Public Housing Capital Fund Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form HUD-5370 EZ General Contract Conditions for Small Construction/Development Contracts	Form and Instruction	Removed	Available
Form HUD 5370 EZ General Contract Conditions for Small Construction/Development Contracts	Form and Instruction	Removed	Available
Form HUD-5370 C1 General Conditions for Non-Construction Contracts Section I — (With or without Maintenance Work)	Form and Instruction	Removed	Available
Form HUD-5370-C1 General Conditions for Non-Construction Contracts Section I — (With or without Maintenance Work)	Form and Instruction	Removed	Available
Form HUD-5370 General Conditions for Construction Contracts - Public Housing Programs	Form and Instruction	Removed	Available
Form HUD-5370 General Conditions for Construction Contracts - Public Housing Programs	Form and Instruction	Removed	Available
Form HUD 5084 Contract for Inspection Services (Turnkey)	Form and Instruction	Removed	Available
Form HUD 52651-A Site, Design and Cost Report	Form and Instruction	Removed	Available
Form HUD 52482 Guide Form of Turnkey Developer's Packet	Form and Instruction	Removed	Available
Form HUD 52829 Physical Needs Assessment Capital Fund Financing Program/ Operating Fund Financing Program	Form and Instruction	Removed	Available
Form HUD-52828 Green Physical Needs Assessment	Form and Instruction	Removed	Available
Form HUD 52836 HA Board Resolution Approving Comprehensive Plan or Annual Statement	Form and Instruction	Removed	Available
Form HUD 53001 Actual Modernization Cost Certificate	Form and Instruction	Removed	Available
Form HUD 52483-A Proposal for a Public Housing Project	Form and Instruction	Removed	Available
Form HUD 52427 Actual Development Cost Certificate	Form and Instruction	Removed	Available
Form HUD 51002 Schedule of Change Orders	Form and Instruction	Removed	Available
Form HUD 51001 Periodic Estimate for Partial Payment	Form and Instruction	Removed	Available
Form HUD 51000 Schedule of Amounts for Contract Payments	Form and Instruction	Removed	Available
Form HUD 53015 Instructions for Preparation of Turnkey Contract of Sale Form Part 1 and Part 2	Form and Instruction	Removed	Available
Form HUD 52849 Capital Fund Financing Program Pooled Transaction: List of Participating PHAs	Form and Instruction	Removed	Available
Form HUD 52847 CFFP Monthly Debt Service Schedule - Formula Funds Only - Part A Annual Summary	Form and Instruction	Removed	Available
Form HUD 52846 CFFP Periodic Payment Debt Service Schedule - Formula Funds Only	Form and Instruction	Removed	Available
Form HUD 52845 Term Sheet	Form and Instruction	Removed	Available
Form HUD 52833 Management Needs Assessment Capital Fund Program (CFP)	Form and Instruction	Removed	Available
Form HUD 52830 lio Schedule for Capital Fund Financing Proposal	Form and Instruction	Removed	Available
Form HUD 52486 CFFP Periodic Payment Debt Service Schedule - Formula Funds Only	Form and Instruction	Removed	Available
Form HUD 52485 Demonstration of Financial Feasibility	Form and Instruction	Removed	Available
Form HUD 52484 Development Cost Budget/Cost Statement	Form and Instruction	Removed	Available
Form HUD 52396 Analysis of Proposed Main Construction Contract	Form and Instruction	Removed	Available
Form HUD 51971 and 5197 Offer of Sale of Real Property and Purchase Agreement	Form and Instruction	Removed	Available
Form HUD 51915a Contract Provisions Required by Federal Law or Owner Contract with HUD	Form and Instruction	Removed	Available
Form HUD 51915 Model Form of Agreement Between Owner and Design Professional	Form and Instruction	Removed	Available
Form HUD 51004 Summary of Materials Stored	Form and Instruction	Removed	Available
Form HUD 51003 Schedule of Materials Stored	Form and Instruction	Removed	Available
Form HUD 50075.1 Annual Statement Performance and Evaluation Report	Form and Instruction	Removed	Available
Form HUD 50071 Certification of Payments to Influence Federal Transactions	Form and Instruction	Removed	Available
Form HUD 5460 Insurance Information	Form and Instruction	Removed	Available
Form HUD 5378 Public Housing Construction Report	Form and Instruction	Removed	Available
Form HUD 5372 Construction Progress Schedule	Form and Instruction	Removed	Available
Form HUD 5370-C2 General Conditions for Non-Construction Contracts Sec II	Form and Instruction	Removed	Available
Form HUD 5087 Outline Specification	Form and Instruction	Removed	Available
Form HUD 5087 Public Housing Capital Fund Program	Form and Instruction	Removed	Repair queued
Form HUD 5370 General Contract for Construction Contracts Public Housing Programs	Form	New	Available
Form HUD-5370 EZ General Contract Conditions for Smal Construction Development Contracts	Form	New	Available
Form HUD 52849 Capital Fund Financing Program Pooled Transaction List of Participating PHAs	Form	New	Available
Form HUD 52847 Monthly Debt Service Schedule Pt A Annual Summary	Form	New	Available
Form HUD 52846 Periodic Payment Debt Service Schedule	Form	New	Available
Form HUD 52845 Demonstration of Finanicial Feasibility	Form	New	Available
