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USDA Forest Service
OMB 0596-0217
FS-1500-19
MODIFICATION OF GRANT OR AGREEMENT
I. U.S. FOREST SERVICE GRANT/AGREEMENT
2. RECIPIENT/COOPERATOR GRANT or
AGREEMENT NUMBER, IF ANY:
NUMBER:
07-FI-l l 020000-00 I
I
PAGE
I
1
OF PAGES
I
4
3. MODIFICATION NUMBER:
004
4. NAMFJADDRESS OF U.S. FOREST SERVICE UNIT ADMINISTERING
GRANT/AGREEMENT (unit name, street, city, state, and zip+ 4):
S. NAMFJADDRESS OF U.S. FOREST SERVICE UNIT ADMINISTERING
PROJECT/ACTIVITY (unit name, street, city, state, and zip+4):
Rocky Mountain Region
740 Simms St.
Golden, CO 8040 I
Rocky Mountain Region
740 Simms St.
Golden, CO 8040 I
6. NAMFJADDRESS OF RECIPIENT/COOPERATOR (street, city, state, and zip
+ 4, county):
7. RECIPIENT/COOPERATOR'S HHS SUB ACCOUNT NUMBER (For HHS
payment use only):
Various Cooperators see attached.
8. PURPOSE OF MODIFICATION
CHECK ALL
THAT APPLY:
x
This modification is issued pursuant to the modification provision in the grant/agreement
referenced in item no. l, above.
CHANGE IN PERFORMANCE PERIOD: Extend agreement period to 02/16/2015 or until revised
CHANGE IN FUNDING:
ADMINISTRATIVE CHANGES:
OTHER (Specify type of modification):
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):
See additional page for changes
10. ATTACHED DOCUMENTATION (Check all that apply):
Revised Scope of Work
Revised Financial Plan
Other:
11. SIGNATURES
AUTHORIZED REPRESENTATIVE: BY SIGNATURE BELOW, THE SIGNING PARTIES CERTIFY THAT THEY ARE THE OFFICIAL REPRESENTATIVES OF
THEIR RESPECTIVE PARTIES AND AUTHORIZED TO ACT IN THEIR RESPECTIVE AREAS FOR MATTERS RELATED TO THE ABOVE-REFERENCED
GRANT/AGREEMENT.
111~•
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12.A 7:•:il'~d}"j'
CRISTIE B. LEE
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U.S. Fon::st Scn·icc Gr.·uus & Asm:cmcnt.s SP<.~ialist
12. G&A REVIEW
b"n mfowed and approved lo,slgnntun, by,
12.B.DATE
SIGNED
11-1 ?-17
Im
USDA Forest S<rnre
OMB05%-0217:
FS-1500-19
Burden Statement
Accordif'IJ lo the Papeiwork Reduction Act. of 1995, an agency may not conduct. or sponsor, and aperson is not required lo respond to acollection of infonnalion unless it cflSj)lays avalid OMB
control number. Toe valid OM3 control number for this inronnation collection is 0596-0217. Toe time required to complete this information collection is estimated to average 30 minutes per
response, includif'IJ the lime for reviewil'IJ instructions, searching exislif'IJ data souroos, gatherif'IJ and maintainil'IJ the data needed, and coll'4)!etil'IJ and reviewif'IJ the rollection or information.
Toe U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of rare, color, national origin, age, disability, and M1ere 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
assistanre. (Not all prohibited bases apply to all programs.) Persons with cfisabRifies who require alternative means for communication of program information (Braille, large print audiotape,
etc.) should contact USDA's TARGET Center at 202-720-2600 (voire and TDD).
To file a complaint of cflSCrimination, write USDA, Direct.or, Office or Civil Rights, 1400 lndependenre Avenue, SW, Washir1Jton, DC 20250-9410 or call toll free (866) 632-9992 (voire). TDD
users can conlacl. USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voire). USDA is an equal opportunity provider and employer.
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USDA Forest Service
OMB 0596-0217
FS-1500-19
MODIFICATION NO. 4 To INTERAGENCY COOPERATIVE FIRE MANAGEMENT AGREEMENT Between US FOREST SERVICE, ROCKY MOUNTAIN REGION and NORTHERN REGION And the USDI, BUREAU OF LAND MANAGEMENT, MONTANA DAKOTAS STATE OFFICE USDI, NATIONAL PARK SERVICE, MIDWEST REGION USDI, BUREAU OF INDIAN AFFAIRS, GREAT PLAINS REGION AND ROCKY MOUNTAIN REGION USDI, FISH AND WILDLIFE SERVICE, MOUNTAIN PRAIRIE REGION And the STATE OF SOUTH DAKOTA, DEPARTMENT OF AGRICULTURE DIVISION OF WILDLAND FIRE SUPPRESSION This MODIFICATION, is hereby entered into by and between the above listed parties, as specified under the provisions of the Interagency Cooperative Fire Management Agreement 07-FI-1I020000-001, executed February
16, 2007.
The purpose of this Modification No. 4, is to extend the expiration date of Modification No. 3 to February 16, 2015
to allow for additional time to work through the new proposed Cooperative Fire Agreement.
THE PARTIES HERETO, have executed this instrument as of the last date shown below.
SOUTH DAKOTA DEPARTMENT OF
AGRICULTURE
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US FOREST SERVICE ROCKY MOUNTAIN REGION r ~~
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USDI BUREAU OF LAND MANAGEMENT
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USDA Forest SeMre
FS-1500-19
USDI BUREAU OF INDIAN AFFAIRS
GREAT PLAINS REGION
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