Information Collection

non-profit / private sector

IC 209670 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⚠️ Notice: This information collection may be referencing outdated material.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 non-profit / private sector	Form
AD -1047 Certification Regarding Debarment AD-1047 2018.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
AD- 1048 Certification Regarding Debarment, Suspension, Ineligibi AD-1048 2018.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
AD - 1049 Certification Regarding Drug-Free Workplace AD-1049 2018.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
RD Instruction 194 Certification for Contracts, Grants and Loans REgarding RD Instruction 1940Q A-1 2018.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form and Instruction
RD 400-1 Equal Opportunity Agreement RD400-1 2018.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
RD 400-4 Assurance Agreement RD 400-4 2018.PDF www.rurdev.usda.gov/FormsAndPublications.html	Form
RD 442-22 Opinion of COunsel relative to RIght-of-Way & Easments RD0442-0022 2018.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
RD 1942-46 Letter of Intent to Meet Conditions RD1942-46 2018.pdf www.rurdev.usda.gov/FormsAndPublications.html	Form
SF 424 Application for Federal Assistance SF424 FORM AND INSTRUCTION.pdf www.grants.gov	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 SOA Grant Agreement RAVG SOA Grant Agreement FINAL.docx www.rurdev.usda.gov/FormsAndPublications.html	Form
RAVG ANTHC Grant Agreement RAVG ANTHC Grant Agreement FINAL.doc www.rurdev.usda.gov/FormsAndPublications.html	Form
SF424C_2_0-V2.0 (1).pdf SF 424C - Budget Information - Construciton Programs	IC Document
SF424D-V1.1 2018.pdf SF 424D - Assurances - Construction Programs	IC Document
SFLLL_1_2-V1.2 2018.pdf SF LLL - Disclosure of Lobbying Activities	IC Document
SF424A-V1.0 2018.pdf SF-424A, “Budget Information--Non-Construction Programs	IC Document
SF424B-V1.1 2018.pdf SF-424B, “Assurances--Non-construction Programs	IC Document
UP_ET_form_266 2018.pdf RUS Form 266 “Compliance Assurance	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

non-profit / private sector

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	Certification Regarding Debarment	AD-1047 2018.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	AD- 1048	Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Transaction	AD-1048 2018.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	AD - 1049	Certification Regarding Drug-Free Workplace	AD-1049 2018.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form and Instruction	RD Instruction 1940Q A-1	Certification for Contracts, Grants and Loans REgarding Lobbying	RD Instruction 1940Q A-1 2018.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 400-1	Equal Opportunity Agreement	RD400-1 2018.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 400-4	Assurance Agreement	RD 400-4 2018.PDF	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 442-22	Opinion of COunsel relative to RIght-of-Way & Easments	RD0442-0022 2018.pdf	http://www.rurdev.usda.gov/FormsAndPublications.html	Yes	No	Fillable Printable
Form	RD 1942-46	Letter of Intent to Meet Conditions	RD1942-46 2018.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://www.grants.gov	Yes	No	Fillable Printable
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 SOA Grant Agreement	RAVG SOA Grant Agreement FINAL.docx	http://www.rurdev.usda.gov/FormsAndPublications.html	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

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: 10

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	138	138
Annual IC Time Burden (Hours)	188	188
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SF 424C - Budget Information - Construciton Programs	SF424C_2_0-V2.0 (1).pdf	09/05/2018
SF 424D - Assurances - Construction Programs	SF424D-V1.1 2018.pdf	09/05/2018
SF LLL - Disclosure of Lobbying Activities	SFLLL_1_2-V1.2 2018.pdf	09/05/2018
SF-424A, âBudget Information--Non-Construction Programs	SF424A-V1.0 2018.pdf	09/05/2018
SF-424B, âAssurances--Non-construction Programs	SF424B-V1.1 2018.pdf	09/05/2018
RUS Form 266 âCompliance Assurance	UP_ET_form_266 2018.pdf	09/05/2018

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