Information Collection

New Equipment Contract (Form 395) for Telecommunications and Broadband Borrowers

IC 210082 under ICR 201401-0572-003 · OMB 0572-0149.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0572-0149 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 395a New Equipment Contract (Form 395) for Telecommunications and Broadband Borrowers	Form
AD 1048 Certification Regarding Debarment, Suspension, Ineligibi AD1048-F-01-92.pdf www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Form
395 Equipment Contract Form 395 (Third Party-Rider-09-18-13)1-2-14.docx www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Form
395a Certificate of Completion (Equipment Contract Including Form 395a(04-11-12) (2).docx www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Form
395b Certificate of COmpletion (Equipment Contract Not Includ Form 395b(04-11-12) 1-2-14.docx www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Form
395c Cetificate of Contractor and Indemnity Form 395c(04-11-12) (2) 1-2-14.docx www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Form
395d Results of Acceptance Test Form 395d(04-11-12) 1-2-13.docx www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Form

IC Title:

New Equipment Contract (Form 395) for Telecommunications and Broadband Borrowers

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 7 CFR 1755 7 CFR 1753

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	395a	Certificate of Completion (Equipment Contract Including Installation)	Form 395a(04-11-12) (2).docx	http://www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Yes	No	Fillable Fileable
Form	395b	Certificate of COmpletion (Equipment Contract Not Including Installation)	Form 395b(04-11-12) 1-2-14.docx	http://www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Yes	No	Fillable Fileable
Form	395c	Cetificate of Contractor and Indemnity	Form 395c(04-11-12) (2) 1-2-14.docx	http://www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Yes	No	Fillable Fileable
Form	395d	Results of Acceptance Test	Form 395d(04-11-12) 1-2-13.docx	http://www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Yes	No	Fillable Fileable
Form	AD 1048	Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclsion - Lower Tier Covered Transactions	AD1048-F-01-92.pdf	http://www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Yes	No	Fillable Fileable
Form	395	Equipment Contract	Form 395 (Third Party-Rider-09-18-13)1-2-14.docx	http://www.rurdev.usda.gov/UP_ETPW_Forms.html#Telecom	Yes	No	Fillable Fileable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 279

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	1,407	1,407
Annual IC Time Burden (Hours)	890	890
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.