Spreadsheet

USDA - RUS				Title of Information Document						OMB No.
				Rural e-Connectivity Pilot Program							0572-0152
SUMMARY OF INFORMATION COLLECTION				(ReConnect Program)						Date Prepared
											Sept. 2019
INSTRUCTIONS:						>	(f) TOTAL		(h) TOTAL		(k) TOTAL
Use this form when a single information collection document involves multiple reporting and						>	-	= (e) Average	-	= (g) Average	-	= (j) Average
recordkeeping requirements.						>	(d) TOTAL		(f) TOTAL		(i) TOTAL
IDENTIFICATION OF REPORTING AND RECORDKEEPPING REQUIREMENTS								ANNUAL BURDEN
				FORM			REPORTS				RECORDS
				NO(s)	NO. OF	NO. OF	TOTAL	HOURS	TOTAL	NO. OF	ANNUAL	TOTAL
	SECTION OF			(If "none"	RESPON-	RESPONSES	ANNUAL	PER	HOURS	RECORD-	HOURS PER	RECORD-
	REGULATIONS		DESCRIPTION	so state)	DENTS	PER	RESPONSES	RESPONSE	(Col. f & g)	KEEPERS	RECORD-	KEEPING
						RESPON-	(Col. d & e)				KEEPER	HOURS
	(a)					DENT						(Col. i & j)
Grants	Combos	Loans	(b)	(c)	(d)	(e)	(f)	(g)	(h)	(i)	(j)	(k)
			Items Cleared Under This Docket
			Applicant Information
			Funding Request	None	500	1	500	2.00
			Executive Summary	None	500	1	500	4.00	2,000
			Legal Opinion	None	500	1	500	2.00	1,000
			Organizational Charts	None	500	1	500	1.00	500
			Resumes of Key Management Personnel	None	500	1	500	1.00	500
			Broadband Operations Experience	None	500	1	1,000	1.00	1,000
			Proposed Funded Service Area Description	None	500	1	500	20.00	10,000
			Proposed Funded Service Area Map	None	500	1	500	30.00	15,000
			Subscriber Projections	None	500	1	500	10.00	5,000
			Competitive Analysis	None	500	1	500	8.00	4,000
			Network Design	None	500	1	500	40.00	20,000
			Licenses, Agreements, and Regulatory Approvals	None	500	1	500	10.00	5,000
			Summary and Itemized Budgets	None	500	1	500	20.00	10,000
			Pro Forma Financial Analysis	None	500	1	500	60.00	30,000
			Sources of Other Funding	None	500	1	500	2.00	1,000
	N/A	N/A	Matching Requirement (required for 100 percent grant request only)	None	250	1	250	2.00	500
			List of Outstanding and Contingent Obligations	None	500	1	500	2.00	1,000
			Historical Financial Statements	None	500	1	500	2.00	1,000
			Audited Financial Statements	None	500	1	500	2.00	1,000
			Evaluation Criteria	None	500	1	500	20.00	10,000
			Environmental Information	None	500	1	500	10.00	5,000
			State-funded Areas Certification	None	500	1	500	2.00	1,000
			Certification of Investor Compliance	None	500	1	500	1.00	500
N/A	N/A		Acquisition Agreement (applicable to 100 percent loan request only)	None	50	1	50	3.00	150
			Certification of Tribal Support (if applicable)	None	50	1	50	5.00	250
			Substantially Underserved Trust Area Application (if applicable)	None	50	1	50	30.00	1,500
			Evidence of Legal Existence	None	500	1	500	2.00	1,000
			Certificate Regarding Architectural Barriers	None	500	1	500	1.00	500
			Certification Regarding Debarment, Suspension, and Other Responsibility Matters – Primary Covered Transactions	None	500	1	500	1.00	500
