Information Collection

State, Local, Tribal Governments

IC 247144 under ICR 202105-0570-001 · OMB 0570-0074.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0570-0074 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD-1047 State, Local, Tribal Governments	Form
RCDA IC List Placeholder.docx	Other-Written Narratives
AD-1047 Certification Regarding Debarment, Suspension, and Other AD_1047.pdf	Form
AD-1048 Certification Regarding Debarment, Suspension, Ineligibi AD_1048.pdf	Form
AD-1049 Certification Regarding Drug-Free Workplace Requirements AD_1049.pdf	Form
AD-3031 Assurance Regarding Felony Conviction AD_3031_1_1-V1.1 (1).pdf	Form

IC Title:

Agency IC Tracking Number:

IC Status:

Obligation to Respond:

CFR Citation:

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

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents:

Number of Respondents for Small Entity:

Affected Public:

Percentage of Respondents Reporting Electronically:

table that charts list of burden
		Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC
Annual IC Time Burden (Hours)
Annual IC Cost Burden (Dollars)

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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