Information Collection

State, Local & Tribal Governments (Public Bodies)

IC 219233 under ICR 201606-0575-003 · OMB 0575-0198.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0575-0198 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD 1047 State, Local & Tribal Governments (Public Bodies)	Form
AD 1047 Certification Regarding Debarment, Suspension, and Other AD-1047.pdf	Form
AD 1048 Certification Regarding Debarment, Suspension, Ineligibi AD-1048.pdf	Form
AD 1049 Certification Regarding Drug Free Workplace Requirements AD-1049.pdf	Form
RD 400-1 Equal Opportunity Agreement RD0400-0001.pdf	Form
RD 400-4 Assurance Agreement RD0400-0004.pdf	Form
RD 3570-4 Community Facilities Technical Assistance and Training G FormRD3570-04_915.doc	Form

IC Title:

State, Local & Tribal Governments (Public Bodies)

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 1047	Certification Regarding Debarment, Suspension, and Other Responsibility Matters	AD-1047.pdf	Yes	No	Fillable Printable
Form	AD 1048	Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion	AD-1048.pdf	Yes	No	Fillable Printable
Form	AD 1049	Certification Regarding Drug Free Workplace Requirements	AD-1049.pdf	Yes	No	Fillable Printable
Form	RD 400-1	Equal Opportunity Agreement	RD0400-0001.pdf	Yes	No	Fillable Printable
Form	RD 400-4	Assurance Agreement	RD0400-0004.pdf	Yes	No	Fillable Printable
Form	RD 3570-4	Community Facilities Technical Assistance and Training Grant Agreement	FormRD3570-04_915.doc	Yes	No	Fillable Printable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

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
	Approved	Previously Approved
Annual Number of Responses for this IC	630	630
Annual IC Time Burden (Hours)	1,119	1,119
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.