Form HUD 52836 HA Board Resolution Approving Comprehensive Plan	Form	New	Available
Form HUD 52833 Management Needs Assessment Capital Fund Program	Form	New	Available
Form HUD 52830 Schedule for Capital Fund Financing Proposal	Form and Instruction	New	Available
Form HUD 52829 Physical Needs Assessment Capital Fund Financing	Form	New	Available
Form HUD 52828 Green Physical Needs Assessment	Form	New	Available
Form HUD 52651A Site Design and Cost Report	Form	New	Available
Form HUD 52485 Demonstration of Financial Feasibility	Form	New	Available
Form HUD 52484 Development Cost Budget Cost Statement	Form and Instruction	New	Available
Form HUD 52482 Proposal for Public Housing Project	Form	New	Available
Form HUD 52482 Guide Form of Turnkey Developers Packet	Form	New	Available
Form HUD 52427 Actual Development Cost Certificate	Form	New	Available
Form HUD 52396 Analysis of Proposed Main Construction Contract	Form	New	Available
Form HUD 51971-1 and 51 Offer of Sale of Real Property and Purchase Agreement	Form	New	Available
Form HUD 51951A Contract Provisions Required by Federal Law or Owner Contract with HUD	Form	New	Available
Form HUD 51951 Model Form Agreement Between Owner and Design Profl	Form	New	Available
Form HUD 51004 Summary of Materials Stored	Form	New	Available
Form HUD 51003 Schedule of Materials Stored	Form	New	Available
Form HUD 51002 Schedule of Change Orders	Form	New	Available
Form HUD 51001 Periodic Estimate for Partial Payment	Form	New	Available
Form HUD 51000 Schedule of Amts for Contract Payments	Form	New	Available
Form HUD 50075.1 Annual Statement Performance and Evaluation Report	Form	New	Available
Form HUD 50071 Certification of Payments to Influence Federal Transactions	Form	New	Available
Form HUD 5460 Insurance Information	Form	New	Available
Form HUD 5378 Public Housing Construction Report	Form	New	Available
Form HUD 5372 Construction Progress Schedule	Form	New	Available
Form HUD 5087 Outline Specification	Form	New	Available
Form HUD 5084 Contract for Inspection Services	Form	New	Available
Form HUD-53001 Actual Modernization Cost Certificat Capital Fund Program	Form	New	Available
Form HUD-53001 Public Housing Capital Fund Program	Form	New	Repair queued
2577-0157 30-Day Notice Public Housing Capital Fund 11-1-23.pdf	Supplementary Document	Uploaded 2023-11-07	Repair queued
2577-0157 Supporting Statement for Paperwork Reduction Act Submissions 9-15-23.docx	Supporting Statement A	Uploaded 2023-09-15	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	General Contract Conditions for Small Construction/Development Contracts
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	General Contract Conditions for Small Construction/Development Contracts
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	General Conditions for Non-Construction Contracts Section I — (With or without Maintenance Work)
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	General Conditions for Non-Construction Contracts Section I — (With or without Maintenance Work)
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	General Conditions for Construction Contracts - Public Housing Programs
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	General Conditions for Construction Contracts - Public Housing Programs
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Contract for Inspection Services (Turnkey)
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Site, Design and Cost Report
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Guide Form of Turnkey Developer's Packet
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Physical Needs Assessment Capital Fund Financing Program/ Operating Fund Financing Program
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Green Physical Needs Assessment
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	HA Board Resolution Approving Comprehensive Plan or Annual Statement
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Actual Modernization Cost Certificate
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Proposal for a Public Housing Project
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Actual Development Cost Certificate
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Schedule of Change Orders
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Periodic Estimate for Partial Payment
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Schedule of Amounts for Contract Payments
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Instructions for Preparation of Turnkey Contract of Sale Form Part 1 and Part 2
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Capital Fund Financing Program Pooled Transaction: List of Participating PHAs
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	CFFP Monthly Debt Service Schedule - Formula Funds Only - Part A Annual Summary
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	CFFP Periodic Payment Debt Service Schedule - Formula Funds Only
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Term Sheet
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Management Needs Assessment Capital Fund Program (CFP)
