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USDA, Forest Service OMB 0596-0217 <br />FS-1500-11 <br />Page 7 of 7 (Rev. 11-13) <br />The authority and format of this agreement (16-CO-11061700-100) have been <br />reviewed and approved for signature. <br />DE ETTE M. STOFLETH <br />U.S. Forest Service Grants Management Specialist <br /> Date <br />Burden Statement <br />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 <br />unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0217. The time required to complete this <br />information collection is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and <br />maintaining the data needed, and completing and reviewing the collection of information. <br />The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and <br />where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part <br />of an individual’s income is derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative <br />means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD). <br />To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call toll free <br />(866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is <br />an equal opportunity provider and employer.