Information Collection

New Equipment Contract (Form 395) for Telecommunications and Broadband Borrowers

IC 210082 under ICR 201401-0572-003 · OMB 0572-0149.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0572-0149 can be found here:

Documents and Forms

Document Name Document Type
Form 395a New Equipment Contract (Form 395) for Telecommunications and Broadband Borrowers Form
AD 1048 Certification Regarding Debarment, Suspension, Ineligibi AD1048-F-01-92.pdf www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms Form
395 Equipment Contract Form 395 (Third Party-Rider-09-18-13)1-2-14.docx www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom Form
395a Certificate of Completion (Equipment Contract Including Form 395a(04-11-12) (2).docx www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom Form
395b Certificate of COmpletion (Equipment Contract Not Includ Form 395b(04-11-12) 1-2-14.docx www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom Form
395c Cetificate of Contractor and Indemnity Form 395c(04-11-12) (2) 1-2-14.docx www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom Form
395d Results of Acceptance Test Form 395d(04-11-12) 1-2-13.docx www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	New Equipment Contract (Form 395) for Telecommunications and Broadband Borrowers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 7 CFR 1755 7 CFR 1753

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	395a	Certificate of Completion (Equipment Contract Including Installation)	Form 395a(04-11-12) (2).docx	http://www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Yes	No	Fillable Fileable
Form	395b	Certificate of COmpletion (Equipment Contract Not Including Installation)	Form 395b(04-11-12) 1-2-14.docx	http://www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Yes	No	Fillable Fileable
Form	395c	Cetificate of Contractor and Indemnity	Form 395c(04-11-12) (2) 1-2-14.docx	http://www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Yes	No	Fillable Fileable
Form	395d	Results of Acceptance Test	Form 395d(04-11-12) 1-2-13.docx	http://www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Yes	No	Fillable Fileable
Form	AD 1048	Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclsion - Lower Tier Covered Transactions	AD1048-F-01-92.pdf	http://www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Yes	No	Fillable Fileable
Form	395	Equipment Contract	Form 395 (Third Party-Rider-09-18-13)1-2-14.docx	http://www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Yes	No	Fillable Fileable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 279	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,407	1,407
Annual IC Time Burden (Hours)	890	890
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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