FS 6500 235 16-LE-11031200-005_2019 DEOBLIGATION_1 SIGN INFO.PDF

USDA FOREST SERVICE
FS-6500-235 (REV. 5/2010)
1
Forest Service Agreement No.
Modification No.
DE-OBLIGATION AND CLOSEOUT REQUEST FORM
FSM 1580 GRANTS & AGREEMENTS
(One request per package)
Send a signed copy of this form and the supporting documentation, if applicable, to your assigned G&A technician or 
specialist.  Retain copies for your program records.  The G&A specialist shall complete Block #11.
CONTACT INFORMATION
1. TRANSMITTING UNIT
PHONE
2. PROJECT/PROGRAM MANAGER
E-MAIL
TYPE OF REQUEST
3. TYPE OF INSTRUMENT (CHOOSE ONE)
INTERAGENCY
AGREEMENT
FEDERAL FINANCIAL
ASSISTANCE
OTHER TYPE OF FSM
1580
OBLIGATING INSTRUMENT
MASTER
AGREEMENT/MOU
4. Action Required
CLOSEOUT
DE-OBLIGATION AND CLOSEOUT
5. Obligation Document # (i.e.,
MO#):
6. Amount to de-obligate, if any:
ATTACHMENTS AND COMMENTS
7. ATTACHMENTS  (CHECK ALL THAT ARE APPLICABLE)
FINAL PROGRESS REPORT
FINAL FINANCIAL REPORT
OTHER SUBSTANTIVE DOCUMENTATION
NONE 
8. COMMENTS:
ACKNOWLEDGEMENTS
9. PROGRAM MANAGER ACKNOWLEDGES (PLEASE CHECK ONE ONLY):
Substantial documentation is attached for a de-obligating/obligating instrument.  The program manager (this 
block) and the assigned G&A specialist (block #11) are required to sign.
No substantial documentation is attached for a de-obligating/obligating instrument.  The Forest Service 
Program Manager (this block), the Forest Service and Cooperator Signatory Officials (block #10), and the 
assigned G&A specialist (block #11) are required to sign.
No substantial documentation is required, since the instrument is a MOU.  The program manager (this block) 
and the assigned G&A specialist (block #11) are required to sign.
FS PROGRAM MANAGER
SIGNATURE:
DATE:
TYPE/PRINT NAME:
TITLE:
PHONE NUMBER:
FAX NUMBER:
E-MAIL ADDRESS:
1. TRANSMITTING UNIT
2. PROJECT/PROGRAM MANAGER
PHONE
E-MAIL
Forest Service Agreement No.
SIGNATURE:
DATE:
TYPE/PRINT NAME:
TITLE:
PHONE NUMBER:
FAX NUMBER:
E-
ADDRESS:
-MAIL

USDA FOREST SERVICE
FS-6500-235 (REV. 5/2010)
2
RELEASE 
10. NOTE:
SIGNATURES FROM BOTH THE FOREST SERVICE SIGNATORY OFFICIAL AND COOPERATOR ARE REQUIRED
BELOW.
RELEASE INFORMATION: ALL APPLICABLE ADMINISTRATIVE ACTIONS AND ALL REQUIRED WORK AS DESCRIBED IN 
THE INSTRUMENT LISTED ABOVE HAVE BEEN COMPLETED, MINUS THIS REQUEST FOR CLOSEOUT ONLY OR DE-
OBLIGATION AND CLOSEOUT ACTIVITY(IES).  ALL INVOICES, INCLUDING THE FINAL INVOICE, HAVE BEEN PROVIDED TO
THE FOREST SERVICE, AND, IF APPLICABLE, THE FOREST SERVICE HAS EITHER PAID THE COOPERATOR FOR ALL
MONIES OWED, OR THE FOREST SERVICE HAS COLLECTED ALL OVER PAYMENTS MADE TO THE COOPERATOR.
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 INSTRUMENT.
FS SIGNATORY OFFICIAL (OR DESIGNEE)
SIGNATURE:
DATE:
TYPE/PRINT NAME:
TITLE:
PHONE NUMBER:
FAX NUMBER:
E-MAIL ADDRESS:
COOPERATOR (OR DESIGNEE) 
SIGNATURE:
DATE:
TYPE/PRINT NAME:
TITLE:
PHONE NUMBER:
FAX NUMBER:
E-MAIL ADDRESS:
G&A REVIEW 
11. FOREST SERVICE GRANTS & AGREEMENTS ACKNOWLEDGES: (PLEASE CHECK)
 All documentation (if required) is attached, and all required signatures have been provided on this form. 
FOREST SERVICE GRANTS AND AGREEMENTS 
SIGNATURE: 
DATE:
TYPE/PRINT NAME:
TITLE:
PHONE NUMBER:
FAX NUMBER:
E-MAIL ADDRESS:
Attest for Maricopa County: 
________________________________________________________
Clerk of the Board 
 
