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State and Local Governments
The Rural Alaska Village Grant (RAVG) Program
OMB: 0572-0150
IC ID: 209668
OMB.report
USDA/RUS
OMB 0572-0150
ICR 201809-0572-001
IC 209668
( )
⚠️ Notice: This information collection may be referencing outdated material.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
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:
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
207
0
0
0
0
207
Annual IC Time Burden (Hours)
281
0
0
0
0
281
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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, “Budget Information--Non-Construction Programs
SF424A-V1.0.pdf
09/05/2018
SF-424B, “Assurances--Non-construction Programs
SF424B-V1.1.pdf
09/05/2018
RUS Form 266 “Compliance 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.