE OF PERSON SIGNING ON BEHALF OF HOLDER, DATE
IF HOLDER IS AN ENTITY]
#HOLDER_NAME#
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond, to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0082. Response to this collection of information is mandatory. The authority to collect the information is the Organic Administration Act, 16 U.S.C. 551. The time required to complete this information collection is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
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 of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your 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: program.intake@usda.gov.
USDA is an equal opportunity provider, employer, and lender.
The Privacy Act of 1974, 5 U.S.C. 552a, and the Freedom of Information Act, 5 U.S.C. 552, govern the confidentiality to be provided for information received by the Forest Service.
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