Information Collection

Public/Tribal

IC 181552 under ICR 201401-0575-003 · OMB 0575-0180.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0575-0180 can be found here:

Documents and Forms

Document Name Document Type
Form AD-1047 Public/Tribal Form
AD-1047 Certification Regarding Debarrment, etc. RD AD1047-F-01-92.docx Form
AD-1048 Certification Regarding Debarrment, etc. - Lower Tier RD AD1048-F-01-92.docx Form
AD-1049 Certification for Drug-Free Workplace RD AD1049-F-05-90.docx Form
SF 424 Application for Federal Assistance SF424_2_1-V2.1.pdf Form
RD 400-1 Equal Opportunity Agreement RD0400-0001.pdf Form
RD 400-4 Assurance Agreement RD0400-0004.pdf Form
RD 442-2 Statement of Budget, Income and Equity RD0442-0002.pdf Form
RD 442-3 Balance Sheet RD0442-0003.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Public/Tribal	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 Debarrment, etc.	RD AD1047-F-01-92.docx	Yes	No	Fillable Printable
Form	AD-1048	Certification Regarding Debarrment, etc. - Lower Tier	RD AD1048-F-01-92.docx	Yes	No	Fillable Printable
Form	AD-1049	Certification for Drug-Free Workplace	RD AD1049-F-05-90.docx	Yes	No	Fillable Printable
Form	SF 424	Application for Federal Assistance	SF424_2_1-V2.1.pdf	Yes	No	Fillable Printable
Form	RD 400-1	Equal Opportunity Agreement	RD0400-0001.pdf	Yes	No	Fillable Printable
Form	RD 400-4	Assurance Agreement	RD0400-0004.pdf	Yes	No	Fillable Printable
Form	RD 442-2	Statement of Budget, Income and Equity	RD0442-0002.pdf	Yes	No	Fillable Printable
Form	RD 442-3	Balance Sheet	RD0442-0003.pdf	Yes	No	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	440	93	347
Annual IC Time Burden (Hours)	556	137	419
Annual IC Cost Burden (Dollars)	0	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.