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	lio Schedule for Capital Fund Financing Proposal
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	CFFP Periodic Payment Debt Service Schedule - Formula Funds Only
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Demonstration of Financial Feasibility
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Development Cost Budget/Cost Statement
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Analysis of Proposed Main Construction Contract
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Offer of Sale of Real Property and Purchase Agreement
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Contract Provisions Required by Federal Law or Owner Contract with HUD
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Model Form of Agreement Between Owner and Design Professional
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Summary of Materials Stored
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Schedule of Materials Stored
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Annual Statement Performance and Evaluation Report
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Certification of Payments to Influence Federal Transactions
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Insurance Information
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Public Housing Construction Report
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Construction Progress Schedule
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	General Conditions for Non-Construction Contracts Sec II
27829	Public Housing Capital Fund Program	Form and Instruction	Removed	Outline Specification
27829	Public Housing Capital Fund Program	Form and Instruction	Removed
262188	Public Housing Capital Fund Program	Form	New	General Contract for Construction Contracts Public Housing Programs
262188	Public Housing Capital Fund Program	Form	New	General Contract Conditions for Smal Construction Development Contracts
262188	Public Housing Capital Fund Program	Form	New	Capital Fund Financing Program Pooled Transaction List of Participating PHAs
262188	Public Housing Capital Fund Program	Form	New	Monthly Debt Service Schedule Pt A Annual Summary
262188	Public Housing Capital Fund Program	Form	New	Periodic Payment Debt Service Schedule
262188	Public Housing Capital Fund Program	Form	New	Demonstration of Finanicial Feasibility
262188	Public Housing Capital Fund Program	Form	New	HA Board Resolution Approving Comprehensive Plan
262188	Public Housing Capital Fund Program	Form	New	Management Needs Assessment Capital Fund Program
262188	Public Housing Capital Fund Program	Form and Instruction	New	Schedule for Capital Fund Financing Proposal
262188	Public Housing Capital Fund Program	Form	New	Physical Needs Assessment Capital Fund Financing
262188	Public Housing Capital Fund Program	Form	New	Green Physical Needs Assessment
262188	Public Housing Capital Fund Program	Form	New	Site Design and Cost Report
262188	Public Housing Capital Fund Program	Form	New	Demonstration of Financial Feasibility
262188	Public Housing Capital Fund Program	Form and Instruction	New	Development Cost Budget Cost Statement
262188	Public Housing Capital Fund Program	Form	New	Proposal for Public Housing Project
262188	Public Housing Capital Fund Program	Form	New	Guide Form of Turnkey Developers Packet
262188	Public Housing Capital Fund Program	Form	New	Actual Development Cost Certificate
262188	Public Housing Capital Fund Program	Form	New	Analysis of Proposed Main Construction Contract
262188	Public Housing Capital Fund Program	Form	New	Offer of Sale of Real Property and Purchase Agreement
262188	Public Housing Capital Fund Program	Form	New	Contract Provisions Required by Federal Law or Owner Contract with HUD
262188	Public Housing Capital Fund Program	Form	New	Model Form Agreement Between Owner and Design Profl
262188	Public Housing Capital Fund Program	Form	New	Summary of Materials Stored
262188	Public Housing Capital Fund Program	Form	New	Schedule of Materials Stored
262188	Public Housing Capital Fund Program	Form	New	Schedule of Change Orders
262188	Public Housing Capital Fund Program	Form	New	Periodic Estimate for Partial Payment
262188	Public Housing Capital Fund Program	Form	New	Schedule of Amts for Contract Payments
262188	Public Housing Capital Fund Program	Form	New	Annual Statement Performance and Evaluation Report
262188	Public Housing Capital Fund Program	Form	New	Certification of Payments to Influence Federal Transactions
262188	Public Housing Capital Fund Program	Form	New	Insurance Information
262188	Public Housing Capital Fund Program	Form	New	Public Housing Construction Report
262188	Public Housing Capital Fund Program	Form	New	Construction Progress Schedule
262188	Public Housing Capital Fund Program	Form	New	Outline Specification
262188	Public Housing Capital Fund Program	Form	New	Contract for Inspection Services
262188	Public Housing Capital Fund Program	Form	New	Actual Modernization Cost Certificat Capital Fund Program
262188	Public Housing Capital Fund Program	Form	New

