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Title of Information Document |
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OMB No. |
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Distance Learning and Telemedicine |
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0572-0096 |
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| SUMMARY OF INFORMATION COLLECTION |
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Loan and Grant Program, 7 CFR 1734 - A, B, C, and D |
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Date Prepared |
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2022 |
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| INSTRUCTIONS: |
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> |
(h) TOTAL |
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(j) TOTAL |
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(m) TOTAL |
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| Use this form when a single information collection document involves multiple reporting and |
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> |
- |
= (e) Average |
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= (g) Average |
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= (j) Average |
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| recordkeeping requirements. |
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> |
(f) TOTAL |
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(h) TOTAL |
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(k) TOTAL |
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| IDENTIFICATION OF REPORTING AND RECORDKEEPING 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 |
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SECTION OF |
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(If "none" |
RESPON- |
RESPONSES |
ANNUAL |
PER |
HOURS |
RECORD- |
HOURS PER |
RECORD- |
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REGULATIONS |
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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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(a) |
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DENT |
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(Col. i & j) |
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| Grants |
Combos |
Loans |
(b) |
(c) |
(d) |
(e) |
(f) |
(g) |
(h) |
(i) |
(j) |
(k) |
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Items and Burden Hours Approved Under Other Dockets |
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| 1734.25(a) |
1734.34(a) |
1734.44(a) |
Application for Federal Assistance (OMB Control NO. 4040-0004) |
SF-424 |
300 |
1 |
190 |
0.75 |
142.5 |
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| 1734.6(b)(1) |
1734.6(b)(1) |
1734.6(b)(1) |
Request for Advance or Reimbursement (OMB Control NO. 4040-0012) |
SF-270 |
180 |
3 |
540 |
1.00 |
540 |
350 |
1.00 |
350.00 |
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| 1734.8 |
1734.8 |
1734.8 |
Audit Report (OMB control NO. 0572-0095) |
None |
76 |
1 |
76 |
11.00 |
836 |
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Project Performance Report and SF-425 are collected by PMRA. Audit reports are collected by External Compliance Division (ECD - aka Accounting Branch) |
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Assurance Regarding Felony Conviction or Tax Delinquent Status for Corporate Applicants (OMB Control NO. 0505-0025) |
AD 3030 |
25 |
1 |
25 |
0.25 |
1.6 |
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This is covered in the 'Compliance with other Federal Statutes' section of the application (J-2). |
| 1734.6(b)(1) |
1734.6(b)(1) |
1734.6(b)(1) |
ACH VENDOR / MISCELLANEOUS PAYMENT ENROLLEMENT FORM (OMB Control NO. 1510-0056) |
SF 3881 |
300 |
1 |
190 |
0.50 |
95 |
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Total Annual Row |
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1,021 |
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1,520 |
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Items Cleared Under THIS Collection Package |
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Applicant Information |
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2 CFR 200 |
SAMS Registration, Certifications and Representations |
SAM.gov |
300 |
1 |
300 |
2 |
600 |
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| 1734.25(b) |
1734.34(b) |
1734.44(b) |
Executive Summary |
None |
300 |
1 |
300 |
2.20 |
660.00 |
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| 1734.25(c) |
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Scoring Criteria Documentation |
None |
300 |
1 |
300 |
6.60 |
1,980.00 |
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| 1734.25(d) |
1734.34(c) |
1734.44(c) |
Proposed Scope of Work |
None |
300 |
1 |
300 |
1.10 |
330.00 |
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| 1734.25(e) |
1734.34(d) |
1734.44(d) |
Financial Information |
None |
300 |
1 |
300 |
2.20 |
660.00 |
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| 1734.25(f) |
1734.34(e) |
1734.44(e) |
Statement of Experience |
None |
