Information Collection

Technical Assistance Program - American Indian Tribes

IC 193387 under ICR 201307-0572-003 · OMB 0572-0112.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0572-0112 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD 1047 Technical Assistance Program - American Indian Tribes	Form and Instruction
AD 1047 Certification Regarding Debarment AD 1047.pdf www.usda.gov/rus/water/wwforms.htm	Form and Instruction
AD 1048 Certification Regarding Debarment - Lower Tiered AD 1048.pdf www.usda.gov/rus/water/wwforms.htm	Form and Instruction
AD 1049 Certification for a Drug Free Workplace AD 1049.pdf www.usda.gov/rus/water/wwforms.htm	Form and Instruction

IC Title:

Technical Assistance Program - American Indian Tribes

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 7 CFR 1775

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 and Instruction	AD 1047	Certification Regarding Debarment	AD 1047.pdf	http://www.usda.gov/rus/water/wwforms.htm	Yes	No	Fillable Printable
Form and Instruction	AD 1048	Certification Regarding Debarment - Lower Tiered	AD 1048.pdf	http://www.usda.gov/rus/water/wwforms.htm	Yes	No	Fillable Printable
Form and Instruction	AD 1049	Certification for a Drug Free Workplace	AD 1049.pdf	http://www.usda.gov/rus/water/wwforms.htm	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: 20

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	279	-90	-7	376
Annual IC Time Burden (Hours)	981	-109	72	1,018
Annual IC Cost Burden (Dollars)	0	0	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.