Information Collection

Public/Tribal

IC 181552 under ICR 202102-0575-004 · OMB 0575-0180.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0575-0180 can be found here:

2025-01-21 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD-1047 Public/Tribal	Form
Form AD-1047 Certification Regarding Debarrment, etc. Public/Tribal	Form
Form AD-1048 Certification Regarding Debarrment, etc. - Lower Tier Public/Tribal	Form
Form AD-1049 Certification for Drug-Free Workplace Public/Tribal	Form
Form RD 400-1 Equal Opportunity Agreement Public/Tribal	Form
Form RD 400-4 Assurance Agreement Public/Tribal	Form
Form RD 442-2 Statement of Budget, Income and Equity Public/Tribal	Form
Form RD 442-3 Balance Sheet Public/Tribal	Form
Form AD 3030 Representations Regarding Felony Conviction and Tax Delinquent Status for Coporate Applicants Public/Tribal	Form
AD-1047 Certification Regarding Debarrment, etc. AD_1047-V1.0.pdf	Form
AD-1047 Certification Regarding Debarrment, etc. AD_1047-V1.0.pdf	Form
AD-1048 Certification Regarding Debarrment, etc. - Lower Tier AD_1048-V1.0.pdf	Form
AD-1048 Certification Regarding Debarrment, etc. - Lower Tier AD_1048-V1.0.pdf	Form
AD-1049 Certification for Drug-Free Workplace AD_1049-V1.0.pdf	Form
AD-1049 Certification for Drug-Free Workplace AD_1049-V1.0.pdf	Form
RD 400-1 Equal Opportunity Agreement rd 400-1.pdf	Form
RD 400-1 Equal Opportunity Agreement rd 400-1.pdf	Form
RD 400-4 Assurance Agreement rd 400-4.pdf	Form
RD 400-4 Assurance Agreement rd 400-4.pdf	Form
RD 442-2 Statement of Budget, Income and Equity RD0442-0002_970900 V04.pdf	Form
RD 442-2 Statement of Budget, Income and Equity RD0442-0002_970900 V04.pdf	Form
RD 442-3 Balance Sheet rd 442-3.pdf	Form
RD 442-3 Balance Sheet rd 442-3.pdf	Form
AD 3030 Representations Regarding Felony Conviction and Tax Deli AD_3030_1_1-V1.1.pdf	Form
AD 3030 Representations Regarding Felony Conviction and Tax Deli AD_3030_1_1-V1.1.pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Public/Tribal

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	AD-1047	Yes	No	Fillable Printable
Form	AD-1048	Yes	No	Fillable Printable
Form	AD-1049	Yes	No	Fillable Printable
Form	RD 400-1	Yes	No	Fillable Printable
Form	RD 400-4	Yes	No	Fillable Printable
Form	RD 442-2	Yes	No	Fillable Printable
Form	RD 442-3	Yes	No	Fillable Printable
Form	AD 3030	Yes	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: 9

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-364	364
Annual IC Time Burden (Hours)	-455	455
Annual IC Cost Burden (Dollars)	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.

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