Certification Regarding Debarment, Suspension, and other Responsibility Matters

Federal-State Marketing Improvement Program (FSMIP)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0581-0240 can be found here:

Documents and Forms

Document Name Document Type
Form AD-1047 Certification Regarding Debarment, Suspension, and other Responsibility Matters Form and Instruction
AD-1047 Certification Regarding Debarment, Suspension, and Other Cert. re Debarment, Suspension and Other AD-1047.pdf www.rurdev.usda.gov/rbs/coops/ad1047.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Certification Regarding Debarment, Suspension, and other Responsibility Matters	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	AD-1047	Certification Regarding Debarment, Suspension, and Other Responsibility Matters	Cert. re Debarment, Suspension and Other AD-1047.pdf	http://www.rurdev.usda.gov/rbs/coops/ad1047.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: 75 %

	Approved	Previously Approved
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	5	5
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.