Summer Food Pilot

Uniform Grant Application for Non-Entitlement Discretionary Grants

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Summer Food Pilot	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 42 USC 1766

Information Collection 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 %

	Requested	Previously Approved
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

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.