HomeMy WebLinkAboutUSDA Forest Service USDA Forest Service OMB 0596-0217
FS-1500-19
MC Contract 19-084
MODIFICATION OF GRANT OR AGREEMENT PAGE OF PAGES
1 3
1.U.S.FOREST SERVICE GRANT/AGREEMENT NUMBER: 2,RECIPIENT/COOPERATOR GRANT or 3.MODIFICATION NUMBER:
16-PA-11060900-006 AGREEMENT NUMBER,IF ANY: 03
4.NAME/ADDRESS OF U.S.FOREST SERVICE UNIT ADMINISTERING 5.NAME/ADDRESS OF U.S.FOREST SERVICE UNIT ADMINISTERING
GRANT/AGREEMENT(unit name,street,city,state,and zip+4): PROJECT/ACTIVITY(unit name,street,city,state,and zip+4):
Amy Verellen Susan Piper, Forest Wildlife Biologist and Terrestrial
Grants Management Specialist Program Manager
215 Melody Lane Olympic National Forest
Wenatchee, WA 98801 1835 Black Lake Blvd. SW
Email: amy.verellen@usda.gov Olympia, WA 98512
Email: susan.piper@usda.gov
6.NAME/ADDRESS OF RECIPIENT/COOPERATOR(street,city,state,and zip+ 7.RECIPIENT/COOPERATOR'S HI-IS SUB ACCOUNT NUMBER(For HI-IS
4,county): payment use only):
Patricia Grover Same
Mason County Noxious Weed Control Board
303 N. 4th Street
Shelton, WA 98584
8. PURPOSE OF MODIFICATION
CHECK ALL This modification is issued pursuant to the modification provision in the grant/agreement
THAT APPLY: referenced in item no. 1, above.
❑ CHANGE IN PERFORMANCE PERIOD:
CHANGE IN FUNDING:Additional funding in the amount of$21,263.88.
® ADMINISTRATIVE CHANGES:Change Grants Management Specialist from Sarah Russell to Amy Verellen. See
box 4.
® OTHER(Specify type of modification):Update U.S.Forest Service email addresses for Susan Piper(see box 5)
and Albuquerque Service Center(see box 9).
Except as provided herein,all terms and conditions of the Grant/Agreement referenced in 1,above,remain unchanged and in full
force and effect.
9.ADDITIONAL SPACE FOR DESCRIPTION OF MODIFICATION(add additional pages as needed):
IV.THE U.S.FOREST SERVICE SHALL:
A.PAYMENT/REIMBURSEMENT.The U.S.Forest Service shall reimburse the County for the U.S.Forest Service's share of actual
expenses incurred,not to exceed$21,263.88,as shown in the Financial Plan.In order to approve a Request for Reimbursement,the U.S.
Forest Service shall review such requests to ensure payments for reimbursement are in compliance and otherwise consistent with the terms
of the agreement.The U.S.Forest Service shall make payment upon receipt of County's annual invoice.Each invoice from the County
shall display the total project costs for the billing period,separated by U.S.Forest Service and the County's share. In-kind contributions
must be displayed as a separate line item and must not be included in the total project costs available for reimbursement.The final invoice
must display the County's full match towards the project,as shown in the financial plan,and be submitted no later than 90 days from the
expiration date.
Each invoice must include,at a minimum:
I. The County's name,address,and telephone number.
2. U.S.Forest Service agreement number.
3. Invoice date.
4. Performance dates of the work completed(start&end).
5. Total invoice amount for the billing period,separated by the U.S.Forest Service and the County share with in-kind contributions
displayed as a separate line item.
6. Display all costs,both cumulative and for the billing period,by separate cost element as shown on the financial plan.
7. Cumulative amount of U.S.Forest Service payments to date.
8. Statement that the invoice is a request for payment by"reimbursement".
9. If using SF-270,a signature is required.
S USDA Forest SeD ice OIN13 0596-112 1 7
FS-I500-19
10.Invoice Number,ifapplicable.
The invoice must be forwarded to:
EMAIL:SM.FS.asc ga@usda.gov
FAX: 877-687-4894
POSTAL: USDA Forest Service
Albuquerque Service Center
Pa)ments-Grants&Agreements
I OI B Sun Ave NE
Albuquerque.NM 87109
Send a copy to:Susan Piper(susan.piper@usda.gov)
L. LIMITATION OF FUNDS.U.S.Forest Service funds in the amount of S21263.88 and all remaining funds are currently available for
perli nnance of this instrument through September 30,2021.The U.S.Forest Service's obligation for performance of this instrument
beyond is contingent upon the availability of appropriated funds from which payment can made.There is no legal liability on the part of
the U.S.Forest Service for any payment may arise for performance under this instrument beyond this amount until the County receives
notice of availability to he confirmed in a\\ritlen modification by the U.S.Forest Service.