			Certificate Regarding Flood Hazard Area Precautions	None	500	1	500	1.00	500
			Certification Regarding Lobbying for Contracts, Grants, Loans and Cooperative Agreements	None	500	1	500	1.00	500
			Civil Rights Compliance Certification	None	500	1	500	1.00	500
			Federal Collection Policies for Commercial Debt Certification	None	500	1	500	1.00	500
			Lobbying Certification for Loan Guarantees and Loan Insurance	None	500	1	500	1	500
			Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 Certification	None	500	1	500	1.00	500
			Public Notice Filing Information
			Public Notice Responses	None	500	3	6,000	1.50	9,000
			Recipient Information
			Updated Information for the Preparation of Legal Documents	None	165	1	165	10.00	1,650
			Execution of Legal Documents	None	165	1	165	5.00	825
			Evidence of Fidelity Bond Coverage	None	165	1	165	2.00	330
			Evidence of First Lien	None	165	1	165	4.00	660
			Semiannual Performance Reports	None	165	1	165	5.00	825
			Annual Audited Financial Statements	None	165	1	165	10.00	1,650
			Annual Service Area Maps and Progress Report	None	165	1	165	10.00	1,650
			Final Service Area Map and Accomplishments	None	165	1	165	16.00	2,640
Total burden hours for forms approved under this OMB Docket 0572-0152					500	47.44	23,720	6.41	152,130
			FORMS APPROVED UNDER OTHER OMB DOCKETS
			Forms approved under OMB Docket No.0505-0025
		5 U.S.C. 552(a), as amended	Representations Regarding Felony Conviction (AD 3030) - For Corporations Only	AD 3030	500	1	500	0.25	125
		5 U.S.C. 552(a), as amended	Assurance Regarding Felony Conviction or Tax Delinquent Status for Corporate Applicants (AD 3031)	AD 3031	500	1	500	0.05	25
			Forms approved under OMB Docket No. 0572-0059
			Construction Certification Program
			Engineering and Architectural Services
		1753	Postloan Engineering Service Contract	217	165	1	165	7.00	1,155
		Subpart B	● Approval of Postloan Engineering Service Contract
			The Postloan Eng. Serv. Contract incl. using the following forms:
			RUS Form 217a-Project Design, Assistance and Coordination:
			RUS Form 217b-Central Office Equipment Engineering Services;
			RUS Form 217c-Transmission Facilities Engineering Services;
			RUS Form 217d-Building Engineering Services;
			RUS Form 217e-Outside Plant Staking Services;
			RUS Form 217f-Outside Plant Contract Doc. Phase Engr. Servs.
			RUS Form 217g-Outside Plant Construction Phase Engr. Servs.
			RUS Form 216 - Construction Change Order	216	165	1	200	1.00	200
			RUS Form 526 – Construction Contract Amendment	526	165	1	200	3.00	600
			RUS Form 270 - Equal Opportunity Addendum	270	165	1	200	0.15	30
			Miscellaneous Engineering Services Forms
		1753.15,	Engineering Service Contract - Special Services - Telephone	245	165	1	165	0.75	124
		81	● Engineering services for minor construction may be
			contracted using Form 245 (This contract form does not
			require RUS approval).
