Contract Termination / Cancellation-Request Form

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CONTRACT TERMINATION / CANCELLATION - REQUEST
Participant Name: _____________________________________________ Contract Number: __________________________
NRCS Servicing Office: ________________________________________ County: __________________________
Program:
WHIP
EQIP
CSP
Other: ____________________________________
Copies of signed CCC-1200 and Appendix, current AD-1155/1156, Ranking Worksheet, Status Reviews, are attached
Document on current AD-1155/1156 all practices completed and the date that practice was completed
Contract expiration date: ___________________
Total contract obligation amount $ _____________________
Total current financial assistance obligated at the time of termination/cancellation $ ______________________
Cancellation requested by participant
Date letter received: _________________
Copy of letter is attached
Termination initiated by NRCS
Date: _____________________
Situation Number:___________ (
From Recovery of Costs Guidance Worksheet)
Justification Details:___________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Will failure to perform remaining practices impair effectiveness of practices performed?
Yes
No
Will the performed practices provide environmental benefits consistent with program goals?
Yes
No
Will the performed practices be operated and maintained for the practice service life?
Yes
No
District Conservationist (DC) RECOMMENDATION:
Does the DC recommend termination/cancellation?
Yes
No
Does the DC recommend Recovery of Costs?
Yes
No
Amount:$_______________
DC Comments: ______________________________________________________________________________________________
____________________________________________________________________________________________________________
DC Signature & Date ________________________________________________________________________________
Contracting Officer (CO) DECISION on Cancellation/Termination:
I approve the cancellation or termination of this contract
Yes
No
CO RECOMMENDATION on Recovery of Cost:
Liquidated Damages:
Yes
No Amount:$_______________
Refund of Financial Assistance Payments:
Yes
No Amount:$_________________
_______________________________________________________________
CO Signature & Date
___________
Program Staff Reviewer’s Comments:___________________________________________________________________________
Does recommendation meet program policy?
Yes
No
________________________________________________
Signature & Date
_______________________________
State Conservationist (STC) CONCURRENCE on Cancellation/Termination Action:
Yes
No
STC Concurrence on Recovery of Cost and/or Refund of Financial Assistance Payments:
Yes
No
______________________________________________
STC Signature & Date
7/14/06
CONTRACT TERMINATION / CANCELLATION - REQUEST
Participant Name: _____________________________________________ Contract Number: __________________________
NRCS Servicing Office: ________________________________________ County: __________________________
Program:
WHIP
EQIP
CSP
Other: ____________________________________
Copies of signed CCC-1200 and Appendix, current AD-1155/1156, Ranking Worksheet, Status Reviews, are attached
Document on current AD-1155/1156 all practices completed and the date that practice was completed
Contract expiration date: ___________________
Total contract obligation amount $ _____________________
Total current financial assistance obligated at the time of termination/cancellation $ ______________________
Cancellation requested by participant
Date letter received: _________________
Copy of letter is attached
Termination initiated by NRCS
Date: _____________________
Situation Number:___________ (
From Recovery of Costs Guidance Worksheet)
Justification Details:___________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Will failure to perform remaining practices impair effectiveness of practices performed?
Yes
No
Will the performed practices provide environmental benefits consistent with program goals?
Yes
No
Will the performed practices be operated and maintained for the practice service life?
Yes
No
District Conservationist (DC) RECOMMENDATION:
Does the DC recommend termination/cancellation?
Yes
No
Does the DC recommend Recovery of Costs?
Yes
No
Amount:$_______________
DC Comments: ______________________________________________________________________________________________
____________________________________________________________________________________________________________
DC Signature & Date ________________________________________________________________________________
Contracting Officer (CO) DECISION on Cancellation/Termination:
I approve the cancellation or termination of this contract
Yes
No
CO RECOMMENDATION on Recovery of Cost:
Liquidated Damages:
Yes
No Amount:$_______________
Refund of Financial Assistance Payments:
Yes
No Amount:$_________________
_______________________________________________________________
CO Signature & Date
___________
Program Staff Reviewer’s Comments:___________________________________________________________________________
Does recommendation meet program policy?
Yes
No
________________________________________________
Signature & Date
_______________________________
State Conservationist (STC) CONCURRENCE on Cancellation/Termination Action:
Yes
No
STC Concurrence on Recovery of Cost and/or Refund of Financial Assistance Payments:
Yes
No
______________________________________________
STC Signature & Date
7/14/06

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