300 |
1 |
300 |
0.55 |
165.00 |
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| 1734.25(g) |
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Funding Commitment from Other Sources |
None |
300 |
1 |
300 |
0.55 |
165.00 |
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| 1734.25(h) |
1734.34(f) |
1734.44(f) |
Telecommunications System Plan |
None |
300 |
1 |
300 |
33.00 |
9,900.00 |
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| 1734.25(i)(1) |
1734.34(g)(1) |
1734.44(g)(1) |
Equal Opportunity and Nondiscrimination Requirements |
None |
300 |
1 |
300 |
0.10 |
30.00 |
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| 1734.25(i)(2) |
1734.34(g)(2) |
1734.44(g)(2) |
Certification Regarding Architectural Barriers |
None |
300 |
1 |
300 |
0.10 |
30.00 |
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| 1734.25(i)(3) |
1734.34(g)(3) |
1734.44(g)(3) |
Certification Regarding Flood Hazard Areas |
None |
300 |
1 |
300 |
0.10 |
30.00 |
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| 1734.25(i)(4) |
1734.34(g)(4) |
1734.44(g)(4) |
Certification Regarding Uniform Relocation Assistance, etc. |
None |
300 |
1 |
300 |
0.10 |
30.00 |
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| 1734.25(i)(5) |
1734.34(g)(5) |
1734.44(g)(5) |
Certification Regarding Drug-Free Workplace |
AD1049 |
300 |
1 |
300 |
0.25 |
75.00 |
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Obtained via financial representations and certifications in SAM.gov |
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Approved under OMB 0505-0027-burden hours are accounted for in this collection package.) |
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300 |
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| 1734.25(i)(6) |
1734.34(g)(6) |
1734.44(g)(6) |
Certification Regarding Debarment and Suspension |
AD-1047 |
300 |
1 |
300 |
0.25 |
75.00 |
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Obtained via financial representations and certifications in SAM.gov |
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Approved under OMB 0505-0027-burden hours are accounted for in this collection package.) |
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| 1734.25(i)(7) |
1734.34(g)(7) |
1734.44(g)(7) |
Certification Regarding Lobbying |
None |
300 |
1 |
300 |
0.13 |
39.00 |
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Obtained via financial representations and certifications in SAM.gov |
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| 1734.25(b)(8) |
1734.34(b)(8) |
1734.44(b)(8) |
Non-Duplication of Services |
None |
300 |
1 |
300 |
0.10 |
30.00 |
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| 1734.25(j) |
1734.34(h) |
1734.44(h) |
Environmental Information |
None |
300 |
1 |
300 |
0.50 |
150.00 |
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| 1734.25(k) |
1734.34(i) |
1734.44(i) |
Evidence of Legal Existence and Authority |
None |
300 |
1 |
300 |
0.25 |
75.00 |
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| 1734.25(l) |
1734.34(j) |
1734.44(j) |
Federal Obligations Certification on Delinquent Debt |
None |
300 |
1 |
300 |
0.50 |
150.00 |
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Sames as AD 3030 above |
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| 1734.25(m) |
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Consultation w/ State Director RE: Other Funding Sources |
None |
300 |
1 |
300 |
1.65 |
495.00 |
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Recipient Information |
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| 1734.5(e) |
1734.5(e) |
1734.5(e) |
Updated Information for Preparing Legal Documents |
None |
210 |
1 |
210 |
3.00 |
630.00 |
100 |
0.50 |
50.00 |
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| 1734.5(f) |
1734.5(f) |
1734.5(f) |
Execution of Legal Documents |
None |
210 |
1 |
210 |
1.00 |
210.00 |
100 |
1.00 |
100.00 |
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| 1734.6(a) |
1734.6(a) |
1734.6(a) |
Evidence of Fidelity Bond Coverage |
None |
210 |
1 |
210 |
0.50 |
105.00 |
100 |
0.50 |
50.00 |
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| 1734.7(a) |
1734.7(a) |
1734.7(a) |
Project Performance Report |
None |
210 |
1 |
210 |
4.00 |
400.00 |
100 |
1.00 |
100.00 |
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| 1734.6(b)(1) |
1734.6(b)(1) |
1734.6(b)(1) |
Certificate of Authority |
None |
300 |
1 |
300 |
0.50 |
150.00 |
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TOTAL |
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6,840 |
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17,164.00 |
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650.00 |
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Reporting Burden |
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17,164.00 |
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Recordkeeping Burden |
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650.00 |
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Total Burden Hours |
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17,814.00 |
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