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USDA Forest Service OMB 0596-0217
<br />FS -1500-19
<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 unless it displays a valid OMB
<br />control number. The valid OMB control number for this information collection is 0596-0217. The time required to complete this information collection is estimated to average 30 minutes per
<br />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.
<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 where applicable, sex, marital
<br />status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived from any public
<br />assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape,
<br />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 (866) 632-9992 (voice). TDD
<br />users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.
<br />11. SIGNATURES
<br />AUTHORIZED REPRESENTATIVE: BY SIGNATURE BELOW, THE SIGNING PARTIES CERTIFY THAT THEY ARE THE OFFICIAL REPRESENTATIVES OF
<br />THEIR RESPECTIVE PARTIES AND AUTHORIZED TO ACT IN
<br />THEIR RESPECTIVE AREAS FOR MATTERS RELATED TO THE ABOVE -REFERENCED
<br />GRANT/AGREEMENT.
<br />11. A. KITTITAS COUNTY SIGNATURE
<br />11 B. DATE
<br />11. C. U.S. FOREST SERVICE SIGNATURE
<br />11. D. DATE
<br />SIGNED
<br />SIGNED
<br />(Signature of Signatory Official
<br />(Signature of Signatory Official)
<br />11. E. NAME (type or print):
<br />11. F. NAME (type or print):
<br />CLAY MYERS
<br />KRISTIN M. BAIL
<br />11. G. TITLE (type or print):
<br />11. H. TITLE (type or print):
<br />SheriffKittitas County
<br />Forest Supervisor, Okanogan -Wenatchee National Forest
<br />11. 1. .KITTITAS COUNTY SIGNATURE
<br />11 J. DATE
<br />11. K. U.S. FOREST SERVICE SIGNATURE
<br />11. L. DATE
<br />SIGNED
<br />Digitally signed by C
<br />SIGNED
<br />C C O R I E L L CORIELL
<br />Date: 2021.12.16 13:01:32
<br />-08'00'
<br />(Signature of Signatory Official)
<br />(Signature of Signatory Official)
<br />11. M. NAME (type or print): BRETT WACHSMITH
<br />11. N. NAME (type or print): JOHN BYAS
<br />11. O. TITLE (type or print): BOCC Chairman
<br />11. P. TITLE (type or print): Special Agent in Charge
<br />12. G&A REVIEW
<br />12. A. The authority and format of this modification (19 -LE -11061700-009-M3) have been reviewed and
<br />12. B. DATE
<br />approved for signature by:
<br />SIGNED
<br />KELLY Digitally signed by KELLY
<br />UNDERWOOD
<br />020900'
<br />UNDERWOOD
<br />14i8
<br />KELLY M. UNDERWOOD
<br />U.S. Forest Service Grants Management Specialist
<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 unless it displays a valid OMB
<br />control number. The valid OMB control number for this information collection is 0596-0217. The time required to complete this information collection is estimated to average 30 minutes per
<br />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.
<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 where applicable, sex, marital
<br />status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived from any public
<br />assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape,
<br />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 (866) 632-9992 (voice). TDD
<br />users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.
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