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oMB 0596-0217 <br />rs-ts00-8AUSDA, Forcst Scrvicc <br />4€ <br />Date <br />County Commissioner <br />/ -zq - z,zp <br />JO YAS,in Charge Date <br />6 Pacific Northwest <br />The authority and lbrmat of this agreement (1g-LH-l1061700-009 Ml) have been <br />revierved and approved for signature. <br />A MY VERELL E N ?l,,':l'll,i'*"d <br />bv AMY <br />Date: 2020.01.13 1835:39 .08'00. <br />AMY D. VERELLEN <br />U.S. Forest Service Grants Management Specialist <br />Date <br />Burden Statemenl <br />According to the Paperworft Redudion Acl of 1995, an agensy may nol conducl or sponsor, and a person is nol required lo respond t0 a colleclion ol inlormation <br />unless it displays a valid oMB conuol number. The valid OMB confol number lor lhis intormation colleclion is 0596.0217. The lime required to complete fiis <br />intormalion collection is estimated to avetage 3 houa per response, including the lime for reviewing inslruclions, searchirg existing dala sources, galhering and <br />mainlaining he dala needed, and ompleling and reviesing the colbdion ol information. <br />The U.S, Deparlment of Agriculture (USDA) prohibib discrimination in all ils programs afld activities on lhe basis of nce, color, national origin, age, disability, and <br />parl ol an indivdual's income is derived from any public assistance. {Nol all prohibiled bases apply to all prognms.} Persons wilh disabilities erho require <br />altemalive rne€ns for communicalion ol pmgram inlormalion (Bnaille, h$e print, audiotape, elc.) should conhcl USDA'5 TARGET Center at 202-720-2600 {voice <br />and TDO). <br />To lile a complainl ol disctiminalion, wrile USDA, Oireclor, Ofiice ol Civil Rights, |400 lndependence Avenue, SW, Washington, <br />(866) 6324992 (voice). TDD usea can contacl USOA through local relay or lhe Fedenl relay at (800) 87i.8339 (TDDI or {866) <br />is an equalopprlunity provider6nd empbyer. <br />DC 20250.9410 or call toll free <br />3n4UZ (relay voice). USDA <br />Page 8 of8 (Rev. l2-13)