Form FS-2400-0016 Timber Purchaser's Request for Work

Cooperative Agreement

(16 USC 572)

FS-2400-0016 (REV.xx/xxxx) OMB 0596-0225 Exp x/xx/xxxx

Contract Number				Contract Name
Date of Contract	National Forest		Award Date
Under the terms of the timber sale contract referred to above, the Forest Service agrees to perform the work described below. The Purchaser agrees to make advance deposits of $ per (unit of volume or lump sum) in accordance with Section* of the above-designated contract, to cover the estimated cost, based on actual cost experience in such work. These deposits may be combined for similar cooperative work and no further accounting or refund will be made unless provided otherwise below. The rate shown above, which includes necessary overhead charges, may be adjusted from time to time by 10 days advance written notice to the Purchaser by the Forest Service. It is understood that either the Forest Service or the Purchaser may cancel this arrangement by 10 days advance written notice to the other party at the end of any calendar year or following adjustment of the rates. If the work is not complete at cancellation, it will be completed by the purchaser. A Forest Service appraisal will compare the value of the work done with the deposits made for that purpose and if due, a refund will be made.
Description of Work to be Performed**
Date (mm/dd/yyyy)		Signature			Title
Acceptance for the Forest Service While this arrangement is in effect, The Forest Service agrees to perform the work described above for the purchaser
Date (mm/dd/yyyy)		Signature			Title
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 0596-0225. The time required to complete this information collection is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.
* Insert applicable section number ** Refer to contract provisions and specifications. Indicate whether it is all or portions of the work required by the contract. If Purchaser requests an accounting of such cooperative work, specify the basis on which monthly accounts will be rendered.

File Code: 2450 Page 1 of 1