FS-2700-4i, Append Special Use Permit for Outfitting and Guiding, Appendix

Contact Name: #AUTH_ID#
Expiration Date: #EXPIRATION_DATE#

U.S. DEPARTMENT OF AGRICULTURE
FOREST SERVICE

FS-2700-4i (XX/XXXX)
OMB No. 0596-0082
FS-2700-4i, Appendix I

SPECIAL USE PERMIT FOR OUTFITTING AND GUIDING
APPENDIX I
STEWARDSHIP ACT FEE OFFSET CLAIM
AUTHORITY:
Section 7 of the National Forest System Trails Stewardship Act, 16 U.S.C. 583k-5
________________________________[name of] NATIONAL FOREST NATIONAL FOREST
________________________________[name of] Ranger District RANGER DISTRICT
Project Name:_____________________________________________Holder's Fiscal Year:_______
Total allowable costs may be offset under an annual Stewardship Act fee offset agreement to the extent they do not
exceed the total annual land use fee for this permit. Costs submitted under this claim shall be documented and determined
by the Forest Service to be reasonable, allocable, and allowable, in accordance with the terms of this permit and the
annual Stewardship Act fee offset agreement for this permit.
Approval of this fee offset claim is subject to all provisions in the annual Stewardship Act fee offset agreement (FS-2700-4i,
Appendix H) executed by the U.S. Department of Agriculture, U.S. Forest Service, ______________________[name of]
NATIONAL FOREST National Forest, and #HOLDER_NAME# of #HOLDER_ADD_LINE_1#, on ____________[date of
annual Stewardship Act fee offset agreement].
COSTS
Salaries and Wages________________________________$
Materials and Supplies______________________________$
Subcontracts______________________________________$
Other (specify)_____________________________________$
TOTAL COSTS CLAIMED FOR FEE OFFSET PROJECT _______$
Itemize claimed costs by category, and attach schedules showing the cost breakdown by category.
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 the documents supporting its claim for land use fee offset are accurate and
complete. The Forest Service reserves the right not to grant the land use fee offset claim if it contains any inaccurate or
incomplete representations. Failure to sign the certification shall vitiate the land use fee offset claim.

Signed:
__________________________________________________________________________________________________
HOLDER NAME, PRECEDED BY NAME AND TITLE
SIGNATURE
DATE
OF PERSON SIGNING ON BEHALF OF HOLDER,
IF HOLDER IS AN ENTITY
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 National Forest System Trails Stewardship Act, 16 U.S.C. 583k-5. The time required to complete this information
collection request is estimated to average 1 hour 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 National Forest System Trails
Stewardship Act, 16 U.S.C. 583k-5.
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, gender identity (including gender expression), sexual 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 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.