Information Collection

7 CFR 1776, "Household Water Well System Grant Program"

IC 1889 under ICR 201710-0572-001 · OMB 0572-0139.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0572-0139 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD-1047 7 CFR 1776, "Household Water Well System Grant Program"	Form
AD-1047 Certification Regarding Debarment-Primary AD-1047 (Dec '15).pdf www.ocio.usda.gov/document/ad-1047	Form
AD-1048 Certification Regarding Debarment AD_1048-V1.0.pdf www.ocio.usda.gov/document/ad-1048	Form
AD-1049 Certification Regarding Drug-Free Workplace Requirements AD_1049-V1.0.pdf www.ocio.usda.gov/document/ad-1049	Form

IC Title:

7 CFR 1776, "Household Water Well System Grant Program"

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 7 CFR 1776

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	AD-1047	Certification Regarding Debarment-Primary	AD-1047 (Dec '15).pdf	https://www.ocio.usda.gov/document/ad-1047	Yes	No	Fillable Printable
Form	AD-1048	Certification Regarding Debarment	AD_1048-V1.0.pdf	https://www.ocio.usda.gov/document/ad-1048	Yes	No	Fillable Printable
Form	AD-1049	Certification Regarding Drug-Free Workplace Requirements	AD_1049-V1.0.pdf	https://www.ocio.usda.gov/document/ad-1049	Yes	No	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7

Number of Respondents for Small Entity: 5

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	146	139	7
Annual IC Time Burden (Hours)	770	-6	776
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.