Information Collection

Annual Representations and Certification

IC 217811 under ICR 201505-3037-001 · OMB 3037-0013.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3037-0013 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Reps and Certs Annual Representations and Certification	Form and Instruction
Reps and Certs Annual Reps and Certs Annual Reps and Certs Form 7_27_15.doc	Form and Instruction
Supporting Statement annual reps and certs.docx Supporting Document	IC Document
Public Comment.docx Public Comments	IC Document
Reps Certs Fact Sheet.docx Fact Sheets	IC Document

IC Title:

Annual Representations and Certification

Agency IC Tracking Number:

0013

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 41 CFR 51-4.3 (To search for a specific CFR, visit the Code of Federal Regulations.)

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	Reps and Certs	Annual Reps and Certs	Annual Reps and Certs Form 7_27_15.doc		Yes	No	Printable Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: Annual Representations and Certification

FR Citation: 80 FR 27930

Number of Respondents: 559

Number of Respondents for Small Entity: 559

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	559	559
Annual IC Time Burden (Hours)	4,472	4,472
Annual IC Cost Burden (Dollars)	178,880	178,880

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Document	Supporting Statement annual reps and certs.docx	08/10/2015
Public Comments	Public Comment.docx	08/10/2015
Fact Sheets	Reps Certs Fact Sheet.docx	08/10/2015

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