| USDA - RUS |
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Title of Information Document |
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OMB No. |
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0572-0139 |
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| SUMMARY OF INFORMATION COLLECTION |
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Date Prepared |
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7 CFR 1776 Household Water System Program |
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October, 2017 |
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| INSTRUCTIONS: |
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> |
(f) TOTAL |
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(h) TOTAL |
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(k) TOTAL |
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| Use this form when a single information collection document involves multiple reporting and |
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> |
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= (e) Average |
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= (g) Average |
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= (j) Average |
| recordkeeping requirements. |
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(d) TOTAL |
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(f) TOTAL |
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(i) TOTAL |
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| IDENTIFICATION OF REPORTING AND RECORDKEEPPING REQUIREMENTS |
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ANNUAL BURDEN |
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FORM |
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REPORTS |
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RECORDS |
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NO(s) |
NO. OF |
NO. OF |
TOTAL |
HOURS |
TOTAL |
NO. OF |
ANNUAL |
TOTAL |
| SECTION OF |
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(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 |
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RESPON- |
(Col. d & e) |
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KEEPER |
HOURS |
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DENT |
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(Col. i & j) |
| (a) |
(b) |
(c) |
(d) |
(e) |
(f) |
(g) |
(h) |
(i) |
(j) |
(k) |
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Items Cleared With This Package (by regulation reference) |
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Initial Application/Application Processing |
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| 1776.2 and RD Inst. 1900-D |
Identify Employee Relationship |
Written |
6 |
1 |
6 |
0.25 |
1.50 |
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| 1776.5 |
Organizational Documents-Evidence of Legal Existence and Authority |
Written |
6 |
1 |
6 |
0.25 |
1.50 |
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| 1776.5 |
List of Directors and Officers |
Written |
6 |
1 |
6 |
0.25 |
1.50 |
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| 1776.5 |
Evidence of Tax Exempt Status |
Written |
6 |
1 |
6 |
0.25 |
1.50 |
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| 1776.7 (b) |
Work Plan (Project Proposal, Work Plan, and Budget Justification) |
Written |
6 |
1 |
6 |
80.00 |
480.00 |
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| 1776.7(c) |
Statement of Experience |
Written |
6 |
1 |
6 |
4.00 |
24.00 |
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| 1776.9 (d) (1) |
Pro-forma Balance Sheet |
Written |
6 |
1 |
6 |
4.00 |
24.00 |
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| 1776.7 (d) (2) |
Prior year Audit / Financial Statement |
Written |
6 |
1 |
6 |
0.25 |
1.50 |
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| 1776.7 (d) (3) |
Pro-forma Income Statement and Cash Flow |
Written |
6 |
1 |
6 |
4.00 |
24.00 |
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Post Application |
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| 1776.2, 3019.26 and 3052 |
Annual Audit / Financial Statement |
Written |
5 |
1 |
5 |
0.25 |
1.25 |
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| 1776.2 and 3019.51 |
Project Performance Report |
Written |
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Initial |
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6 |
4 |
24 |
2.00 |
48.00 |
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Extension |
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4 |
4 |
16 |
2.00 |
32.00 |
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| 1776.2 and 3019.25 |
Request written approval of workplan changes |
Written |
4 |
1 |
4 |
2.00 |
8.00 |
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| 1776.10 |
Grant Agreement |
Written |
6 |
1 |
6 |
2.00 |
12.00 |
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| 1776.2 and 3017.335 |
Cert. Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered Transactions (Cleared under 0505-0027) |
AD 1047 |
7 |
1 |
7 |
0.25 |
1.75 |
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| 1776.2 and 3017.335 |
Cert. Regarding Debarment, Suspension, and other Responsibility Matters- Lower Tier Transactions (Cleared under 0505-0027) |
AD 1048 |
7 |
1 |
7 |
0.25 |
1.75 |
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| 1776.2 and 3021.23 |
Cert. Regarding Drug-Free Workplace Requirements (Grants) Alternative I - for Grantees Other Than Individuals (Cleared under 0505-0027) |
AD 1049 |
7 |
1 |
7 |
0.25 |
1.75 |
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Total for this Package |
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7 |
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130.00 |
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666.00 |
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Items Cleared Under Other Packages (by form number) |
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| 1776.2 |
Equal Opportunity Agreement (Cleared under 0575-0018) |
RD 400-1 |
6 |
1 |
6 |
0.17 |
1.02 |
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| 1776.2 |
Assurance Agreement (Cleared under 0575-0018) |
RD 400-4 |
6 |
1 |
6 |
0.25 |
1.50 |
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| 1776.2 and 3018.11 |
Disclosure of Lobbying Activities-(Cleared under 4040-0013) |
SF-LLL |
6 |
1 |
6 |
0.25 |
1.50 |
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| 1776.2 and 3019.22 |
Request for Advance or Reimbursement - (Cleared under 4040-0012) |
SF 270 |
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Initial |
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6 |
12 |
72 |
1.00 |
72.00 |
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Extension |
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6 |
12 |
72 |
1.00 |
72.00 |
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| 1776.7 (a)(1) |
Application for Federal Assistance (Cleared under 4040-0004) |
SF-424 |
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Initial |
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6 |
1 |
6 |
0.75 |
4.50 |
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Revised |
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6 |
1 |
6 |
0.75 |
4.50 |
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| 1776.9(a)(2) |
Budget Information - (Cleared under 4040-0006) |
SF-424A |
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Initial |
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6 |
1 |
6 |
3.00 |
18.00 |
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Revised |
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6 |
1 |
6 |
3.00 |
18.00 |
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| 1776.9(a)(3) |
Assurances - Non Construction Programs - (Cleared under 4040-0007) |
SF-424B |
6 |
1 |
6 |
0.25 |
1.50 |
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| 1776.2 and 3019.52 |
Federal Financial Report - (Cleared under 4040-0014) |
SF-425 |
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Initial |
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6 |
4 |
24 |
1.50 |
36.00 |
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Extension |
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6 |
4 |
24 |
1.50 |
36.00 |
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Total for items cleared unter other Packages |
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240.00 |
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267 |
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