Reporting and Recordkeeping Requirements

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INSTRUCTIONS: Use this form when a single information collection document involves multiple reporting and
TITLE OF INFORMATION COLLECTION DOCUMENT
USDA-FPAC-BC
SUMMARY OF INFORMATION COLLECTION
recordkeeping requirements. The totals of the figures in cols. should be entered in item 13 of OMB-83-I:
cols. (D)
&/or (I) = 13a (respondent is only counted once); cols. F & I = 13b;
cols. H & K = 13c.

OMB NO.

Certified Mediation Program

June 11, 2026
ANNUAL BURDEN

IDENTIFICATION OF REPORTING OR RECORDKEEPING REQUIREMENT

REPORTS

DESCRIPTION

(A)

(B)

Page 1 of 2

DATE PREPARED

(F)Total/(D)Total = (E)Average (H)Total/(F)Total = (G)Average (K)Total/(I)Total = (J)Average
NOTE: The columns will calculate automatically. If Col. E's response is something other than annually, i.e., 1/6 years, list
as "1/6" & decimal will display.

SECTION OF
REGS.

0560-0165

FORMS NO (S)
(If "none"
so state)

NO. OF
RESPONDENTS

(C)

(D)

NO OF
RESPONSES
PER

RECORDS

TOTAL ANNUAL
RESPONSES
(Col. D x E)

HOURS
PER
RESPONSE

(F)

(G)

RESPONDENT

TOTAL BURDEN HOURS
(Col. F x G)
(H)
EXEMPT

(E)

RESPONDENT COST
TOTAL

NO. OF
RECORDKEEPERS

NON-EXEMPT

ANNUAL
HOURS PER
RECORD-

(Col. I x J)

COST
PER
HOUR

(K)

(L)

RECORDKEEPING HOURS

KEEPER
(I)

(J)

N/A

Request for Advance of Reimbursement (State
Agencies) (OMB No. 4040-0012)

SF-270

46

4

184

1.0000

184

$67.29

N/A

Application for Federal Assistance (State Agencies)
SF-424
(OMB No. 4040-0004)

46

2

92

1.0000

92

$67.29

N/A

Federal Financial Report (State Agencies) (OMB No
SF-425
4040-0014)

46

1

46

2.0000

30

$67.29

N/A

Assurances - Non-Construction Programs (State
Agencies) (OMB No. 4040-0007)

SF-424B

46

1

46

1.0000

46

$67.29

N/A

Budget Information - Non-Construction Programs
(State Agencies) (OMB 4040-0006)

SF-424A

46

1

46

2.0000

92

$67.29

785.3(b)

Recertification

Narrative

46

1

46

8.0000

368

$67.29

785.5(a)

Annual Report

Narrative

46

1

46

13.0000

598

$67.29

785.8(b)

Mid-Year Report

Narrative

46

1

46

8.0000

368

$67.29

552

1,334

0.00

TOTAL OF ALL PAGES

552

1,334

0.00

TOTAL - COLUMNS "F" AND "I" = OMB 83-I, 13b;
COLUMNS "H" AND "K" = OMB 83-I, 13c

552

1,334

RESPONDENT COST
TOTAL
COST
(Col. H x L)

(M)

$12,381.36

$6,190.68
$2,018.70
$3,095.34
$6,190.68

$24,762.72

$40,239

$24,763
$119,642
$119,642