Information Collection

Public/Tribal

IC 181552 under ICR 201804-0575-001 · OMB 0575-0180.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0575-0180 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD-1047 Public/Tribal	Form
AD-1047 Certification Regarding Debarrment, etc. AD_1047-V1.0.pdf	Form
AD-1048 Certification Regarding Debarrment, etc. - Lower Tier AD_1048-V1.0.pdf	Form
AD-1049 Certification for Drug-Free Workplace AD_1049-V1.0.pdf	Form
RD 400-1 Equal Opportunity Agreement rd 400-1.pdf	Form
RD 400-4 Assurance Agreement rd 400-4.pdf	Form
RD 442-2 Statement of Budget, Income and Equity RD0442-0002_970900 V04.pdf	Form
RD 442-3 Balance Sheet rd 442-3.pdf	Form
AD 3030 Representations Regarding Felony Conviction and Tax Deli AD_3030_1_1-V1.1.pdf	Form

IC Title:

Public/Tribal

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 Debarrment, etc.	AD_1047-V1.0.pdf	Yes	No	Fillable Printable
Form	AD-1048	Certification Regarding Debarrment, etc. - Lower Tier	AD_1048-V1.0.pdf	Yes	No	Fillable Printable
Form	AD-1049	Certification for Drug-Free Workplace	AD_1049-V1.0.pdf	Yes	No	Fillable Printable
Form	RD 400-1	Equal Opportunity Agreement	rd 400-1.pdf	Yes	No	Fillable Printable
Form	RD 400-4	Assurance Agreement	rd 400-4.pdf	Yes	No	Fillable Printable
Form	RD 442-2	Statement of Budget, Income and Equity	RD0442-0002_970900 V04.pdf	Yes	No	Fillable Printable
Form	RD 442-3	Balance Sheet	rd 442-3.pdf	Yes	No	Fillable Printable
Form	AD 3030	Representations Regarding Felony Conviction and Tax Delinquent Status for Coporate Applicants	AD_3030_1_1-V1.1.pdf	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: 9

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	364	-76	440
Annual IC Time Burden (Hours)	455	-101	556
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.