Information Collection

State and Local Governments

IC 209668 under ICR 201809-0572-001 · OMB 0572-0150.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0572-0150 can be found here:

2022-02-22 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD-1047 State and Local Governments	Form
AD-1047 Certificate Regarding Debarment AD-1047 (Dec '15).pdf www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Form
AD-1048 Certification Regarding Debarment, Suspension and other AD-1048 (Dec '15).pdf www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Form
AD-1049 Certification Regarding Drug-Free Workplace Requirements AD-1049 (Dec '15).pdf www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Form
RD Instruction 194 Certification for Contracts, Grants, and Loans RD Instruction 1940Q A-1.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form and Instruction
RD 400-1 Equal opportunity Agreement RD400-1.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
RD 400-4 Assurance Agreement RD400-4.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
RD 442-22 Opinion of Counsel Regarding Right of Way RD0442-0022.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
RD 1942-46 Letter of Intent to Meet Conditions RD1942-46.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
SF 424 Application for Federal Assistance SF424 FORM AND INSTRUCTION.pdf apply07.grants.gov/apply/forms/sample/SF424_2_1-V2.1.pdf	Form and Instruction
RUS Bulletin 1780- RUS Bulletin 1780-12 RUS_Bulletin_1780-12.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form and Instruction
RAVG ANTHC Grant Agreement RAVG ANTHC Grant Agreement FINAL.doc www.rurdev.usda.gov/FormsAndPublications.html	Form
RAVG SOA Grant Agreement RAVG SOA Grant Agreement FINAL.docx www.rurdev.usda.gov/FormsAndPublications.html	Form
SF424C_2_0-V2.0 (1).pdf Budget Information	IC Document
Individual_SF424D-V1.1.pdf Assurances - Construction Programs	IC Document
SFLLL_1_2-V1.2.pdf Disclosure of Lobbying Acitivites	IC Document
SF424A-V1.0.pdf SF-424A, “Budget Information--Non-Construction Programs	IC Document
SF424B-V1.1.pdf SF-424B, “Assurances--Non-construction Programs	IC Document
UP_ET_form_266.pdf RUS Form 266 “Compliance Assurance	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

State and Local Governments

Agency IC Tracking Number:

0572

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 7 CFR 1784

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	Certificate Regarding Debarment	AD-1047 (Dec '15).pdf	http://www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Yes	No	Fillable Printable
Form	AD-1048	Certification Regarding Debarment, Suspension and other Responsibility Matters - Lower Tier Covered Transactions.	AD-1048 (Dec '15).pdf	http://www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Yes	No	Fillable Printable
Form	AD-1049	Certification Regarding Drug-Free Workplace Requirements (Grrants) Alternative I - for Grantees Other Than Individuals	AD-1049 (Dec '15).pdf	http://www.ocio.usda.gov/policy-directives-records-forms/forms-management/approved-computer-generated-forms	Yes	No	Fillable Printable
Form and Instruction	RD Instruction 1940Q A-1	Certification for Contracts, Grants, and Loans	RD Instruction 1940Q A-1.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 400-1	Equal opportunity Agreement	RD400-1.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 400-4	Assurance Agreement	RD400-4.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 442-22	Opinion of Counsel Regarding Right of Way	RD0442-0022.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 1942-46	Letter of Intent to Meet Conditions	RD1942-46.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form and Instruction	SF 424	Application for Federal Assistance	SF424 FORM AND INSTRUCTION.pdf	http://apply07.grants.gov/apply/forms/sample/SF424_2_1-V2.1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	RUS Bulletin 1780-12	RUS Bulletin 1780-12	RUS_Bulletin_1780-12.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	None	RAVG ANTHC Grant Agreement	RAVG ANTHC Grant Agreement FINAL.doc	http://www.rurdev.usda.gov/FormsAndPublications.html	No		Fillable Printable
Form	None	RAVG SOA Grant Agreement	RAVG SOA Grant Agreement FINAL.docx	http://www.rurdev.usda.gov/FormsAndPublications.html	No		Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

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	Previously Approved
Annual Number of Responses for this IC	207	207
Annual IC Time Burden (Hours)	281	281
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Budget Information	SF424C_2_0-V2.0 (1).pdf	09/05/2018
Assurances - Construction Programs	Individual_SF424D-V1.1.pdf	09/05/2018
Disclosure of Lobbying Acitivites	SFLLL_1_2-V1.2.pdf	09/05/2018
SF-424A, âBudget Information--Non-Construction Programs	SF424A-V1.0.pdf	09/05/2018
SF-424B, âAssurances--Non-construction Programs	SF424B-V1.1.pdf	09/05/2018
RUS Form 266 âCompliance Assurance	UP_ET_form_266.pdf	09/05/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.