10. ATTACHED DOCUMENTATION(Check all that apply):
Revised Scope of Work
—
_ Revised Financial Plan
171 Other:
II. SIGNATURES
At'F lORViinity't3l_SEN I ATJVj;; By SIONA I31121'i ISO OW,'I'i Ili sic-NIN(i PARTIES CERTIFY MAT Tlll(Y ARE'HIE(wtricIAI.REPRESENTATIVES OF
I IIIEI13 RESI'EU11VP PART II-S AND AIITIIORIZI'I)TO ACC IN'rlllflll RESPF('FIVtr AREAS I'OR M.ATFERS RIi1 ATIit)TO I llli ABOVE-REFERENCED
GRANT/AGREEMENT.
I I.:\ MASON Cr I'N'rl'SR)NA ruar ILK DATI' I LC.Rs.F :S'I' rRVI(' si 1 ltw I ID.DATE
SIGNED9/3//r SIGNED 9
I Signature orSig Ion Official) (Signature fSignuloryOfficial) 9711/I/
II t: NAME Itypcorprint):KEVIN SHUTTY II I: NAME(t)pcorprint) RETA LAI'ORD ( 1
I I(i lilt 1 (Iypc or print(-County Commissioner Chair I t.l t.TITLE(type or print(:Forest Supervisor,Olympic N.F.
12.G&A REVIEW
I2.A.The authority and format of this modification#3(16-PA-I 1060900-006)have been reviewed and approved 121. .DA'rt;
for signature by: SIGNEDH
AMY D. VEREI.I.EN
I.S.Forest Service Goons&Agreement.Specialist
Burden Statement
According b the Paperwork Reduction Act of 1995,an agency may not conduct or sponsor.and a person is not required to respond to a colection of infatuation unless it displays a valid OMB
control number.The valid WMB control number for this inbrtnalion colection is 0596-0217.The time required to complete this information collection a estimated to average 30 minutes per
response.including Me time for reviewing instructions,searching existing data sources.gathering and maintaining the data needed.and comptegrp and reviewing the oolecion of information
The U S Department of Agricuttee(USDA)prohibits disaimination in all its programs end activities on the basis of race,color,national origin,age,disabrry,and where applicable,sex.marital
status.familial status.parental status,relgbn,sexual orientation,genetic information,political beliefs,reprisal,or because al or part of an inctividuars income is derived from any pubic
USDA Forest Service OMB 0596-0217
FS-1500-19
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.
U.S. Forest Service OMB 0596-0217
FS-1500-17B
USFS Agreement No.: 16PA11060900006 Mod.No.: 3
Cooperator Agreement No.:
Agreements Financial Plan (Short Form)
Financial Plan Matrix: Note:All columns may not be used.Use depends on source and type of contribution(s).
FOREST SERVICE CONTRIBUTIONS COOPERATOR CONTRIBUTIONS
1 `'.: .i" ".' (b) (c) (d)
Cash
COST ELEMENTS Nom:ash to Noncash In-Kind (e)
Direct Costs ,,,,,,,,•,,,..,.4, Cooperator Total
Salaries/Labor $3,622.70 S17,782.50 $4,923.65 $0.00 $26,328.85
Travel $0.00 S510.40 S280.00 $0.00 S790.40
Equipment $0.00 $0.00 S660.00 $0.00 $660.00
Supplies/Materials $0.00 S273.31 S350.00 $0.00 S623.31
Printing $0.00 $0.00 $0.00 S0.00 $0.00
Other $0.00 $0.00 $720.00 $0.00 S720.00
Other $0.00
Subtotal S3,622.70 S18,566.21 S6,933.65 $0.00 $29,122.56
Coop Indirect Costs S2,697.67 $1,007.46 $3,705.13
FS Overhead Costs S36227 $362.27
Total 53 984.97 $21,263.88 S7,941.11 S0.00
Total Project Value: S33,189.96
Note: This Financial Plan may be used when:
(1) No program income is expected and
(2) The Cooperator is not giving cash to the FS and
(3) There is no other Federal funding
Matching Costs Determination Reimbursement Calculation
Total Forest Service Share= (f) Forest Service reimbursement percent(as%of expenses directly incurred by the Cooperator-i.e.,Cooperator's
(a+b)+(e)_(f) 76.07% non-cash contributions only that are subject to Forest Service reimbursement)
(b)-(b±c)_(i) (i)
I 72.81%
Total Cooperator Share (g) Cooperator non-cash contributions not reimbursed by Forest Service (j)
(c)+(b+c)-(j)
(c+d)_(e)=(g) 23.93% I 27.19%
Reimbursable Amount=Total actual cost incurred to date(sum of cost elements from the Cooperator's
Total(f+a)=(h) (h) invoice as prescribed in agreement provision and multiplied by
100.00% 72.81%I(i)minus any previous Forest Service payments,not to exceed the subtotal amount
listed in column(b).)
