Information Collection

State and Local Governments

IC 209668 under ICR 201312-0572-001 · OMB 0572-0150.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0572-0150 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD-1047 State and Local Governments	Form
AD-1047 Certificate Regarding Debarment AD1047-F-01-92.docx www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Form
AD-1048 Certification Regarding Debarment, Suspension and other AD1048-F-01-92.docx www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Form
AD-1049 Certification Regarding Drug-Free Workplace Requirements AD1049-F-05-90.docx www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Form
RD Instruction 194 Certification for Contracts, Grants, and Loans RD Instruction 1940Q A-1.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form and Instruction
RD 400-1 Equal opportunity Agreement RD400-1.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
RD 400-4 Assurance Agreement RD400-4.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
RD 442-2 Statement of Budget, Income and Equity RD442-2.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form and Instruction
RD 442-3 Balance Sheet RD442-3.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
RD 442-7 Operating Budget RD442-7.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
RD 442-22 Opinion of Counsel Regarding Right of Way RD442-22.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
RD 1942-19 Agreement for Engineering Services RD1942-19.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
RD 1942-46 Letter of Intent to Meet Conditions RD1942-46.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
SF 424 Application for Federal Assistance SF424.pdf apply07.grants.gov/apply/forms/sample/SF424_2_1-V2.1.pdf	Form and Instruction
SF424C_.pdf Budget Information	IC Document
SF424D.pdf Assurances - Construction Programs	IC Document
SFLLL.pdf Disclosure of Lobbying Acitivites	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

State and Local Governments

Agency IC Tracking Number:

0572

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	Certificate Regarding Debarment	AD1047-F-01-92.docx	http://www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Yes	No	Fillable Printable
Form	AD-1048	Certification Regarding Debarment, Suspension and other Responsibility Matters - Lower Tier Covered Transactions.	AD1048-F-01-92.docx	http://www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Yes	No	Fillable Printable
Form	AD-1049	Certification Regarding Drug-Free Workplace Requirements (Grrants) Alternative I - for Grantees Other Than Individuals	AD1049-F-05-90.docx	http://www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Yes	No	Fillable Printable
Form and Instruction	RD Instruction 1940Q A-1	Certification for Contracts, Grants, and Loans	RD Instruction 1940Q A-1.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 400-1	Equal opportunity Agreement	RD400-1.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 400-4	Assurance Agreement	RD400-4.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form and Instruction	RD 442-2	Statement of Budget, Income and Equity	RD442-2.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 442-3	Balance Sheet	RD442-3.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 442-7	Operating Budget	RD442-7.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 442-22	Opinion of Counsel Regarding Right of Way	RD442-22.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 1942-19	Agreement for Engineering Services	RD1942-19.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 1942-46	Letter of Intent to Meet Conditions	RD1942-46.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form and Instruction	SF 424	Application for Federal Assistance	SF424.pdf	http://apply07.grants.gov/apply/forms/sample/SF424_2_1-V2.1.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	724	724
Annual IC Time Burden (Hours)	753	753
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Budget Information	SF424C_.pdf	12/12/2013
Assurances - Construction Programs	SF424D.pdf	12/12/2013
Disclosure of Lobbying Acitivites	SFLLL.pdf	12/12/2013

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