Information Collection

State, Local & Tribal Governments (Public Bodies)

IC 219233 under ICR 202210-0575-003 · OMB 0575-0198.

Documents and Forms

Document Name Document Type
Form RD 400-1 State, Local & Tribal Governments (Public Bodies) Form
RD 400-1 Equal Opportunity Agreement RD0400-0001.pdf Form
AD-1047 Certification Regarding Debarment, Suspension, and Other AD-1047 DebarmentCert-PrimaryCovered.pdf Form
AD-1048 Certification Regarding Debarment, Suspension, Ineligibi AD-1048 DebarmentCert-LowerTierCovered.pdf Form
AD-1049 Certification Regarding Drug-Free Workplace Requirements AD-1049 DrugFreeCert-Alt1.pdf Form
RD 400-4 Assurance Agreement RD 400-4.pdf Form
RD 3570-4 Community Facilities Technical Assistance and Training G RD 3570-4.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State, Local & Tribal Governments (Public Bodies)	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	RD 400-1	Equal Opportunity Agreement	RD0400-0001.pdf	Yes	No	Fillable Printable
Form	AD-1047	Certification Regarding Debarment, Suspension, and Other Responsibility Matters Primary Covered Transactions	AD-1047 DebarmentCert-PrimaryCovered.pdf	Yes	No	Fillable Printable
Form	AD-1048	Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions	AD-1048 DebarmentCert-LowerTierCovered.pdf	Yes	No	Fillable Printable
Form	AD-1049	Certification Regarding Drug-Free Workplace Requirements (Grants) Alternative I - For Grantees Other Than Individiual	AD-1049 DrugFreeCert-Alt1.pdf	Yes	No	Fillable Printable
Form	RD 400-4	Assurance Agreement	RD 400-4.pdf	Yes	No	Fillable Printable
Form	RD 3570-4	Community Facilities Technical Assistance and Training Grant Agreement	RD 3570-4.pdf	Yes	No	Fillable Printable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25	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	-458	458
Annual IC Time Burden (Hours)	-698	698
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.