Page 1
WORKSHEET FOR
rFS Non-Cash Contribution Cost Analysis, Column (a) 1
Salaries/Labor L.
Standard Calculation
Job Description Cost/Day #of Days Total
Invasive Plant Program Coordinator $362.27 10.00 $3,622.70
Total Salaries/Labor $3,622.70
Travel
Standard Calculation
Travel Expense Employees Cost/Trip #of Trips Total
$0.00
Total Travel $0.00
Equipment
Standard Calculation
Piece of Equipment #of Units Cost/Day #of Days Total
$0.00
Total Equipment $0.00
Supplies/Materials
Standard Calculation
Supplies/Materials #of Items Cost/Item Total
$0.00
Total Supplies/Materials $0.00
Printing
Standard Calculation
Paper Material #of Units Cost/Unit Total
Total Printing $0.00
Other Expenses
Standard Calculation
Item #of Units Cost/Unit Total
$0.00
Total Other $0.00
Subtotal Direct Costs $3,622.70
Forest Service Overhead Costs
Current Overhead Rate Subtotal Direct Costs Total
10.00% $3,622.70 $362.27
Total FS Overhead Costs $362.27
TOTAL COST $3,984.97
WORKSHEET FOR
FS Cash to the Cooperator Cost Analysis, Column (b)
Salaries/Labor
Standard Calculation
Job Description Cost/Day #of Days Total
MCNWCB Coordinator $304.55 30.00 $9,136.50
Crewmember $172.92 50.00 $8,646.00
Total Salaries/Labor $17,782.50
Travel
Non-Standard Calculation
Travel to/from worksite 880 miles X 0.58/mile $510.40
Total Travel $510.40
Supplies/Materials
Standard Calculation
Supplies/Materials #of Items Cost/Item Total
PPE, herbicide, hand pruners, heavy garbage bags, etc. $273.31
Total Supplies/Materials $273.31
Other Expenses
Standard Calculation
Item #of Units Cost/Unit Total
Total Other $0.00
Subtotal Direct Costs $18,566.21
Cooperator Indirect Costs
Current Overhead Rate Subtotal Direct Costs Total
14.53% $18,566.21 $2,697.67
Total Coop. Indirect Costs $2,697.67
TOTAL COST $21 ,263.88
WORKSHEET FOR
Cooperator Non-Cash Contribution Cost Analysis, Column (c)
Salaries/Labor
Standard Calculation
Job Description Cost/Day #of Days Total
MCNWCB Coordinator $304.55 10.00 $3,045.50
Office Manager $313.03 6.00 $1,878.15
Total Salaries/Labor $4,923.65
Travel
Standard Calculation _
Travel Expense Employees Cost/Trip #of Trips Total
Vehicle Use/Mileage 1 $28.00 10.00 $280.00
Total Travel $280.00
Equipment
Standard Calculation
Piece of Equipment #of Units Cost/Day #of Days Total
Non-Standard Calculation
Backpack Sprayers 3.00 $140.00 $420.00
Misc. Small tools 3.00 $80.00 $240.00
Total Equipment $660.00
Supplies/Materials
Non-Standard Calculation
PPE/Field Supplies-
1st aid kits, vests, garbage bags, spill kit, safety glasses,weather equip, etc. $250.00
Office Supplies $100.00
Total Supplies/Materials $350.00
Other Expenses
Non-Standard Calculation
Storage building-$60/month x 12 months $720.00
Total Other $720.00
Subtotal Direct Costs $6,933.65
Cooperator Indirect Costs
Current Overhead Rate Subtotal Direct Costs Total
14.53% $6,933.65 $1,007.46
Total Coop. Indirect Costs $1,007.46
TOTAL COST $7,941 .11