FS-2700-6b Recreation Residence Self-Inspection Report

USDA Forest Service

FS-2700-6b (XX/202X)
OMB No. 0596-0082

RECREATION RESIDENCE SELF-INSPECTION REPORT
RANGER DISTRICT
ATTN:
ADDRESS
ADDRESS
FAX

PART I - TERMS AND CONDITIONS

Permit Holder/Primary & Mailing Address/Telephone

Tract:

Lot #:

1. Have you built or modified your structures during the past year? (Clause III-A)
If yes, explain.

Yes
No

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2. Do you plan to construct or modify structures on the lot during the next year?
(Clause III-B) If yes, explain.

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

4. Have you or do you plan to cut down any trees, altered the vegetation, or
caused disturbance to the soil on the lot? (Clause IV-D) If yes, explain.
5. Have your kept your structures and access road in good repair, and maintained
a neat appearance on the lot? (Clause IV-E) If no, explain.
6. Have you removed dangerous trees, limbs, or other hazardous conditions that
could pose a risk of injury? (Clause IV-G) If no, explain what hazards exist.
7. Have you paid your rental fees for the current year? (Clause VI) If no, explain.
8. Have you received written approval for renting or subleasing your structures?
(Clause VII-E) If no, explain.

D

Yes
No

3. Do your structures meet state and local regulations and have you had an
annual inspection if required by these entities? (Clause IV-A) If no, explain.

R
AF

Yes
No

Yes
No
Yes
No

9. Are you planning to sell your structures in the next year? (Clauses IV-H & VIIC, D) If yes, request a FS-2700-3a form and complete.
10. Are you living at the recreation residence full-time, to the exclusion of a home
elsewhere? (Clause I-C) If yes, explain.

Comments:

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Attach additional sheets, if necessary
Please sign, date, and return this form to your local Ranger District by:

____________________________________

D

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PART II - OPERATION AND MAINTENANCE PLAN STANDARDS
!**USE THIS SECTION TO LIST STANDARDS FROM APPROVED LOCAL O & M PLANS**!
Item Inspected
Meets Standard Action Required/Due Date
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

I certify that I have inspected the structures and permitted area, and the above information is accurate and true. I
understand that any modifications to the structures and lot require prior written approval by the authorized officer.
___________________________________________
_________________________________
Signature of Permit Holder

Date

____________________________________
Print Name

18 U.S.C. Section 1001 makes it a crime for any person knowingly and willfully to make to any department or agency of
the United State any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.

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PAPERWORK REDUCTION ACT STATEMENT
According to the Paperwork Reduction Act of 1995, a Federal agency may not conduct or sponsor, and a person is not required to respond to, an
information collection request unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this
information collection request is 0596-0082. Response to this information collection request is required to obtain or retain benefits, specifically, a special
use authorization. The authority for this information collection request is the Act of March 4, 1915, 16 U.S.C. 497. The time required to complete this
information collection request is estimated to average 2.5 hours per response, including the time for reviewing instructions, searching existing data
sources, collecting and maintaining the data needed, and completing and reviewing the information collection request. Send comments regarding this
burden estimate or any other aspect of this information collection request, including suggestions for reducing the burden, to Forest Service Information
Collections Officer, SM.FS.InfoCollect@usda.gov, with OMB control number 0596-0082 in the subject line.
PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act statement serves to inform you of the following concerning the collection of the information on this
form.
Purpose: The Privacy Act of 1974 requires that the Director of Recreation, Heritage, and Volunteer Resources staff and the Director of Lands, Minerals,
and Geology Management staff provide the following statements to individuals from whom they request information.
Authority: Collection of this information solicited on this form is authorized by the Act of March 4, 1915, 16 U.S.C. 497.

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Routine Uses: The information collected will be used by Forest Service officials to ensure that your use of National Forest System lands is
administered in accordance with applicable statutes, regulations, and directives. The information collected from you is retained in the Special Uses Data
System (SUDS) and is retrieved by the Forest Service create reports for the Agency’s Special Uses Program, generate bills for collection of land use
fees for your authorization, monitor compliance with your special use authorization, and other matters pertaining to administration of your special use
authorization. SUDS is a component of the Forest Service’s Natural Resources Manager database (NRM). A complete list of the routine uses of NRM
can be found in the system of records notice associated with this form, FS-24.

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Disclosure: The submission of this information is required to obtain or retain benefits, specifically, a special use authorization.
NONDISCRIMINATION STATEMENT

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 participating in or administering USDA programs are prohibited from discriminating based on race, color,
national origin, religion, sex, 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 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.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign
Language, etc.) should contact the State or local Agency that administers the program or contact USDA through the Telecommunications Relay
Service at 711 (voice and TTY). Additionally, program information may be made available in languages other than English.
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 USDA office or write a letter addressed to USDA and provide in the letter all the information requested in
the form. To request a copy of the complaint form, call (866) 632-9992. Submit the 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; (2) fax: (202) 690-7442;
or (3) email: program.intake@usda.gov.

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USDA is an equal opportunity provider, employer, and lender.

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