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Home My WebLink AboutSH21-041 - MOD 4 USFSUSDA Forest Service OMB 0596-0217 FS -1500-19 MODIFICATION OF GRANT OR AGREEMENT PAGE OPAGES F I 1 3 1 U.S. FOREST SERVICE GRANT/AGREEMENT NUMBER: 2. RECIPIENT/COOPERATOR GRANT or 3. MODIFICATION NUMBER - UMBER:19-LE-11061700-009 19 -LE -1 1061700-009(COOPERATIVE AGREEMENT NUMBER, IF ANY. 004 LAW ENFORCEMENT AGREEMENT 4 NAME/ADDRESS OF U.S. FOREST SERVICE UNIT ADMINISTERING 5. NAME/ADDRESS OF U.S. FOREST SERVICE UNIT ADMINISTERING GRANT/AGREEMENT (unit name, street, city, state, and zip + 4): PROJECT/ACTIVITY (unit name, street, city, state, and zip + 4): Okanogan -Wenatchee National Forest Okanogan -Wenatchee National Forest 215 Melody Lane 215 Melody Lane Wenatchee, Washington 98801 Wenatchee, Washington 98801 6. NAME/ADDRESS OF RECIPIENT/COOPERATOR (street, city, state, and zip + 7. RECIPIENT/COOPERATOR'S HHS SUB ACCOUNT NUMBER (For HHS 4, county): payment use only): Kittitas, County of 205 W 5th Ave Ste 108 N/A Ellensburg, Washington 98926-2887 8. PURPOSE OF MODIFICATION CHECK ALL This modification is issued pursuant to the modification provision in the grant/agreement THAT APPLY: referenced in item no. 1, above. CHANGE IN PERFORMANCE PERIOD: ® CHANGE IN FUNDING: Add allocated calendar year 2022 funds in the amount of $39,552.60 to agreement ADMINISTRATIVE CHANGES: ® OTHER (Specify type of modification): Update provision -See box 9. Except as provided herein, all terms and conditions of the Grant/Agreement referenced in 1, above, remain unchanged and in full force and effect. 9. ADDITIONAL SPACE FOR DESCRIPTION OF MODIFICATION (add additional pages as needed): The following provision is updated to reflect this modification: III. The U.S. Forest Service Shall: B. Reimburse the Cooperator for the U.S. Forest Service's share of actual expenses incurred, not to exceed $47,960.00* as shown in the Financial Plan for this modification. The U.S. Forest Service shall make payment upon receipt of the Cooperator's monthly invoice. Each invoice from the Cooperator shall display the total project costs for the billing period, separated by U.S. Forest Service and the Cooperator's share. In-kind contributions must be displayed as a separate line item and must not be included in the total project costs available for reimbursement. The final invoice must display the Cooperator's full match towards the project, as shown in the financial plan, and be submitted no later than 120 days from the expiration date. Each invoice must include, at a minimum: 1. Cooperator's name, address, and telephone number. 2. U.S. Forest Service agreement number. 3. Invoice date. 4. Performance dates of the work completed (start & end). 5. Total invoice amount for the billing period, separated by the U.S. Forest Service and Cooperator share with in-kind contributions displayed as a separate line item. 6. Display all costs, both cumulative and for the billing period, by separate cost element as shown on the financial plan. 7. Cumulative amount of the U.S. Forest Service payments to date. 8. Statement that the invoice is a request for payment by `reimbursement'. 9. If using SF -270, a signature is required. 10. Invoice Number, if applicable. USDA Forest Service OMB 0596-0217 FS -1500-19 The invoice shall be forwarded to: EMAIL: SM.FS. ea(i�usda.gov FAX: 877-687-4894 POSTAL: USDA Forest Service Albuquerque Service Center Payments — Grants & Agreements 10113 Sun Ave NE Albuquerque, NM 87109 Send a copy to: Shirley Tutino Okanogan -Wenatchee National Forest 215 Melody Lane Wenatchee, WA 98801 shirley.tutino cr,usda.eov * $47,960.00 reflects the $39,552.60 added in Modification 4 and $8,407.40 added in Modification 3 to fund Calendar Year 2022 10. ATTACHED DOCUMENTATION (Check all that apply): ❑ Revised Scope of Work ❑ Revised Financial Plan ❑ Other: 2022 Annual Operating and Financial Plan 11. SIGNATURES AUTHORIZED REPRESENTATIVE: BY SIGNATURE BELOW, THE SIGNING PARTIES CERTIFY THAT THEY ARE THE OFFICIAL REPRESENTATIVES OF THEIR RESPECTIVE PARTIES AND AUTHORIZED TO ACT IN THEIR RESPECTIVE AREAS FOR MATTERS RELATED TO THE ABOVE -REFERENCED GRANVAGREEMENT. 11. A KITTITAS COUNTY SIGNATURE I l B. DATE 11. C. U.S. FOREST SERVICE SIGNATURE 1 I, D. DATE SIGNED SIGNED (Signature of Signatory Official (Signature of Signatory Official 11. E. NAME (type or print): 11. F. NAME (type or print): CLAY MYERS KRISTIN M. BAIL 11. G. TITLE (type or print); 11. H. TITLE (type or print): Sheriff, Kittitas County Forest Supervisor, Okanogan -Wenatchee National Forest 11, L U.S FOREST SERVICE SIGNATURE 11. J. DATE Digitally signed by SIGNED ALEXANDER LOMVARDIAS Date: 2022.04.04 09:59:12 -07'00' (Signature of Signatory Official) 11. K. NAME (type or print): ALEX LOWARDIAS 11. P. TITLE (type or print): Special Agent in Charge USDA Forest Service OMB 0596-0217 FS -1500-19 12. G&A REVIEW 12. A. The authority and format of this modification (19 -LE -11061700-009-M4) have been reviewed and 12 B. DATE approved for signature by: SIGNED KELLY Digitally signed by KELLY UNDERWOOD UNDERWOOD 0700?0220329130213 KELLY A UNDERWOOD U.S. Forest Service Grants Management Specialist Burden Statement 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 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 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. 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