Information Collection

American Rescue Plan Act Emergency Rural Health Care Grant Program

IC 247396 under ICR 202105-0575-001 · OMB 0575-0200.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0575-0200 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AD-1047 American Rescue Plan Act Emergency Rural Health Care Grant Program	Form
0575-NEW - Application Submissions- Non Forms.docx	Other-Application Submissions Non-Fo
0575-NEW - Application Submissions- Non Forms.docx	Other-Application Submissions Non-Fo
0575-NEW -Reporting Requirements -Non Forms.docx	Other-Reporting Requirements - Non-F
0575-NEW -Reporting Requirements -Non Forms.docx	Other-Reporting Requirements - Non-F
AD-1047 Certification Regarding Debarment, Suspension, and Other AD-1047.pdf	Form
SF-425.pdf SF 425 - Federal Financial Report	IC Document
RD 3570-3.pdf RD 3570-3 - Community Facilities Grant Application	IC Document
RD 400-1.pdf RD 400-1 Equal Opportunity Agreement	IC Document
RD 400-4.pdf RD 400-4 Assurance Agreement	IC Document
RD 442-7.pdf RD 442-7 Operating Budget	IC Document
RD 442-2.pdf RD 442-2 Statement of Budget, Income, and Equity	IC Document
RD 442-3.pdf RD 442-3 Balance Sheet	IC Document
SF 424.pdf SF 424 Application for Federal Assistance	IC Document

IC Title:

American Rescue Plan Act Emergency Rural Health Care Grant Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 7 CFR 1940

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
Other-Application Submissions Non-Form			0575-NEW - Application Submissions- Non Forms.docx		No		Paper Only
Other-Reporting Requirements - Non-Form			0575-NEW -Reporting Requirements -Non Forms.docx		No		Paper Only

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,392

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	54,300	54,300
Annual IC Time Burden (Hours)	201,272	201,272
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.