Information Collection

Agriculture Innovation Centers

IC 1741 under ICR 201902-0570-002 · OMB 0570-0045.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0570-0045 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD 1047 Agriculture Innovation Centers	Form and Instruction
AD 1047 Certification Regarding Debarement, Suspension, and Othe AD-1047.pdf	Form and Instruction
AD 1048 Certification Regarding Debarement, Suspension, and Othe AD-1048.pdf	Form and Instruction
AD 1049 Certification Regarding Drug-Free Workplace Requirements AD-1049.pdf	Form and Instruction
RD 1940-1 Request for Obligation of Funds RD1940-0001.pdf	Form
RD 1942-46 Letter of Intent to Meet Conditons RD1942-0046.pdf	Form
RD 400-4 Assurance Agreement RD 400-4.pdf	Form
AD 3030 REPRESENTATIONS REGARDING FELONY CONVICTION AND TAX DELI AD-3030 REPRESENTATIONS REGARDING FELONY CONVICTION.pdf	Form
AD 3031 ASSURANCE REGARDING FELONY CONVICTION OR TAX DELINQUENT AD-3031 ASSURANCE REGARDING FELONY CONVICTION.pdf	Form
RD 4280-2 RURAL BUSINESS-COOPERATIVE SERVICE FINANCIAL ASSISTANCE RD 4280-2.pdf	Form

IC Title:

Agriculture Innovation Centers

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 7 CFR 4284-K (To search for a specific CFR, visit the Code of Federal Regulations.)

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 Debarement, Suspension, and Other Responsibility Matters	AD-1047.pdf	Yes	No	Fillable Printable
Form and Instruction	AD 1048	Certification Regarding Debarement, Suspension, and Other Responsibility Matters - Lower Tier	AD-1048.pdf	Yes	No	Fillable Printable
Form and Instruction	AD 1049	Certification Regarding Drug-Free Workplace Requirements	AD-1049.pdf	Yes	No	Fillable Printable
Form	RD 1940-1	Request for Obligation of Funds	RD1940-0001.pdf	Yes	No	Fillable Printable
Form	RD 1942-46	Letter of Intent to Meet Conditons	RD1942-0046.pdf	Yes	No	Fillable Printable
Form	RD 400-4	Assurance Agreement	RD 400-4.pdf	Yes	No	Fillable Printable
Form	AD 3030	REPRESENTATIONS REGARDING FELONY CONVICTION AND TAX DELINQUENT STATUS FOR CORPORATE APPLICANTS	AD-3030 REPRESENTATIONS REGARDING FELONY CONVICTION.pdf	Yes	No	Fillable Printable
Form	AD 3031	ASSURANCE REGARDING FELONY CONVICTION OR TAX DELINQUENT STATUS FOR CORPORATE APPLICANTS	AD-3031 ASSURANCE REGARDING FELONY CONVICTION.pdf	Yes	No	Fillable Printable
Form	RD 4280-2	RURAL BUSINESS-COOPERATIVE SERVICE FINANCIAL ASSISTANCE AGREEMENT	RD 4280-2.pdf	Yes	No	Fillable Printable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25

Number of Respondents for Small Entity: 1

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Farms, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 60 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	89	74	15
Annual IC Time Burden (Hours)	1,053	1,023	30
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.