| USDA - RUS |
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Title of Information Document |
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OMB No. |
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0572-0134 |
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| SUMMARY OF INFORMATION COLLECTION |
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Public Television Station Digital Transition |
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Date Prepared |
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Grant Program |
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2014 |
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| INSTRUCTIONS: |
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> |
(f) TOTAL |
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(h) TOTAL |
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(k) TOTAL |
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| Use this form when a single information collection document involves multiple reporting and |
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> |
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= (e) Average |
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= (g) Average |
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= (j) Average |
| recordkeeping requirements. |
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(d) TOTAL |
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(f) TOTAL |
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(i) TOTAL |
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| IDENTIFICATION OF REPORTING AND RECORDKEEPPING REQUIREMENTS |
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ANNUAL BURDEN |
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FORM |
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REPORTS |
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RECORDS |
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NO(s) |
NO. OF |
NO. OF |
TOTAL |
HOURS |
TOTAL |
NO. OF |
ANNUAL |
TOTAL |
| SECTION OF |
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(If "none" |
RESPON- |
RESPONSES |
ANNUAL |
PER |
HOURS |
RECORD- |
HOURS PER |
RECORD- |
| REGULATIONS |
DESCRIPTION |
so state) |
DENTS |
PER |
RESPONSES |
RESPONSE |
(Col. f & g) |
KEEPERS |
RECORD- |
KEEPING |
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RESPON- |
(Col. d & e) |
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KEEPER |
HOURS |
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DENT |
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(Col. i & j) |
| (a) |
(b) |
(c) |
(d) |
(e) |
(f) |
(g) |
(h) |
(i) |
(j) |
(k) |
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Items Cleared Under this Collection |
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Applicant Registration in "System for Award Management" (SAM) |
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30 |
1 |
30 |
1.00 |
30.00 |
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Application Package - Based on past submissions, the estimated 23 hours per response time to complete the application package covers all required written documentation set forth in the Application Guide including the following summary worksheet and certification forms found in the Tool Kit. |
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30 |
1 |
30 |
23.00 |
690.00 |
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-- Summary Worksheet |
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0.02 |
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Certifications are Mandatory -- Equal Opportunity and Nondiscrimination Certification |
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0.02 |
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-- Certificate Regarding Architectural Barriers |
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0.02 |
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-- Certificate Regarding Flood Hazard Area Precautions |
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0.02 |
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-- Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 Certification |
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0.02 |
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-- Certification Regarding Drug-Free Workplace Requirements Alternative I - for Grantees other than Individuals |
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0.25 |
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-- Certification Regarding Debarment, Suspension, and other Responsibility Matters -- Primary Covered Transactions |
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0.25 |
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Page _ 1_ |
of __ 2__ |
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-- Certification Regarding Lobbying for Contracts, Grants, Loans, and Cooperative Agreements |
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0.25 |
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-- Public Television Station Digital Transition Grant Program Environmental Questionnaire/Certification |
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0.06 |
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-- Federal Obligations Certification on Delinquent Debt |
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0.02 |
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--Survey on Ensuring Equal Opportunity for Applicants (approved under OMB 1894-0010) |
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0.08 |
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Grant Agreement |
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8 |
1 |
8 |
3.00 |
24.00 |
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Items Cleared Under Other Dockets |
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Application for Federal Assistance (common form approved under 4040-0004) |
SF-424 |
30 |
1 |
30 |
0.75 |
22.50 |
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Representations Regarding Felony Conviction and Tax Delinquent Status for Corporate Applicants (approved under OMB 0505-0025) |
AD-3030 |
30 |
1 |
30 |
0.25 |
7.50 |
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Total Hours This Collection |
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30 |
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68 |
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744.00 |
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| RUS Form 36 (07-91) |
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Page __2__ of __2__ |
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