Information Collection

American Rescue Plan Act Emergency Rural Health Care Grant Program

IC 247396 under ICR 202107-0575-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
0575-0200 - Application Submissions- Non Forms.docx Other-Application Submission Non-For
0575-0200 -Reporting Requirements -Non Forms.docx Other-Other Reporting Requirements -
AD Form 1047 Certification Regarding Debarment, Suspension, and Other AD-1047 Section 508 Compliant.pdf Form
RD 3570-3 Community Facilities Grant Agreement RD 3570-3.pdf Form and Instruction
RD 442-2 Statement of Budget, Income and Equity RD 442-2.pdf Form and Instruction
RD 442-3 Balance Sheet RD 442-3.pdf Form and Instruction
RD 442-7 Operating Budget RD 442-7.pdf Form and Instruction

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: Modified

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Application Submission Non-Form			0575-0200 - Application Submissions- Non Forms.docx	No		Paper Only
Other-Other Reporting Requirements - Non-Form			0575-0200 -Reporting Requirements -Non Forms.docx	No		Paper Only
Form	AD Form 1047	Certification Regarding Debarment, Suspension, and Other Responsibility Matters	AD-1047 Section 508 Compliant.pdf	Yes	Yes	Fillable Printable
Form and Instruction	RD 3570-3	Community Facilities Grant Agreement	RD 3570-3.pdf	Yes	Yes	Fillable Printable
Form and Instruction	RD 442-2	Statement of Budget, Income and Equity	RD 442-2.pdf	Yes	Yes	Fillable Printable
Form and Instruction	RD 442-3	Balance Sheet	RD 442-3.pdf	Yes	Yes	Fillable Printable
Form and Instruction	RD 442-7	Operating Budget	RD 442-7.pdf	Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title: USDA/RD-1 Current or Prospective Producers or Landowners, Applicants, Borrowers, Grantees, Tenants, and other participants in RD programs.	FR Citation: 84 FR 21315

Number of Respondents: 1,092	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15,389	-38,911	54,300
Annual IC Time Burden (Hours)	71,681	-129,591	201,272
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.