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IC 191564 under ICR 200912-0572-001 · OMB 0572-0146.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0572-0146 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD 1047 SEARCH	Form
AD 1047 Certification Regarding Debarment ad1047.pdf www.usda.gov/rus/water/wwforms.htm	Form
AD 1049 Certification for a Drug Free Workplace ad1049.pdf www.usda.gov/rus/water/wwforms.htm	Form and Instruction
AD 1048 Certification regarding Debarment AD1048.pdf www.usda.gov/rus/water/wwforms.htm	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	AD 1047	Certification Regarding Debarment	ad1047.pdf	http://www.usda.gov/rus/water/wwforms.htm	Yes	No	Fillable Printable
Form and Instruction	AD 1049	Certification for a Drug Free Workplace	ad1049.pdf	http://www.usda.gov/rus/water/wwforms.htm	Yes	No	Fillable Printable
Form and Instruction	AD 1048	Certification regarding Debarment	AD1048.pdf	http://www.usda.gov/rus/water/wwforms.htm	Yes	No	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 47

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	1,050	1,050
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.