Information Collection

7 CFR 1776, "Household Water Well System Grant Program"

IC 1889 under ICR 202006-0572-006 · OMB 0572-0139.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0572-0139 can be found here:

Documents and Forms

Document Name Document Type
Form AD-1047 7 CFR 1776, "Household Water Well System Grant Program" Form
Form AD-1047 Certification Regarding Debarment-Primary 7 CFR 1776, "Household Water Well System Grant Program" Form
Form AD-1048 Certification Regarding Debarment 7 CFR 1776, "Household Water Well System Grant Program" Form
Form AD-1049 Certification Regarding Drug-Free Workplace Requirements 7 CFR 1776, "Household Water Well System Grant Program" Form
AD-1047 Certification Regarding Debarment-Primary AD_1047-V1.0.pdf www.ocio.usda.gov/document/ad-1047 Form
AD-1047 Certification Regarding Debarment-Primary AD_1047-V1.0.pdf www.ocio.usda.gov/document/ad-1047 Form
AD-1048 Certification Regarding Debarment AD_1048-V1.0.pdf www.ocio.usda.gov/document/ad-1048 Form
AD-1048 Certification Regarding Debarment AD_1048-V1.0.pdf www.ocio.usda.gov/document/ad-1048 Form
AD-1049 Certification Regarding Drug-Free Workplace Requirements AD_1049_2_0-V2.0.pdf www.ocio.usda.gov/document/ad-1049 Form
AD-1049 Certification Regarding Drug-Free Workplace Requirements AD_1049_2_0-V2.0.pdf www.ocio.usda.gov/document/ad-1049 Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	7 CFR 1776, "Household Water Well System Grant Program"	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 7 CFR 1776

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	AD-1047	Certification Regarding Debarment-Primary	AD_1047-V1.0.pdf	https://www.ocio.usda.gov/document/ad-1047	Yes	No	Fillable Printable
Form	AD-1048	Certification Regarding Debarment	AD_1048-V1.0.pdf	https://www.ocio.usda.gov/document/ad-1048	Yes	No	Fillable Printable
Form	AD-1049	Certification Regarding Drug-Free Workplace Requirements	AD_1049_2_0-V2.0.pdf	https://www.ocio.usda.gov/document/ad-1049	Yes	No	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title: 0575-S201810-001	FR Citation: 84 FR 21315

Number of Respondents: 6	Number of Respondents for Small Entity: 5

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	130	-16	146
Annual IC Time Burden (Hours)	666	-104	770
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.

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