Title VI Assurances

Coronavirus State and Local Fiscal Recovery Funds Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1505-0271 can be found here:

Documents and Forms

Document Name Document Type
Title VI Assurances Form and Instruction
Title VI Assurances Title VI Assurance_5-7-21.docx Form and Instruction
Title VI Assurances Title VI Assurance_5-7-21.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Title VI Assurances	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Title VI Assurances	Title VI Assurance_5-7-21.docx		Yes	Yes	Fillable Fileable

Line of Business: Disaster Management

Subfunction: Disaster Repair and Restore

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,050	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	5,050	5,050
Annual IC Time Burden (Hours)	2,525	2,525
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.