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U. S. DEPARTMENT OF AGRICULTURE <br />Forest Service <br />By: <br />(Authorized Officer Signature) <br />SYLVIA G CLARK, District Ranger <br />(Name and Title) <br />Date: <br />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 <br />collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is <br />0596 -0082. The time required to complete this information collection is estimated to average 1 hour per response, including the time for <br />reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the <br />collection of information. <br />The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national <br />origin, age, disability, and, where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic <br />information, political beliefs, reprisal, or because all or part of an individual's income is derived from any public assistance. (Not all <br />prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information <br />(Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at 202 - 720 -2600 (voice and TDD). <br />To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC <br />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- <br />8339 (TDD) or (866) 377 -8642 (relay voice). USDA is an equal opportunity provider and employer. <br />The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 552) govern the confidentiality to be provided for <br />information received by the Forest Service. <br />