Information Collection

Summer Food Pilot

IC 193853 under ICR 200906-0584-002 · OMB 0584-0512.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0512 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD 1047 Summer Food Pilot	Form and Instruction
AD 1047 Certification Regarding Debarment, Suspension, and Other AD1047-F-01-92[1].pdf	Form and Instruction
AD 1048 Certification Regarding Debarment, Suspension, Ineligibi AD1048-F-01-92[2].pdf	Form and Instruction
AD 1052 CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS AD-1052.pdf	Form and Instruction
Cover memo Summer Pilotsdoc.doc Justification Memo	IC Document
Summer Pilots OMB Justification 7-20-10.doc Supporting Statement	IC Document
SEBTC SNAP Model RFA July 19.docx RFA - SNAP	IC Document
SEBTC WIC Model RFA July 19.docx RFA - WIC	IC Document
SF424_2012.pdf SF 424	IC Document
sf424a-7-2010.pdf SF 424A	IC Document
SF_424B-_7-2010.pdf SF 424 B	IC Document
sflll.pdf SF LLL	IC Document
SF-425_(fillable).pdf SF 425	IC Document
SF 425 A.pdf SF 425 A	IC Document
SEBTC SNAP Model RFA (8-3-2010) track changes (4).docx RFA - SNAP (revised)	IC Document

IC Title:

Summer Food Pilot

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 42 USC 1766

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	AD 1047	Certification Regarding Debarment, Suspension, and Other	AD1047-F-01-92[1].pdf	No	Fillable Printable
Form and Instruction	AD 1048	Certification Regarding Debarment, Suspension, Ineligibility	AD1048-F-01-92[2].pdf	No	Fillable Printable
Form and Instruction	AD 1052	CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS	AD-1052.pdf	No	Fillable Printable

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14

Number of Respondents for Small Entity: 2

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	2,625	2,625
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification Memo	Cover memo Summer Pilotsdoc.doc	07/20/2010
Supporting Statement	Summer Pilots OMB Justification 7-20-10.doc	07/20/2010
RFA - SNAP	SEBTC SNAP Model RFA July 19.docx	07/20/2010
RFA - WIC	SEBTC WIC Model RFA July 19.docx	07/20/2010
SF 424	SF424_2012.pdf	07/20/2010
SF 424A	sf424a-7-2010.pdf	07/20/2010
SF 424 B	SF_424B-_7-2010.pdf	07/20/2010
SF LLL	sflll.pdf	07/20/2010
SF 425	SF-425_(fillable).pdf	07/20/2010
SF 425 A	SF 425 A.pdf	07/20/2010
RFA - SNAP (revised)	SEBTC SNAP Model RFA (8-3-2010) track changes (4).docx	08/03/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.