USDA Forms (SLT)

Uniform Grant Application for Non-Entitlement Discretionary Grants

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0512 can be found here:

Documents and Forms

Document Name Document Type
Form AD-1047 USDA Forms (SLT) Form and Instruction
AD-1047 Certification Regarding Debarment, Suspension, and Other AD-1047 (Dec '15).pdf Form and Instruction
AD-1048 Certification Regarding Debarment, Suspension, Ineligibi AD-1047 (Dec '15).pdf Form and Instruction
AD-1049 Certification Regarding Drug-Free Workplace Requirements AD-1049 (Dec '15).pdf Form and Instruction
AD-1052 Certification Regarding Drug-Free Workplace, State and S AD-1052 (Dec '15).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	USDA Forms (SLT)	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	AD-1047	Certification Regarding Debarment, Suspension, and Other Responsibility Matters Primary Covered Transactions	AD-1047 (Dec '15).pdf	Yes	No	Fillable Fileable
Form and Instruction	AD-1048	Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions	AD-1047 (Dec '15).pdf	Yes	No	Fillable Fileable
Form and Instruction	AD-1049	Certification Regarding Drug-Free Workplace Requirements (Grants) Alternative I – For Grantees Other Than Individuals	AD-1049 (Dec '15).pdf	Yes	No	Fillable Fileable
Form and Instruction	AD-1052	Certification Regarding Drug-Free Workplace, State and State Agencies	AD-1052 (Dec '15).pdf	Yes	No	Fillable Fileable

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,197	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1,197	1,197
Annual IC Time Burden (Hours)	299	299
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.