Information Collection

Energy Audit and Energy Assistance - State and Local

IC 188029 under ICR 201412-0570-004 · OMB 0570-0059.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0570-0059 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD 1049 Energy Audit and Energy Assistance - State and Local	Form
Instructions for RD 4280-2.docx	Instruction
AD 1047 Certification Regarding Debarment, Suspension, and Other AD1047-F-01-92.pdf	Form
AD 1048 Certification Regarding Debarment, Suspension, Ineligibi AD1048-F-01-92.pdf	Form
AD 1049 Certification Regarding Drug-Free Workplace Requirements AD1049-F-05-90.pdf	Form
RD 1940-1 Request for Obligation of Funds RD1940-0001_080700V04.pdf	Form
RD 400-4 Assurance Agreement RD0400-0004_100600V03.pdf	Form
RD 1942-46 Letter of Intent RD1942-0046_100600V01.pdf	Form
RD 4280-2 Rural Business and Cooperative Service Grant Agreement RD4280-0002_110800V04.pdf	Form

IC Title:

Energy Audit and Energy Assistance - State and Local

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	AD 1049	Certification Regarding Drug-Free Workplace Requirements (Grants) Alternative I	AD1049-F-05-90.pdf	Yes	Yes	Fillable Printable
Form	RD 1940-1	Request for Obligation of Funds	RD1940-0001_080700V04.pdf	Yes	Yes	Fillable Printable
Form	RD 400-4	Assurance Agreement	RD0400-0004_100600V03.pdf	Yes	Yes	Fillable Printable
Form	RD 1942-46	Letter of Intent	RD1942-0046_100600V01.pdf	Yes	Yes	Fillable Printable
Form	RD 4280-2	Rural Business and Cooperative Service Grant Agreement	RD4280-0002_110800V04.pdf	Yes	No	Fillable Printable
Instruction			Instructions for RD 4280-2.docx	No		Printable Only
Form	AD 1047	Certification Regarding Debarment, Suspension, and Other Responsibility Matters ï¿½ Primary Covered Transactions	AD1047-F-01-92.pdf	Yes	Yes	Fillable Printable
Form	AD 1048	Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion ï¿½ Lower Tier Covered Transactions	AD1048-F-01-92.pdf	Yes	Yes	Fillable Printable

Line of Business: Energy

Subfunction: Energy Production

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	219	-110	329
Annual IC Time Burden (Hours)	512	67	445
Annual IC Cost Burden (Dollars)	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.