ICR Details

OMB Control No: 2577-0157	ICR Reference No: 202308-2577-007
Status: Historical Active	Previous ICR Reference No: 202109-2577-004
Agency/Subagency: HUD/PIH	Agency Tracking No: 2577-0157
Title: Public Housing Capital Fund Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/29/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/13/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2027	36 Months From Approved	01/31/2024
Responses	72,418	0	74,882
Time Burden (Hours)	281,570	0	293,537
Cost Burden (Dollars)	0	0	0

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Abstract: Each year Congress appropriates funds to approximately 3,100 Public Housing Authorities (PHAs) for modernization, development, financing, and management improvements. The funds are allocated based on a complex formula. The forms in this collection are used to appropriately disburse and utilize the funds provided to PHAs. Additionally, these forms provide the information necessary to approve a financing transaction in addition to any Capital Fund Financing transactions. Respondents include the approximately 3,100 PHA receiving Capital Funds and any other PHAs wishing to pursue financing.

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Authorizing Statute(s): US Code: 44 USC Chapter 35, as amended Name of Law: Section 3506 of the Paperwork Reduction Act of 1995
  

Citations for New Statutory Requirements: US Code: 42 USC 1437q Name of Law: Section 9 of the U.S. Housing Act of 1937

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 9530	02/14/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 75013	11/01/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Public Housing Capital Fund Program	HUD 51003, HUD 52830, HUD 52833, HUD 51951, HUD 51951A, HUD 51971-1 and 51971-2, HUD 52396, HUD 52427, HUD 52482, HUD 52482, HUD 52484, HUD 52485, HUD 52651A, HUD 52828, HUD 52829, HUD 52845, HUD 52846, HUD 52847, HUD-53001, HUD 5084, HUD 5087, HUD 5372, HUD 5378, HUD 5460, HUD 50071, HUD 50075.1, HUD 51000 , HUD 51001, HUD 51002, HUD 51004, HUD 52836, HUD 52849, HUD-5370 EZ, HUD 5370	Actual Modernization Cost Certificat Capital Fund Program ,   Contract for Inspection Services ,   Outline Specification ,   Construction Progress Schedule ,   Public Housing Construction Report ,   Insurance Information ,   Certification of Payments to Influence Federal Transactions ,   Annual Statement Performance and Evaluation Report ,   Schedule of Amts for Contract Payments ,   Periodic Estimate for Partial Payment ,   Schedule of Change Orders ,   Schedule of Materials Stored ,   Summary of Materials Stored ,   Model Form Agreement Between Owner and Design Profl ,   Contract Provisions Required by Federal Law or Owner Contract with HUD ,   Offer of Sale of Real Property and Purchase Agreement ,   Analysis of Proposed Main Construction Contract ,   Actual Development Cost Certificate ,   Guide Form of Turnkey Developers Packet ,   Proposal for Public Housing Project ,   Development Cost Budget Cost Statement ,   Demonstration of Financial Feasibility ,   Site Design and Cost Report ,   Green Physical Needs Assessment ,   Physical Needs Assessment Capital Fund Financing ,   Schedule for Capital Fund Financing Proposal ,   Management Needs Assessment Capital Fund Program ,   HA Board Resolution Approving Comprehensive Plan ,   Demonstration of Finanicial Feasibility ,   Periodic Payment Debt Service Schedule ,   Monthly Debt Service Schedule Pt A Annual Summary ,   Capital Fund Financing Program Pooled Transaction List of Participating PHAs ,   General Contract Conditions for Smal Construction Development Contracts ,   General Contract for Construction Contracts Public Housing Programs
