2015 FS MODIFICATION OF GRANT OR AGREEMENT.PDF

USDA Forest Service OMB 0596-0217
FS-1500-19
1 PAGE OF PAGES
MODIFICATION OF GRANT OR AGREEMENT 1 2
1. U.S. FOREST SERVICE GRANT/AGREEMENT NUMBER: 2. RECIPIENT/COOPERATOR GRANT or 3. MODIFICATION NUMBER:
11-LE-11031200-005 AGREEMENT NUMBER, IF ANY: 8
4. NAME/ADDRESS OF U.S. FOREST SERVICE UNIT ADMINISTERING 5. NAME/ADDRESS OF U.S. FOREST SERVICE UNIT ADMINISTERING
GRANT/AGREEMENT (unit name, street, city, state, and zip + 4): PROJECT/ACTIVITY (unit name, street, city, state, and zip + 4):
Sherry Smith, Grant & Agreement Specialist Bray Addison, Patrol Captain
Tonto National Forest, Supervisor's Office Tonto National Forest, Supervisor's Office
2324 East McDowell Road 2324 East McDowell Road
Phoenix, AZ 85006 Phoenix, AZ 85006
6. NAME/ADDRESS OF RECIPIENT/COOPERATOR (street, city, state, and zip + 7. RECIPIENT/COOPERATOR'S HHS SUB ACCOUNT NUMBER (For HHS
4, county): payment use only):
Maricopa County on behalf of the
Maricopa County Sheriff's Office
550 West Jackson Street, 4th Floor
Phoenix, AZ 85003
8. PURPOSE OF MODIFICATION
CHECK ALL This modification is issued pursuant to the modification provision in the grant/agreement
THAT APPLY: referenced in item no. 1, above.
0 CHANGE IN PERFORMANCE PERIOD: Extend the period of performance through December 31, 2015.
0 CHANGE IN FUNDING: Add funding in the amount of $100,400.00 for work to be performed in 2015 Annual
Financial and Operating Plan, attached as Exhibit A.
III ADMINISTRATIVE CHANGES: Add additional language to the Cooperative Law Enforcement Agreement (see 9.
below)
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):
Note: 2015 Annual Operating Plan will be incorporated as Exhibit A to this agreement.
10. ATTACHED DOCUMENTATION (Check all that apply):
Revised Scope of Work
Revised Financial Plan
As, Other: Exhibit A, 2015 Annual Financial and Operating Plan
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.
11.A. MARICOPA COUNTY, ARIZONA SIGNATURE 11.B. DATE 11.C. U.S. FOREST SERVICE SIGNATURE 11.D. DATE
SIGNED SIGNED
(Signature of Signatory Official) (Signature of Signatory Official)
11.E. NAME (type or print): 11.F. NAME (type or print): NEIL J. BOSWORTH
11.G. TITLE (type or print): Chairman Board of Supervisors 11.H. TITLE (type or print): Forest Supervisor
ATTEST:
_

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USDA Forest Service OMB 0596-0217
FS-1500-19
FRAN MCCARROLL Date ROBIN L. POAGUE Date
Clerk of the Board of Supervisors Special Agent in Charge,
Southwestern Region
JOSEPH M. ARPAIO Date
Sheriff
12. G&A REVIEW
12.A. The authority and format of this modification have been reviewed and approved for signature by: 12.B. DATE
SIGNED
SHERRY J. SMITH
U.S. Forest Service Grants & Agreements Specialist

USDA Forest Service OMB 0596-0217
FS-1500-19
APPROVED AS TO FORM
THIS DAY OF , 201
BY:
DEPUTY MARICOPA COUNTY ATTORNEY
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USDA Forest Service OMB 0596-0217
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INSTRUCTIONS FOR FORM FS-1500-19
1. Enter the orginal U.S. Forest Service agreement number.
2. Enter the cooperator's agreement number, if applicable.
3. Enter the number for this Modification, i.e. 01, 02, or 03. The first modification to an instrument is '01', subsequent
modifications receive a subsequent modification number (for example, the fourth modification is '04').
4. Enter the address of the G&A Specialist/Signatory Official responsible for this agreement.
5. Enter the address of the U.S. Forest Service Program/Project Manager or Lead Scientist responsible for this agreement.
6. Enter the cooperator's address.
7. Enter the cooperator's HHS Sub-Account numbers, if funding is provided on this modification (for example: G2412345003)
(Only used by NA/S&PF and NRS)
8. Select all boxes that apply:
- Change in Performance = updated performance period agreed to.
- Change in Funding = obligation OR de-obligation amount and new totals.
- Administrative = change in pay address, administrator address, correcting typing errors, etc.
- Other = any other modification not described, such as update new objective to study plan, change the Principle
Investigator, etc.
9. Insert changes such as updated provision, tasks, or any other data needed by the modification, add additional pages as
needed.
10. Check all boxes that apply and ensure to attach these documents to the modification. Other attachments could include
SF-424 forms.
11. A — D, self explanatory.
11. E — H, Type or print the names of signatory officials.
12. G&A Specialist signs and dates before sending to the individuals in block 11, if all modification data are approved for
signature.