Information Collection

American Rescue Plan Act Emergency Rural Health Care Grant Program

IC 247396 under ICR 202105-0575-001 · OMB 0575-0200.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0575-0200 can be found here:

Documents and Forms

Document Name Document Type
Form AD-1047 American Rescue Plan Act Emergency Rural Health Care Grant Program Form
0575-NEW - Application Submissions- Non Forms.docx Other-Application Submissions Non-Fo
0575-NEW - Application Submissions- Non Forms.docx Other-Application Submissions Non-Fo
0575-NEW -Reporting Requirements -Non Forms.docx Other-Reporting Requirements - Non-F
0575-NEW -Reporting Requirements -Non Forms.docx Other-Reporting Requirements - Non-F
AD-1047 Certification Regarding Debarment, Suspension, and Other AD-1047.pdf Form
SF-425.pdf SF 425 - Federal Financial Report IC Document
RD 3570-3.pdf RD 3570-3 - Community Facilities Grant Application IC Document
RD 400-1.pdf RD 400-1 Equal Opportunity Agreement IC Document
RD 400-4.pdf RD 400-4 Assurance Agreement IC Document
RD 442-7.pdf RD 442-7 Operating Budget IC Document
RD 442-2.pdf RD 442-2 Statement of Budget, Income, and Equity IC Document
RD 442-3.pdf RD 442-3 Balance Sheet IC Document
SF 424.pdf SF 424 Application for Federal Assistance IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	American Rescue Plan Act Emergency Rural Health Care Grant Program	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 1940

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Application Submissions Non-Form			0575-NEW - Application Submissions- Non Forms.docx		No		Paper Only
Other-Reporting Requirements - Non-Form			0575-NEW -Reporting Requirements -Non Forms.docx		No		Paper Only

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,392	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	54,300	54,300
Annual IC Time Burden (Hours)	201,272	201,272
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.