FS-2700-4h, Append Special Use Permit for Campground and Related Granger-Th

Authorization ID: #AUTH_ID#
Contact ID: #HOLDER_ID#
Expiration Date: #EXPIRATION_DATE#

FS-2700-4h, App. H (XX/202X)
OMB No. 0596-0082

U.S. DEPARTMENT OF AGRICULTURE
FOREST SERVICE
SPECIAL USE PERMIT FOR
CAMPGROUND AND RELATED GRANGER-THYE CONCESSIONS
APPENDIX H
GRANGER-THYE FEE OFFSET CLAIM
AUTHORITY:
Section 7 of the Granger-Thye Act, 16 U.S.C. 580d

______________________NATIONAL FOREST
______________________RANGER DISTRICT
AUTHORIZATION ID: #AUTH_ID#

Description of Government MRRI:____________________

Holder’s Fiscal Year (FY): ________

This Granger-Thye (GT) fee offset claim (fee offset claim) is submitted by #HOLDER_NAME# (the holder)
under section 7 of the GT Act, 16 U.S.C. 580d, clause V.D of the special use permit for campground and
related GT concessions issued to the holder on #DATE# (the permit), and the GT fee offset agreement
executed by the holder and the Forest Service on #DATE# (GT fee offset agreement).
All or part of the holder’s annual land use fee under the permit may be offset in accordance with the GT
fee offset agreement by the amount of allowable costs incurred by the holder for Government
maintenance, reconditioning, renovation, and improvement (MRRI) listed in the GT fee offset agreement.
Total allowable costs of Government MRRI included in this GT fee offset claim are the sum of direct costs
and indirect costs allocable to the Government MRRI listed in the GT fee offset agreement. Costs
submitted under this GT fee offset claim shall be documented by the holder as provided below and shall
be determined by the Forest Service to be actual, reasonable, allocable, and allowable, in accordance
with the terms of the permit, the GT fee offset agreement, and applicable Forest Service directives.
The holder shall itemize direct costs of Government MRRI performed by the holder under the GT fee
offset agreement and attach documentation for all itemized direct costs.
Indirect costs of Government MRRI shall be computed using the Forest Service-approved indirect cost
rate. The Forest Service-approved indirect cost rate for FY [ ] is attached.
Approval of this GT fee offset claim is subject to the terms of the permit and GT fee offset agreement.
DIRECT COSTS
Salaries and Wages
Materials and Supplies
Other (specify)
Total of Direct Costs Without Subcontracts

$
$
$
$

Subcontracts

$
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Total of Direct Costs With Subcontracts

$

INDIRECT COSTS (#AMOUNT#% x direct costs)

$

TOTAL GT FEE OFFSET CLAIM

$

Subject to the penalties prescribed in the False Statements Act, 18 U.S.C. 1001, the holder certifies to the
best of its knowledge that the representations in this GT fee offset claim and its supporting documents are
accurate and complete. The Forest Service reserves the right not to grant this GT fee offset claim if any
representations in this GT fee offset claim are inaccurate or incomplete. Failure to sign this GT fee offset
claim shall vitiate the claim.
___________________________________________________________________________________
[NAME AND TITLE OF PERSON SIGNING ON BEHALF OF HOLDER,
DATE
IF HOLDER IS AN ENTITY]
#HOLDER_NAME#
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
Section 7 of the Granger-Thye Act, 16 U.S.C. 580d. The time required to complete this information collection request is estimated
to average 2 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 Section 7 of the Granger-Thye Act, 16 U.S.C. 580d.
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.
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

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

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