Public Housing Capital Fund Program	HUD 52483-A, HUD 51001, HUD 51002, HUD 52427, HUD 53001, HUD 52836, HUD-52828, HUD 52829, HUD 52482, HUD 52651-A, HUD 5084, HUD 5087, HUD-5370 C1, HUD 5370-C2, HUD 5372, HUD 5378, HUD 5460 , HUD 50071, HUD 50075.1, HUD 51003, HUD 51004, HUD 51915, HUD 51915a, HUD 51971 and 51971-2, HUD 52396, HUD 52484, HUD 52485, HUD 52486, HUD 52830, HUD 52833, HUD 52845, HUD 52846, HUD 52847, HUD 52849, HUD 53015, HUD 51000, HUD-5370, HUD-5370-C1, HUD 5370 EZ, HUD-5370 EZ, HUD-5370	Outline Specification ,   General Conditions for Non-Construction Contracts Sec II ,   Construction Progress Schedule ,   Public Housing Construction Report ,   Insurance Information ,   Certification of Payments to Influence Federal Transactions ,   Annual Statement Performance and Evaluation Report ,   Schedule of Materials Stored ,   Summary of Materials Stored ,   Model Form of Agreement Between Owner and Design Professional ,   Contract Provisions Required by Federal Law or Owner Contract with HUD ,   Offer of Sale of Real Property and Purchase Agreement ,   Analysis of Proposed Main Construction Contract ,   Development Cost Budget/Cost Statement ,   Demonstration of Financial Feasibility ,   CFFP Periodic Payment Debt Service Schedule - Formula Funds Only ,   lio Schedule for Capital Fund Financing Proposal ,   Management Needs Assessment Capital Fund Program (CFP) ,   Term Sheet ,   CFFP Periodic Payment Debt Service Schedule - Formula Funds Only ,   CFFP Monthly Debt Service Schedule - Formula Funds Only - Part A Annual Summary ,   Capital Fund Financing Program Pooled Transaction: List of Participating PHAs ,   Instructions for Preparation of Turnkey Contract of Sale Form Part 1 and Part 2 ,   Schedule of Amounts for Contract Payments ,   Periodic Estimate for Partial Payment ,   Schedule of Change Orders ,   Actual Development Cost Certificate ,   Proposal for a Public Housing Project ,   Actual Modernization Cost Certificate ,   HA Board Resolution Approving Comprehensive Plan or Annual Statement ,   Green Physical Needs Assessment ,   Physical Needs Assessment Capital Fund Financing Program/ Operating Fund Financing Program ,   Guide Form of Turnkey Developer's Packet ,   Site, Design and Cost Report ,   Contract for Inspection Services (Turnkey) ,   General Conditions for Construction Contracts - Public Housing Programs ,   General Conditions for Construction Contracts - Public Housing Programs ,   General Conditions for Non-Construction Contracts Section I — (With or without Maintenance Work) ,   General Conditions for Non-Construction Contracts Section I — (With or without Maintenance Work) ,   General Contract Conditions for Small Construction/Development Contracts ,   General Contract Conditions for Small Construction/Development Contracts

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	72,418	74,882	0	-2,464	0	0
Annual Time Burden (Hours)	281,570	293,537	0	-11,967	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Revisions: Made minor revisions to the burden statements on some forms to make sure all elements required by 5 CFR 1320.8(b)(3) are included. Made minor revision to HUD-52483A and HUD52651A to respond to comments from HUD Fair Housing and Equal Opportunity (FHEO) office. There has been a reduction of approximately 330 PHAs since the last renewal which has reduced hours somewhat. The reduction is mainly from the conversion of PHAs to Section 8 with the Rental Assistance Demonstration (RAD) Program and Small Voluntary Conversions.

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Annual Cost to Federal Government: $4,042,688

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/13/2023

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