 
 
Date
Juanita Garza
Reviewed as to Form:
________________________________________________________
Deputy County Attorney            
 
 
Date

USDA FOREST SERVICE
FS-6500-235 (REV. 5/2010)
3
INSTRUCTIONS
The following instruction is for FSM 1580 Grants and Agreements instruments. See FSH 1509.11, 
sec. 16.3, Procedures for De-obligation and Close-out of Instruments. 
1. Transmitting Unit – Enter requesting unit name or unit/sub-unit.
2. Name of Requestor – Enter name, telephone number and email of program contact submitting
this form, if different than the program manager identified in Block #10.
3. Type of instrument – Select type of instrument.
a. Interagency Agreement, i.e. federal to federal contracts
b. Federal Financial Assistance, i.e. grants or cooperative agreement (non-HHS payment type
only)
c. Other type of FSM 1580 obligating instrument, e.g. Participating, Challenge Cost-Share, Joint
Venture, and Cost Reimbursable
d. Master Agreement (i.e., Master Participating or Master Challenge Cost-Share) or MOU
(Memorandum of Understanding)
NOTE: This form does not apply to Intra Agency, HHS-paid grants and agreements or Collection 
agreements. 
4. Action Required
a. Closeout – Select to closeout the instrument with a zero balance, i.e. there is not a remaining
balance (Unliquidated Obligation, or ULO) on the instrument.
b. De-obligation/Closeout – Select to both de-obligate the balance of an open obligation and to
closeout the instrument.
5. Obligation Document Number - If de-obligating an existing obligation, then enter the obligation
number, e.g. MO G13690270 (Note: an MO is the same as “FFIS Document Number”).
6. Amount to de-obligate, if any – If applicable, enter the balance of the open obligation (ULO).
7. Attachments (Describe)
Select the type of attachments that will be provided to closeout the agreement.  The SF-425
(Federal Financial Report) and the SF-PPR (Performance Progress Report) must be attached for
grants and cooperative agreements awarded from FY2010 forward. Select the appropriate boxes
as follows:
a. Substantive Documentation for Interagency Agreements:  Documentation shall include:
o
A signed statement or email from the Cooperator’s responsible fiscal representative that
shows the aggregate amount invoiced, through the applicable federal billing system, the
amount of the total Forest Service obligation (including all modifications), the outstanding
ULO amount, the MO#, if available, and a statement that the final invoice has been sent to
the Forest Service (if applicable) and final payment has been received through the
applicable federal billing system.
b. Final Progress/Accomplishments/Technical Report:   Reports shall contain the following:
o
a comparison of actual accomplishments with the goals and objectives established for the
period;
o
where project output can be quantified, a computation of the cost per unit of output;
o
reason why goals and objectives were not met, if appropriate; and

USDA FOREST SERVICE
FS-6500-235 (REV. 5/2010)
4
o
Other pertinent information including, when appropriate, analysis and explanation of cost
overruns or high unit costs
c. Final Financial Report
o
SF-425 (Federal Financial Assistance)
o
SF-269 (Federal Financial Assistance)
o
SF-272 (Federal Financial Assistance)
o
Detailed transaction report
o
Other Cooperator format
d. Other Substantive Documentation, such as:
o
Correspondence letter to or from the Cooperator documenting closeout and/or de-
obligation of any remaining award funding (i.e., clear, documented indication of the
vendor’s informed knowledge)
o
Confirmation e-mail regarding the final invoice or final report submission
o
Final invoice with cumulative expenditures
o
Billing history
o
Completion of activity confirmation, i.e., training certification, email on training attendance
e. None – Select this box when you do not have any attachments to provide to closeout the grant
or agreement.
8. Comments - Please provide a justification for not providing any or all required documents
according to the terms or conditions described in the instrument.  If pieces of substantive
documentation are already in I-Web, then list those items in this section.  There is no need to
duplicate scanned files already in I-Web.
9. Acknowledgements – The program manager must choose one of the three choices and sign.
The program manager’s signature acknowledges that either substantive documentation is
attached, no substantive documentation is required because the parties’ signatory officials are
releasing responsibilities, or the underlying agreement is an MOU.
10. Release - Bilateral (Cooperator) signatures are required when the terms or conditions are not met
in the instrument, or when substantive documentation is not provided.  The Forest Service
signatory official or designee AND the Cooperator signatory official or designee are required to
sign the form.  If the Forest Service signatory official designates a staff member to act on their
behalf, then documentation should be provided to the G&A specialist indicating the designation
(an email making such a designation is acceptable).
11. G&A Review - Forest Service G&A specialist must review all substantial documentation to ensure
that the documentation confirms that all applicable administration actions and all required work
has been completed. If the documentation is sufficient, check the box and sign and enter date,
type/print name, title, phone number, fax number and e-mail address.  Currently, electronic
signatures are not acceptable.