State, Local & Tribal Governments (Public Bodies)

Community Facilities Technical Assistance and Training Grant Program

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.