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JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO:
Board of Commissioners
Philip Morley, County Admini~trator
FROM:
WSU Jefferson County Extension
l/llin -? [lei} \ ld--
DATE:
RE:
Amendement to WSU Extension's current agreement with US
Forest Service
STATEMENT OF ISSUE:
US Forest Service needs to amend the agreement to reflect administrative changes in their
program. They have named a new person to lldminister the agreement with WSU Extension.
ANALYSIS:
Agreement is not changed other than altering principal contact at the Forest Service
FISCAL IMPACT:
None
RECOMMENDATION:
Sign document to accept changes
DEPARTMENT CONTACT:
Kate Driehaus 319-5610 ext. 206
REVIEWED BY:
. . strator
3;;#2-
Date
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I !9 USDA Forest Service
OMB 0596-02171
FS-15~19
PAGE OF PAGES
MODIFICATION OF GRANT OR AGREEMENT 1 I 2
I. u.s. FOREST SERVICE GRANT/AGREEMENT NUMBER: 2. RECIPIENT/COOPERATOR GRANT or 3. MODIFICATION NUMBER:
1 O-CS-ll 060900-023 AGREEMENT NUMBER, IF ANY: 002
4. NAMFI ADDRESS OF U.S. FOREST SERVICE UNIT ADMINISTERING 5. NAMFIADDRESS OF U.S. FOREST SERVICE UNIT ADMINISTERING
GRANT/AGREEMENT (uoitname. street, city, _ and zip + 4): PROJECT/ACI1VITY (unit name. street, city, _ and zip +4):
OLYMPIC NATIONAL FOREST HOOD CANAL RANGER DISTRICT
1835 BLACK LAKE BLVD. Syv, STE.A 29512 HWY 101, P.O. BOX 280
OLYMPIA, WA 98512-5623 QUlLCENE, W A 98376
6. NAME! ADDRESS OF RECIPIENT/COOPERATOR (street, city, _ and zip + 7. RECIPIENT/COOPERATOR'S HHS SUB ACCOUNT NUMBER (For HHS
4. COU01y): payment use only):
ffiFFERSON COUNTY N/A
BY AND THROUGH ffiFFERSON COUNTY
WASHINGTON 4-H
201 W. P A TISON STREET
PORT HADLOCK, W A 98339
8. PURPOSE OF MODIFICATION
CHECK ALL This modification is issued pursuant to the modification provision in the grant/agreement
TIIAT APPLY: referenced in item no. I, above.
0 CHANGE IN PERFORMANCE PERIOD:
0 CHANGE IN FUNDING:
IZI ADMINISTRATIVE CHANGES: Update PrIncipal Contacts. (See item 9, below.)
0 OTHER (Specify type of modification): .
Except as provided herein, all terms and eonditIons of the Grant! Agreement referenced in 1, above, remaIa unchanged and in full
force and effect.
9. ADDmONAL SPACE FOR DESCRIPTION OF MODIFICATION (edd additiooaI pages as necded):
Revise Section V. as follows:
Update the Principal Contacts: Replace Rebecca Hammm-gren as U.S. Forest Service Program Contact with
Stephanie Neil.
U.S. Forest Service Program Contact
Name: Stephanie Neil
Address: 29512 Hwy 101, PO Box 280
City, State, Zip: Quilcene, W A 98376
Telephone - Office: 360-877-1046
Cell: 360-271-9622
Email: sneil(a)fs.fed.us
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I fB USDA Forest Service
OMB 0596-02171
FS-15()()"19
10. ATTACHED DOCUMENTATION (Check all that apply):
D Revised Scope ofW ork
Revised Financial Plan
Other:
11. SIGNATURES
AUTIlORIZED REPRESENTATIVE: By SIGNATURE BELOW, TIlE SIGNING PARTIES CERTIFY 1lIAT11IEY ARE TIlE OFFICIAL REPRESENTATIVES OF
'fIIEIR RESPECTIVE PARTIES AND AUTIlORIZED TO ACT IN THEIR RESPECTIVE AREAS FORMA TEDTO TIlE ABOVE-REFERENCED
GRANT/AGREEMENT.
Il.A JEFFERSON COUNTY SIGNATURE Il.B. DATE
SIGNED
Si ofSi Official
1l.E. NAME (type or print):
S' S' Offi
II.F. NAME (type or print):
DALE HOM
JOHN AUSTIN
II.G. TITLE (type orprint):
Board of Commissioners
12. G&A REVIEW
12.A The authority and format of tbis modification have been reviewed and approved for signature by:
1l.H. TITLE(typeorprint):
Forest S ervisor
12.B. DATE
SIGNED
t~~
COLLEEN BROWER
U.S. Forest SmiceGnmts & S
2/16/2012
Burdan SlalBment
AooordIng to 1he Paperwork ReduolIon Act of 1995, an agency may not oonduol or sponsor, ami a peraon Is not raquirad to respond 10 a oollaolion of Inlormatlon unIass tt displays a vaid OMB
control number. The vaid OMS oontroI numbar for this Inlormallon ooIIaolion Is 0S9a<l217. The 1Ime raquirad to complete this Inlormallon _n Is asIImaIed to average 30 mInulee per
response, Including 1he!!me lor revIewlng 1nsIruolIone, eearohIng exIsIIng date eowoee galherlng ami maInlaInIng 1he date needed, and complellng amll1lViewfng tha ooOection of Inlormallon.
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assIstenoe. (Not aD prohibited beses apply to aD progrsms.) Persons with dIsab!llIes who require altsmatlve means for 00IIlIIItIt1!ca of progmm Inlormatlon (8mIIie,1arg& print, audIolape,
etc.) should oonteol USDA's TARGET Center 81202.720-2600 (voJoe and TOO).
To fila a complaint of dIsorImInatlon, write USDA, Director, OllIoe of CIvIi Rlghls, 1400 (ndepemlsnoe Avenue, SW, Washington, DC 20250-9410 or caD 100 free (866) 632-9992 (voloa). TOO
users can oonteol USDA through Iooai relay or1he Feders! relay 81 (800) 877-l1339 (TOO) or (866) 377-8642 (relay voloa). USDA Is an equaJ opportunily provider ami employer.
Approved as t9 fonn only:
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Jefferson Co, Prosecu Office