FS-2700-40 Assumption of Risk, Waiver of Liability, and Indemnity A

FS-2700-40 (XX/20XX)
OMB 0596-0082
U.S. DEPARTMENT OF AGRICULTURE
FOREST SERVICE
ASSUMPTION OF RISK, WAIVER OF LIABILITY, AND INDEMNITY AGREEMENT
FOR GOOD SAMARITAN SEARCH AND RECOVERY MISSIONS

AUTHORITY:
Section 9002 of the John D. Dingell, Jr. Conservation, Management, and Recreation Act, Pub. L.
No. 116-9, 43 U.S.C. 1742a
The undersigned good Samaritan, _________________________, has made a voluntary request to
conduct a search on National Forest System (NFS) lands for one or more missing individuals believed to
be deceased (hereinafter “search and recovery mission”).
Name of Missing Person or Persons: ________________________________________________
Starting Date of Search and Recovery Mission: _______________________________________
Anticipated Ending Date of Search and Recovery Mission: ______________________________
Assumption of Risk
The undersigned is aware that a search and recovery mission is inherently dangerous and that the
undersigned may be subjected to the risk of death, personal injury, or damage to the undersigned’s
property by undertaking such a mission on NFS lands. The undersigned voluntarily assumes the risk of
death, personal injury, and property damage arising from or in any way connected with the undersigned’s
search and recovery mission on NFS lands, including but not limited to death, personal injury, and
property damage caused by uneven terrain, exposure, heat stroke, rockslides, avalanches, encounters
with wildlife, or wildfire. The undersigned acknowledges that the undersigned possesses the requisite
knowledge, skills, and training to successfully execute a search and recovery mission on NFS lands
despite its inherent risks.
Waiver of Liability
The undersigned hereby agrees that the United States and its officers, agents, and employees shall not
be liable to the undersigned or the undersigned’s estate, heirs, or assignees for the death of, personal
injury to, or property damage sustained by the undersigned as a result of negligence of an officer, agent,
or employee of the United States in connection with conducting a search and recovery mission on NFS
lands. The undersigned hereby waives any negligence claims the undersigned or the undersigned’s
estate, heirs, or assignees may have against the United States and its officers, agents, and employees
for the death of, personal injury to, or property damage sustained by the undersigned in connection with
conducting a search and recovery mission on NFS lands.
Indemnification, Hold Harmless, and Duty to Defend
The undersigned and the undersigned’s estate, heirs, and assignees shall indemnify, hold harmless, and
defend the United States and its officers, agents, and employees for any injury, loss, or damage the
United States may suffer as a result of claims, demands, losses, or judgments, other than those caused
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by the negligence of the United States or its officers, agents, or employees, arising in connection with the
undersigned’s search and recovery mission conducted on NFS lands.
Legal Status of the Undersigned
The undersigned agrees that (1) the undersigned is acting for private purposes and shall not be
considered to be a USDA Forest Service volunteer; (2) the undersigned shall not be considered to be a
volunteer under 54 U.S.C. 102301(c); (3) the Federal Tort Claims Act, 28 U.S.C. chapter 171, shall not
apply to the undersigned in connection with the undersigned’s search and recovery mission on NFS
lands; and (4) the Federal Employees Compensation Act, 5 U.S.C. chapter 81, shall not apply to the
undersigned in connection with the undersigned’s search and recovery mission on NFS lands, nor shall
the conduct of the undersigned’s search and recovery mission constitute civilian employment.
THE UNDERSIGNED MUST COMPLETE THE FOLLOWING IN THE UNDERSIGNED’S OWN
HANDWRITING:
Yes

Have you read this form in its entirety?

No

Are you or your organization acting in a not-for-profit capacity?

Yes

No

Have you attained the age of majority under the law in the State where the search and recovery
Yes
No
mission is to take place?
Are you aware that by signing this form you are agreeing (1) to assume all risk of death, personal
injury, and property damage, (2) to waive all claims against the United States for negligence, and
(3) to pay the cost of defending the United States in any lawsuit and to pay any damages incurred by
the United States in any lawsuit, other than those caused by the negligence of the United States,
arising in connection with your conducting a search and recovery mission on NFS lands?
Yes

No

____________________________________
[name of good Samaritan]

_________________
Date

____________________________________
[name and title of Forest Service witness]

_________________
Date

PAPERWORK REDUCTION ACT STATEMENT
According to the Paperwork Reduction Act of 1995, a Federal agency may not conduct or sponsor, and a person is not required to
respond to, an information collection request unless it displays a valid Office of Management and Budget (OMB) control number.
The valid OMB control number for this information collection request is 0596-0082. Response to this information collection request
is required to obtain or retain benefits, specifically, a special use authorization. The authority for this information collection request is
Section 9002 of the John D. Dingell, Jr. Conservation, Management, and Recreation Act, Pub. L. No. 116-9, 43 U.S.C. 1742a. The
time required to complete this information collection request is estimated to average 1 hour per response, including the time for
reviewing instructions, searching existing data sources, collecting and maintaining the data needed, and completing and reviewing
the information collection request. Send comments regarding this burden estimate or any other aspect of this information collection
request, including suggestions for reducing the burden, to Forest Service Information Collections Officer,
SM.FS.InfoCollect@usda.gov, with OMB control number 0596-0082 in the subject line.
PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act statement serves to inform you of the following concerning the collection of the
information on this form.

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Purpose: The Privacy Act of 1974 requires that the Director of Recreation, Heritage, and Volunteer Resources staff and the
Director of Lands, Minerals, and Geology Management staff provide the following statements to individuals from whom they request
information.
Authority: Collection of this information solicited on this form is authorized by Section 9002 of the John D. Dingell, Jr.
Conservation, Management, and Recreation Act, Pub. L. No. 116-9, 43 U.S.C. 1742a.
Routine Uses: The information collected will be used by Forest Service officials to ensure that your use of National Forest System
lands is administered in accordance with applicable statutes, regulations, and directives. The information collected from you is
retained in the Special Uses Data System (SUDS) and is retrieved by the Forest Service create reports for the Agency’s Special
Uses Program, generate bills for collection of land use fees for your authorization, monitor compliance with your special use
authorization, and other matters pertaining to administration of your special use authorization. SUDS is a component of the Forest
Service’s Natural Resources Manager database (NRM). A complete list of the routine uses of NRM can be found in the system of
records notice associated with this form, FS-24.
Disclosure: The submission of this information is required to obtain or retain benefits, specifically, a special use authorization.
NONDISCRIMINATION STATEMENT
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 State or local Agency that administers the program or contact USDA
through the Telecommunications Relay Service at 711 (voice and TTY). 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 the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit the 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.

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