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USDA, Forest Service <br />The authority and format of th is agreement (16-CO-l1 061700-1 00) have been <br />reviewed and approved for signature. <br />7/26/2016 <br />DE ETTE M. STOFLETH Date <br />U.S. Forest Service Grants Management Specialist <br />Burden Statement <br />OMB 0596-0217 <br />FS-1500-11 <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 th is information collection IS 0596-0217. The time required to complete this <br />information collection 7s estimated to average 4 hours per response, including the time for rev iew ing instructions, searching existing data sources, gathering and <br />main tai ning 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 th e basJsOf'~. color. naDonal ()(ig ln, a.9~, disab mly, an d <br />where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic in orina li\Jll, polilical be l afs, repri sal. 01' because all or pa rt <br />of an individual's income is derived from any public assistance. (NO\ all prohibite d ba ses apply to all prog(8TT1S .) I?arson s with dlsablli~es who require altemallve <br />means for communication of program information (Braille, large prin~ audiotape , etc.) should contact USDA's TARGET Center at 202-720-2600 (voice and TOO). <br />To file a complaint of discrimination , write USDA, Director , Office of Civi l Rights, 1400 Independence Avenue, SW, Washington, DC 20250-94 10 or call toll free <br />(866) 632 -9992 (voice). TOO users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TOO) or (866) 377-8642 (relay voice). USDA is <br />an equal opportunity provider and employer. <br />Page 7 of7 (Rev . 11-13)