Information Collection

American Rescue Plan Act Emergency Rural Health Care Grant Program

IC 247396 under ICR 202107-0575-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
0575-0200 - Application Submissions- Non Forms.docx	Other-Application Submission Non-For
0575-0200 -Reporting Requirements -Non Forms.docx	Other-Other Reporting Requirements -
AD Form 1047 Certification Regarding Debarment, Suspension, and Other AD-1047 Section 508 Compliant.pdf	Form
RD 3570-3 Community Facilities Grant Agreement RD 3570-3.pdf	Form and Instruction
RD 442-2 Statement of Budget, Income and Equity RD 442-2.pdf	Form and Instruction
RD 442-3 Balance Sheet RD 442-3.pdf	Form and Instruction
RD 442-7 Operating Budget RD 442-7.pdf	Form and Instruction

IC Title:

American Rescue Plan Act Emergency Rural Health Care Grant Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Application Submission Non-Form			0575-0200 - Application Submissions- Non Forms.docx	No		Paper Only
Other-Other Reporting Requirements - Non-Form			0575-0200 -Reporting Requirements -Non Forms.docx	No		Paper Only
Form	AD Form 1047	Certification Regarding Debarment, Suspension, and Other Responsibility Matters	AD-1047 Section 508 Compliant.pdf	Yes	Yes	Fillable Printable
Form and Instruction	RD 3570-3	Community Facilities Grant Agreement	RD 3570-3.pdf	Yes	Yes	Fillable Printable
Form and Instruction	RD 442-2	Statement of Budget, Income and Equity	RD 442-2.pdf	Yes	Yes	Fillable Printable
Form and Instruction	RD 442-3	Balance Sheet	RD 442-3.pdf	Yes	Yes	Fillable Printable
Form and Instruction	RD 442-7	Operating Budget	RD 442-7.pdf	Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title: USDA/RD-1 Current or Prospective Producers or Landowners, Applicants, Borrowers, Grantees, Tenants, and other participants in RD programs.

FR Citation: 84 FR 21315

Number of Respondents: 1,092

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15,389	-38,911	54,300
Annual IC Time Burden (Hours)	71,681	-129,591	201,272
Annual IC Cost Burden (Dollars)	0	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.