Information Collection

State, Local & Tribal Governments (Public Bodies)

IC 219233 under ICR 202210-0575-003 · OMB 0575-0198.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form RD 400-1 State, Local & Tribal Governments (Public Bodies)	Form
RD 400-1 Equal Opportunity Agreement RD0400-0001.pdf	Form
AD-1047 Certification Regarding Debarment, Suspension, and Other AD-1047 DebarmentCert-PrimaryCovered.pdf	Form
AD-1048 Certification Regarding Debarment, Suspension, Ineligibi AD-1048 DebarmentCert-LowerTierCovered.pdf	Form
AD-1049 Certification Regarding Drug-Free Workplace Requirements AD-1049 DrugFreeCert-Alt1.pdf	Form
RD 400-4 Assurance Agreement RD 400-4.pdf	Form
RD 3570-4 Community Facilities Technical Assistance and Training G RD 3570-4.pdf	Form

IC Title:

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.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	RD 400-1	Equal Opportunity Agreement	RD0400-0001.pdf	Yes	No	Fillable Printable
Form	AD-1047	Certification Regarding Debarment, Suspension, and Other Responsibility Matters Primary Covered Transactions	AD-1047 DebarmentCert-PrimaryCovered.pdf	Yes	No	Fillable Printable
Form	AD-1048	Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions	AD-1048 DebarmentCert-LowerTierCovered.pdf	Yes	No	Fillable Printable
Form	AD-1049	Certification Regarding Drug-Free Workplace Requirements (Grants) Alternative I - For Grantees Other Than Individiual	AD-1049 DrugFreeCert-Alt1.pdf	Yes	No	Fillable Printable
Form	RD 400-4	Assurance Agreement	RD 400-4.pdf	Yes	No	Fillable Printable
Form	RD 3570-4	Community Facilities Technical Assistance and Training Grant Agreement	RD 3570-4.pdf	Yes	No	Fillable Printable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25

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	-458	458
Annual IC Time Burden (Hours)	-698	698
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.