FS-1500-20 Grants and Agreements Cover Page

USDA Forest Service OMB 0596-0217

FS-1500-20

Grants & Agreements Cover Sheet

Cooperators, when completing this form, provide information for the green shaded areas only. When completed, provide to the Forest Service program manager that is working with you on the proposed project.

Forest Service program managers, complete this cover sheet, attach the required documents in the first three items below,

and provide entire package to appropriate G&A staff using the local proposal submission process.

Failure to provide the information requested below may result

in rejection or delays of the proposed project.

Unit Area (Region/Station)      

Person submitting request:      

Email Address:      

Telephone Number:      

I-Web Proposal ID No.	     
Expected/Desired Start Date (for workload prioritization)	     
Job Code and Funding Amount	           
For Federal Financial Assistance Agreements (Grants and Cooperative Agreements), Please Attach: SF-424 SF-424A or SF-424C SF-424B or SF-424D AD-1047 Certification Regarding Debarment… AD-1049 (or AD-1052), Certification Regarding Drug-Free… Certification Regarding Lobbying (FS $ over $100K) Cooperator delegation of signing authority Non-Competition Justification Letter (if over $75,000 and not competed) Indirect Cost Rate Documentation (paperwork supporting the cooperators indirect cost rate - may be called a NICRA) Full project narrative including a project timeline Detailed project budget ------------------------OR------------------------------ For All Other Agreements, Please Attach: Draft G&A template Statement of Work which describes proposed project Draft financial plan, when required -----------------------------OR------------------------------ For All Modifications, Please Attach: Draft Modification template Statement of Work, if applicable Financial Plan, if applicable	Attached
For a Modification, Provide the Forest Service Agreement No.	     
Cooperator’s/Organization’s Legal Name	     
Cooperator Current Contact Name, Telephone No., and E-mail	                 
Cooperator’s Complete “Physical” Mailing Address, Including County, Congressional District, and Zip +4 Digits	     
Provide County Name(s) Where Project Activities Take Place	     
Cooperator Tax ID No.	     
Cooperator DUNS Number	     
CCR Registered: “Yes” or “No” If “no”, vendors are required to register to receive payment. Please advise the Cooperator.	Yes
	No:      
For Interagency Agreements Only: Agency Location Code (ALC) and Treasury Account Symbol (TAS)	ALC:      
	TAS:      
Non-Employee Identity System (NEIS): Will Non-FS Employees require access to FS IT Systems and/or have unescorted access to a FS facility? If ‘yes,’ provide names on an attached sheet.	Yes:      
	No
Project Title & Brief Description	     
FS Program Manager Name and Email	     
FS Budget Approver Name and Email	     
FS Administrative Contact Name and Email	     
FS Signature Official Name NOTE: The Signatory Official must be specifically authorized by FSM1580 or a current FY delegation of authority letter.	     

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 5 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.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.