|
USPA E-g Forest Service FS-1500-19 (VER. 05/24)
<br />U.S. DEPARTMENT OFAGRICULTURE OMB No. 0596-0217
<br />EXP: 05/31/2027
<br />I I.I. U.S. FOREST SERVICE SIGNATURE l I.J. DATE
<br />SIGNED
<br />I I.M. NAME (type or print): ANDY CORIELL
<br />11.0. TITLE (type or print): Special Agent in Charge,
<br />USDA Forest Service, Pacific Northwest Region
<br />Law Enforcement & Investigations
<br />12. G&A REVIEW
<br />12.A. The authority and format of this modification have been reviewed and approved for signature by:
<br />12.E. DATE
<br />SIGNED
<br />Isigned by MICHAEL
<br />MICHAEL �Aps
<br />Date: 2024.07.1116:42:15GqnIS
<br />-oroo'
<br />7/11 /24
<br />MICHAEL K. GADDIS (24-LE-11061700-080 Mod. 001)
<br />U.S. Forest Service Grants & A reemcnts S ecialist
<br />Paperwork Reduction Act 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. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number, The OMB control number for this information collection
<br />is 0596-0217. Response to this collection of information is mandatory. The authority to collect the information Section 7 of the Granger-Thye Act (16 U.S.C. 580d) and Title IV of the Federal Land
<br />Policy and Management Act of 1976 (43 U.S.C. 1751-1753), The time required to complete this information collection is estimated to average 30 minutes per response, including the time for
<br />reviewing instructions, searching existing data sources, gathering, and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this
<br />burden estimate or any other aspect of this collection of information, Including suggestions for reducing this burden, to: U.S. Department of Agriculture, Clearance Officer, OIRM, 1400
<br />Independence Avenue, SW, Room 404-W, Washington, D.C, 20250; and to the Office of Management and Budget, Paperwork Reduction Project (OMB# 0596-0217), 725 17th Street NW,
<br />Washington, D.C. 20503.
<br />In accordance with Federal civil rights law and U,S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions
<br />participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual
<br />orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, In any
<br />program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.
<br />Personswith disabilities who require alternative means of communication for program Information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible
<br />agency or USDA's TARGET Center at (202) 720-2600 (voice and TYY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made
<br />available in languages other than English,
<br />To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any
<br />USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your
<br />completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410;
<br />(2) fax: (202) 690.7442; or (3) email: program.intake a@usdgAff.
<br />USDA is an equal opportunity provider, employer, and lender.
<br />The Privacy Act of 1974, 5 U.S.C. 552a and the Freedom of Information Act, 5 U.S.C. 552 govern the confidentiality to be provided for Information received by the Forest Service.
<br />Page 2 of 2
<br />
|