|
|
FS-1500-34 (VER. XX/XX) OMB No. 0596-0217 |
GRANT EQUIPMENT JUSTIFICATION AND CERTIFICATION STATEMENT
|
|
|||||||||||
|
|
|
|
|||||||||
|
Type: (i.e., Dozer, Engine, Pick up, Pump, Map Grade GPS, etc.) |
|
||||||||||
Make & Model: (i.e., Ford F-350 4x4, John Deere 750J, Honda GX340, Trimble Juno, etc.) |
|
|||||||||||
Specialized/Custom/Technical Requirements: (i.e., Briefly describe any special or customized modifications to the equipment required for use in project implementation. Include performance and/or safety items. For Example: screens, shields, manual fuel shut-off valves, etc. that is not standard.) |
|
|||||||||||
|
|
|||||||||||
|
Cost Per Unit: |
|
Total Cost: |
|
||||||||
|
||||||||||||
|
||||||||||||
|
||||||||||||
|
||||||||||||
|
||||||||||||
|
Months: |
|
||||||||||
Days: |
|
|||||||||||
(Note: Equipment cannot be included as a cost or used to meet cost sharing requirements of any other federal award.) |
YES: ☐ NO: ☐
|
|||||||||||
|
||||||||||||
|
||||||||||||
Certified by: |
|
Title: |
|
|||||||||
|
||||||||||||
Approved by: |
|
Program Manager |
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 Response to this collection of information is Mandatory (Title VIII of IIJA). The time required to complete this information collection is estimated to average 25 minutes per response, including the time for reviewing the 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 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, S.W., Washington, DC 20250-9410, or call toll free at (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.
The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 522) govern the confidentiality to be provided for information received by the Forest Service.
Revised 11-25-2013
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | FS-1500-34, Grant Equipment Justification and Certification Statement |
Author | ejbunzendahl |
File Modified | 0000-00-00 |
File Created | 2023-08-23 |