Information Collection

Energy Audit and Energy Assistance - State and Local

IC 188029 under ICR 200902-0570-001 · OMB 0570-0059.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0570-0059 can be found here:

Documents and Forms

Document Name Document Type
Form AD 1047 Energy Audit and Energy Assistance - State and Local Form
AD 1047 Certification Regarding Debarment, Suspension, and Other AD1047-F-01-92.pdf Form
AD 1048 Certification Regarding Debarment, Suspension, Ineligibi AD1048-F-01-92.pdf Form
AD 1049 Certification Regarding Drug-Free Workplace Requirements AD1049-F-05-90.pdf Form
RD 1940-1 Request for Obligation of Funds RD1940-0001_080700V01.pdf Form
RD 400-4 Assurance Agreement 0400-04.pdf Form
RD 1942-46 Letter of Intent 1942-46.pdf Form
424_20090131[1].doc Application for Federal Assistance IC Document
sf269[1].pdf Financial Status Report IC Document
sf270[1].pdf Request for Adance or Reimbursement IC Document
SF424A-V1[1].0.pdf Budget Information - Non-Construction Programs IC Document
SF424B[1].pdf Assurances - Non-Construction Programs IC Document
sflllin[1].pdf Disclosure of Lobbying Activities IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Energy Audit and Energy Assistance - State and Local	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	AD 1047	Certification Regarding Debarment, Suspension, and Other Responsibility Matters ï¿½ Primary Covered Transactions	AD1047-F-01-92.pdf	Yes	Yes	Fillable Printable
Form	AD 1048	Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion ï¿½ Lower Tier Covered Transactions	AD1048-F-01-92.pdf	Yes	Yes	Fillable Printable
Form	AD 1049	Certification Regarding Drug-Free Workplace Requirements (Grants) Alternative I	AD1049-F-05-90.pdf	Yes	Yes	Fillable Printable
Form	RD 1940-1	Request for Obligation of Funds	RD1940-0001_080700V01.pdf	Yes	Yes	Fillable Printable
Form	RD 400-4	Assurance Agreement	0400-04.pdf	Yes	Yes	Fillable Printable
Form	RD 1942-46	Letter of Intent	1942-46.pdf	Yes	Yes	Fillable Printable

Line of Business: Energy

Subfunction: Energy Production

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	329	329
Annual IC Time Burden (Hours)	445	445
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Application for Federal Assistance	424_20090131[1].doc	03/11/2009
Financial Status Report	sf269[1].pdf	03/11/2009
Request for Adance or Reimbursement	sf270[1].pdf	03/11/2009
Budget Information - Non-Construction Programs	SF424A-V1[1].0.pdf	03/11/2009
Assurances - Non-Construction Programs	SF424B[1].pdf	03/11/2009
Disclosure of Lobbying Activities	sflllin[1].pdf	03/11/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.