Energy Audit and Energy Assistance - State and Local

Energy Audit and Renewable Energy Development Assistance Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0570-0059 can be found here:

Documents and Forms

Document Name Document Type
Form AD 1047 Energy Audit and Energy Assistance - State and Local Form
Instructions for RD 4280-2.docx Instruction
AD 1047 Certification Regarding Debarment, Suspension, and Other AD1047-F-01-92.pdf Form
AD 1048 Certification Regarding Debarment, Suspension, Ineligibi AD1048-F-01-92.pdf Form
AD 1049 Certification Regarding Drug-Free Workplace Requirements AD1049-F-05-90.pdf Form
RD 1940-1 Request for Obligation of Funds RD1940-0001_080700V04.pdf Form
RD 400-4 Assurance Agreement RD0400-0004_100600V03.pdf Form
RD 1942-46 Letter of Intent RD1942-0046_100600V01.pdf Form
RD 4280-2 Rural Business and Cooperative Service Grant Agreement RD4280-0002_110800V04.pdf Form

Information Collection (IC) Details

IC Title:	Energy Audit and Energy Assistance - State and Local	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	AD 1047	Certification Regarding Debarment, Suspension, and Other Responsibility Matters � Primary Covered Transactions	AD1047-F-01-92.pdf	Yes	Yes	Fillable Printable
Form	AD 1048	Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion � Lower Tier Covered Transactions	AD1048-F-01-92.pdf	Yes	Yes	Fillable Printable
Form	AD 1049	Certification Regarding Drug-Free Workplace Requirements (Grants) Alternative I	AD1049-F-05-90.pdf	Yes	Yes	Fillable Printable
Form	RD 1940-1	Request for Obligation of Funds	RD1940-0001_080700V04.pdf	Yes	Yes	Fillable Printable
Form	RD 400-4	Assurance Agreement	RD0400-0004_100600V03.pdf	Yes	Yes	Fillable Printable
Form	RD 1942-46	Letter of Intent	RD1942-0046_100600V01.pdf	Yes	Yes	Fillable Printable
Form	RD 4280-2	Rural Business and Cooperative Service Grant Agreement	RD4280-0002_110800V04.pdf	Yes	No	Fillable Printable
Instruction			Instructions for RD 4280-2.docx	No		Printable Only

Line of Business: Energy

Subfunction: Energy Production

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 13	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	219	-110	329
Annual IC Time Burden (Hours)	512	67	445
Annual IC Cost Burden (Dollars)	0	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.