Authorization ID       	
Contact ID      	
Expiration Date            	
APPENDIX G
Granger-Thye Fee Offset Claim Certification 
for
SPECIAL USE PERMIT
AUTHORITY:  Section 7 of the Granger-Thye Act, 16 U.S.C. 580d 
<Reference FSH 2709.11, chapter 50>

     NATIONAL FOREST
     RANGER DISTRICT
PERMIT NUMBER      
Project Name	     		Holder’s Fiscal Year (FY)      
Total allowable costs may be offset under a Granger-Thye (GT) fee offset agreement to the extent they do not exceed the total annual fee for this permit.  Total allowable costs of a GT project included in this GT claim are the sum of the direct GT project costs and indirect costs allocable to this GT project.  Costs submitted under this GT claim will be accepted to the extent they are reasonable, allocable, and determined to be allowable, in accordance with the terms of the permit, GT agreement, and agency policy.
Direct GT Costs:  Provide claimed GT costs by cost element and attach schedules to show the cost breakdown by cost element.  Provide supporting documentation for the cost claim.  
Indirect costs: Indirect costs must be computed based on Forest Service-approved indirect cost rate and may be added to the total direct GT costs.  Attach the approved indirect cost rate for FY [    ] .
Approval of the fee offset claim is subject to all provisions in the Annual Granger-Thye Fee Offset Agreement (FS-2700-4h, Appendix B) executed by the U.S. Department of Agriculture, Forest Service, [name] National Forest, and [holder name] on [date of GT fee offset agreement].
DIRECT GT COSTS 
Salaries and Wages	$      
Materials and Supplies	$      
Subcontracts	$      
Other (specify)	$      
Sum of Direct GT Costs 	$      
INDIRECT COSTS ([    ]% x Direct GT costs)	$      			
TOTAL GT COST CLAIM FOR PROJECT 	$      
Subject to the penalties prescribed in the False Statements Act, 18 U.S.C. 1001, the holder certifies to the best of its knowledge that the representations in the documents supporting its claim for fee offset are accurate and complete.  The Forest Service reserves the right not to grant the fee offset claim if any of these representations is inaccurate or incomplete.  Failure to sign the certification shall vitiate the fee offset claim.

Signed:      		Date:       
	Name of Certifying Official		
			
		          	
	        Title of Certifying Official

Burden Statement

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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 information received by the Forest Service.