Information Collection

USDA Forms (SLT)

IC 219847 under ICR 201711-0584-002 · OMB 0584-0512.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

USDA Forms (SLT)

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

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 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 â 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 %

table that charts list of burden
	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

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.