Form MCSAP-1 Motor Carrier Safety Assistance Program

OMB NO: 2126-0010

Expiration Date:

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays
a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0010. Public reporting for this collection of information is estimated to be approximately 30 minutes per response, including the time for reviewing instructions, gathering the data needed,
and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information
Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-MMI, Washington, D.C. 20590.

us

0

Department

Federal

Motor

Program

Assistance

Safety

Carrier

Motor

of Transportation
Carrier

Safety Administration

(FY)

Surface

the

to enhance

Assistance

Safety

Carrier

amendments

thereto

Motor

a

of

subsequent

and

implementation

97-424)

L.

Program during Federal fiscal year

the

(P.

out

carry

to

of

Act

plans

Agency

Assistance

State

The

[J

Transportation

1982
a Commercial Motor Carrier Safety Program as described in this application.

of

IV

Title

in

authorized

grant

Federal

a

for

Administration

Safety

Carrier

Motor

(StateLeadAgency)hereby applies to the

Federal

The

as describedin the CommercialVehicleSafety

Plan.
0

The State Agency plans to carry out special projects of the Motor Carrier Safety Assistance
Programnot contained in the Basic/Supplementalgrant during Federal fiscal year (FY)
as

herein, incurred in performing the effort described in the attached State Plan.
submit vouchers for the reimbursement of funds expended.

indicated

otherwise

unless

costs,

participating

total

the

of

percent

80

exceed

not

will

share

Federal

The

describedin the attachedplan.
The State agrees to

DUNSt

(Typed"'"

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per response,

including

~

Zip

&

518-

die time for reviewina

instructioos

and completing

and
by

to be 30 minutes

reviewing the collectionof information. All responsesto this collection of informltioo 8R mlnd8CKy. and will be provided

105-178.

allowed

is estimated

P.L.

extent

of information

31101-311041nd

the

for this collcctioo

49 V.S.C.

to

reporting

97-424; P.L. 99-570;

CODfideIItiaiity

The collCttion of this informatioo is authorized under the provisions ofP.L.
Public

eo.)

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(TtIe)

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this

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of

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other

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any

current

or

a
estimate

displays
burden

this

information

of
regarding

collection

that

commeuts

unless

Send

Act
2126-0010.

Reductioo

is

collection

Plperwork

the

of
information

this

for

requirements

die

to

Number

subject

Control

OMB

of

information

valid

The

Number.

collection

law. Not withstanding any other provisioo of law, no person is required to respond to nor shall a persoo be subject to a penalty for failure to comply with a

collection of information, includina suggestions for reducing this burden to: Information Collectioo Clearance OtrK:er. Federal Motor Carrier Safety Administration.

FMCSA

MC-MBI, U.S. Departmentof Transportation,Washington.D.C. 20590.

Form MCSAP-1(Rev. 11/04)

FMCSA Form MCSAP - 1

OMS 2126-0010 (Exp. 11/07)