FS-2700-23 Amendment of a Special Use Authorization

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Use Code: <#Use # #>

FS-2700-23 (XX/202X)
OMB No. 0596-0082

U.S. DEPARTMENT OF AGRICULTURE
FOREST SERVICE
AMENDMENT
FOR

SPECIAL USE AUTHORIZATION
COST RECOVERY AGREEMENT
Amendment #

authorization for

issued to

cost recovery agreement/special use

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This amendment is attached to and made a part of the
on

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which is hereby amended as follows:

This Amendment is accepted subject to the conditions set forth herein, and to conditions
attached hereto and made a part of this Amendment.
Holder:
Holder:

Authorized Officer

Title:

(mm/dd/yyyy)

Date:

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Date:

to

Use this form to document monitoring of compliance with special use authorizations and inspections of the area or
improvements authorized by special use authorizations in accordance with FSM 2716. Insert additional lines as needed.
Identify the authorization involved in the monitoring or inspection, the purpose of the monitoring or inspection, the name of
the monitor or inspector, and the date of the monitoring or inspection. Identify any deficiencies encountered; consider
attaching a map or photograph to enhance identification. Discuss any deficiencies with the holder, and note the date of
the discussion. Corrective actions may be identified and scheduled in the operating plan with the authorized officer’s
concurrence. Keep the report in the case file, and provide a copy to the holder.
Failure to correct deficiencies identified and scheduled must be documented in a notice of noncompliance to the holder.
The notice of noncompliance must specify the items of noncompliance and their factual and legal basis. In addition, the
notice must identify the timeframe for correcting the noncompliance and the consequences for failure to correct it within
that timeframe. Send the notice by certified mail or hand deliver it.
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 Organic Administration Act,16 U.S.C. 551. 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 the Organic Administration Act,16 U.S.C. 551.
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.

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NONDISCRIMINATION STATEMENT

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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.