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OMB 0596-0217 <br />USDA. Forest Service <br />LIS <br />�_- <br />t I <br />GENE D,,ANA,, Sheriff Date <br />Kittlitas County Sheriff's Office <br />MICHAEL R. WILLIAMS, Forest Supervisor Date <br />U.S. Forest Sem*ce, Okanogan -Wenatchee National <br />Forest <br />JaHN BYAS, Special Agent in Charge Date <br />Region 6 Pacific Northwest <br />The authority and format of this agreement (I 9 -LE- 11061700-009) have been <br />reviem,red and approved for signature. <br />lztY <br />AMY Y. VERELLEN Date <br />U.S. Forest Service Grants Management Specialist <br />Burden Statw*nt <br />A=riling to the Paperwork Redudan Act of 19954 an agency may not conduct or sporwr, and a person is not required to mspcxA to a o3kcMn of information <br />unkw it displays a valid 0M8 wntrol number. The valid UAB conal number br this information co0ecft is 0596-0217. The tkne required tD =Mlele this <br />infomutim collection*3 estimated to avem9e 3 hturs per response. including the tkne for reviewing instrudons. searching existing data sources, gatherer and <br />rnaintat ning the data needed, and =npletiV and mviewhV ft cot of lrtfornWon. <br />In a=rdance with, Federal dd rights law and U.S. Dopa*mnt of Agrkultm (USDA) dvil rights mutations and polfties, to USDA, ft Agenzies, offices, and <br />employees, and Insftbons partbpatirg 'M or adufmisterirg USDA pmgrarns are prohibRed from disaiminating based on race, color, natimal oio. r0gion, sex, <br />gender gritty (IncJuding gender expmssion), semi to n, disabilty, age* maftl status, famispar ental status, irimm dea pubfic assistance <br />program, poRbol bere�. or reprisal or ieta4aficn 16r per cMl eghts acfiv4, in any pmgram or activity =ducted or funded by USDA (not ag bases a to aff <br />progranis). Renvdies and compaiml firaV dea6m vary by program or indent,. <br />Perms with disatftes, who require aftemaWe means of c=mnicafion for program infomation (eg., Braft, large print audidtape, Amerimn Sin Languages <br />etc.) sMuld contact the msponsbile Agency co USDXs TARGET Center at (202) 720-2600( ' and TTY) or contact USDA throqh te FM Relay SeMce <br />voce <br />at (800) 877-8339. Addifionagy, pmgram Womakn may be rmde avail in WVuages other than English. <br />To Me a p discrmiinathn cpm t ccm*te the USDA Pmgram Discriminaten Corn;9aint Form, AD -3027, tund once at He* b File a Progmm <br />DisairMnation GompWnt and at any USDA ofte or wrfte a letter addressed to USDA and provide in ft letter a# of the iftmation mquested in te form. To <br />request a copy of the complaint form, cal (866) 632-9992. Submit your completed form or letter to USDA by: (1) mak U.S. Depa*vnt of AgrWbxie, Office of the <br />Assistant Secretary for Cid fthts, 1400 Independence Avenue, SK Washington. D.C. 20250-9410; (2) fax_- (202) 6%-744 3) email: <br />program.intake@usda.gov. USCA is an equal oppotmity pmvider, employer, and lendm <br />Page 9 of 9 (Rev. 9-15) <br />