Information Collection

Public/Tribal

IC 181552 under ICR 202102-0575-004 · OMB 0575-0180.

⚠️ Notice: This information collection may be referencing outdated material.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

2025-01-21 - Revision of a currently approved collection

Documents and Forms

Document Name Document Type
Form AD-1047 Public/Tribal Form
Form AD-1047 Certification Regarding Debarrment, etc. Public/Tribal Form
Form AD-1048 Certification Regarding Debarrment, etc. - Lower Tier Public/Tribal Form
Form AD-1049 Certification for Drug-Free Workplace Public/Tribal Form
Form RD 400-1 Equal Opportunity Agreement Public/Tribal Form
Form RD 400-4 Assurance Agreement Public/Tribal Form
Form RD 442-2 Statement of Budget, Income and Equity Public/Tribal Form
Form RD 442-3 Balance Sheet Public/Tribal Form
Form AD 3030 Representations Regarding Felony Conviction and Tax Delinquent Status for Coporate Applicants Public/Tribal Form
AD-1047 Certification Regarding Debarrment, etc. AD_1047-V1.0.pdf Form
AD-1047 Certification Regarding Debarrment, etc. AD_1047-V1.0.pdf Form
AD-1048 Certification Regarding Debarrment, etc. - Lower Tier AD_1048-V1.0.pdf Form
AD-1048 Certification Regarding Debarrment, etc. - Lower Tier AD_1048-V1.0.pdf Form
AD-1049 Certification for Drug-Free Workplace AD_1049-V1.0.pdf Form
AD-1049 Certification for Drug-Free Workplace AD_1049-V1.0.pdf Form
RD 400-1 Equal Opportunity Agreement rd 400-1.pdf Form
RD 400-1 Equal Opportunity Agreement rd 400-1.pdf Form
RD 400-4 Assurance Agreement rd 400-4.pdf Form
RD 400-4 Assurance Agreement rd 400-4.pdf Form
RD 442-2 Statement of Budget, Income and Equity RD0442-0002_970900 V04.pdf Form
RD 442-2 Statement of Budget, Income and Equity RD0442-0002_970900 V04.pdf Form
RD 442-3 Balance Sheet rd 442-3.pdf Form
RD 442-3 Balance Sheet rd 442-3.pdf Form
AD 3030 Representations Regarding Felony Conviction and Tax Deli AD_3030_1_1-V1.1.pdf Form
AD 3030 Representations Regarding Felony Conviction and Tax Deli AD_3030_1_1-V1.1.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: Removed

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.	AD_1047-V1.0.pdf	Yes	No	Fillable Printable
Form	AD-1048	Certification Regarding Debarrment, etc. - Lower Tier	AD_1048-V1.0.pdf	Yes	No	Fillable Printable
Form	AD-1049	Certification for Drug-Free Workplace	AD_1049-V1.0.pdf	Yes	No	Fillable Printable
Form	RD 400-1	Equal Opportunity Agreement	rd 400-1.pdf	Yes	No	Fillable Printable
Form	RD 400-4	Assurance Agreement	rd 400-4.pdf	Yes	No	Fillable Printable
Form	RD 442-2	Statement of Budget, Income and Equity	RD0442-0002_970900 V04.pdf	Yes	No	Fillable Printable
Form	RD 442-3	Balance Sheet	rd 442-3.pdf	Yes	No	Fillable Printable
Form	AD 3030	Representations Regarding Felony Conviction and Tax Delinquent Status for Coporate Applicants	AD_3030_1_1-V1.1.pdf	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-364	364
Annual IC Time Burden (Hours)	-455	455
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.

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