		175349	Tabulation of Materials Furnished by Borrower
			● Closeout of major outside plans construction by contract.	281	165	4	660	2.00	1,320
		1753.8(b)	Subcontracts (Under Construction or Equipment)
			● Approval of subcontracts (per 1753.8(b))	282	165	2	330	0.75	248
		1753.16	Certificate of Architect
			● Approval of final statement of cost-architectural services	284	165	1	165	0.50	83
		1753.17	Statement of Engineering Fees - Telecommunications
			● Estimates	506	165	1	165	6.00	990
		1753.17	● Final		165	1	165	6.00	990
			Major Outside Plant Construction
			Telephone System Construction Contract (Labor and Materials)
		1753.47	● Approval of plans and specifications for major outside	515
			plant construction by contract		165	1	165	4.00	660
		1753.48	● Approval of the outside plant contract		165	1	165	6.00	990
		1753.48	● Owner-Furnished Materials -Info. Included under RUS Form 787 below
		1753.48	● Approval of negotiated contracts		165	1	165	2.00	330
			Miscellaneous Outside Plant Construction Forms
		1753.49	Final Inventory, Telephone Construction Contract
			(Labor and Materials)	724	165	2	330	0.75	248
			● Closeout of major outside plant construction by contract
		1753.49	Final Inventory, Telephone Construction Contract
			(Labor and Materials) - Detailed	724a	165	2	330	3.00	990
			● Tabulation of Assembly Units
		1753.49	Final Inventory, Telephone Construction Contract
			(Labor and Materials) - Detailed	724b	165	2	330	0.75	248
			● Removals
		1753.18	Contract Closeout Certification	756	165	1	165	0.50	83
		1753.81-82	Summary of Work Order
			Inspection by licensed Engineer or Borrower's Staff Engineer	771a	165	2	330	0.50	165
		1753	Miscellaneous Construction Work and Maintenance
			Service Contract	773
			● Issued for minor construction by contract		165	2	330	3.00	990
		1753.48 (f)	Supplement A to Construction Contract RUS Form 515	787	165	5	825	0.25	206
			● Approval for the borrower to furnished materials for outside
			plant construction by contract
		1753.15	Preloan Engineering Service Contract, Telephone
		(a)(2)	System Design	835	165	1	165	0.75	124
			Forms approved under OMB Docket No. 0572-0149
		1753	Equipment Contract	395	165	2	330	1.50	495
		Subpart E, H
		1753.37, 38,	Certificate of Completion, Equipment Contract	395a	165	1	165	0.50	83
		39, 68	(Including Installation)
		1753.37, 38,	Certificate of Completion, Equipment Contract	395b	165	1	165	0.50	83
		39, 68	(Not Including Installation)
			Forms approved under OMB Docket No. 0572-0107
		1753, 1788	Contractor's Bond	168b	165	2	330	0.02	5.3
		1753.30	Certificate of Completion - Contract Construction for Building	181	165	1	165	0.10	17
			Closeout of Contract Form 257 for Building Construction.
		1753	Certificate ("Buy American")	213	165	1	0	0.02	0.0
			RUS Form 224 -Waiver and Release	224	165	1	200	0.01	2.0
			RUS Form 743 - Certificate of Contractor and Indemnity Agreement	743	165	1	200	0.01	2.0
		1753.30,	Certificate of Contractor	231	165	1	0	0.02	0.0
		39, 49
		1753.11,	Construction or Equipment Contract Amendment	238	165	2	0	0.02	0.0
		28, 38, 68
		1753	Contract to Construct Building	257	165	1	0	0.08	0.0
		Subpart D
			Bid Bond	307	165	2	0	0.02	0.0
			Form approved under OMB Docket No. 0572-0023
		1744.66	Financial Requirements Statement	481	165	3	495	2.00	990
			Form approved under OMB Docket No. 0572-0074
		1744.66	Certification of Authority	675	165	2	330	0.10	33
			Form approved under OMB Docket No. 0572-0118
		Subpart B	Architectural Services Contract	220	165	1	165	1.00	165
			Form approved under OMB Docket No. 0572-0142
		1773.4	Selection of CPA	n/a	165	1	165	0.25	41
		1773	Submission of Auditor's Report	n/a	165	1	165	11.00	1,815
			Plan of Corrective Action	n/a	165	1	165	0.25	41
			Submission of Peer Review Reports	n/a	165	1	165	0.25	41
			Scope Limitation	n/a	165	1	165	0.25	41
			Irregularities	n/a	30	1	30	2.00	60
			Quartertly Submission of Financial Information through BCAS	n/a	165	4	660	4.00	2,640
		1770	Index of Records and Recordkeeping	n/a	165	1	165	2.00	330
		Subpart A
		1770	GAAP System of Accounts	n/a						165	24	3,960
		Subpart B
		Total burden hours for forms approved under other OMB Dockets			165	60	9,940	1.78	17,655.0	165		3,960
											Page __1__ of __1__
							Annual Burden Hours		152,130
							Record Keeping Hours		3,960
			TOTAL ANNUAL BURDEN AND RECORDKEEPING HOURS				Total Burden Hours		156,090
RUS Form 36 (07-91)