| USDA - RUS |
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Title of Information Document |
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OMB No. |
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Form 395 - Equipment Contract for Telecommunications |
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0572-0149 |
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| SUMMARY OF INFORMATION COLLECTION |
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and Broadband Borrowers |
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Date Prepared |
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5/12/2022 |
| INSTRUCTIONS: |
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> |
(f) TOTAL |
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(h) TOTAL |
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(k) TOTAL |
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| Use this form when a single information collection document involves multiple reporting and |
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> |
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= (e) Average |
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= (g) Average |
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= (j) Average |
| recordkeeping requirements. |
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(d) TOTAL |
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(f) TOTAL |
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(i) TOTAL |
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| IDENTIFICATION OF REPORTING AND RECORDKEEPING REQUIREMENTS |
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ANNUAL BURDEN |
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FORM |
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REPORTS |
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RECORDS |
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NO(s) |
NO. OF |
NO. OF |
TOTAL |
HOURS |
TOTAL |
NO. OF |
ANNUAL |
TOTAL |
| SECTION OF |
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(If "none" |
RESPON- |
RESPONSES |
ANNUAL |
PER |
HOURS |
RECORD- |
HOURS PER |
RECORD- |
| REGULATIONS |
DESCRIPTION |
so state) |
DENTS |
PER |
RESPONSES |
RESPONSE |
(Col. f & g) |
KEEPERS |
RECORD- |
KEEPING |
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RESPON- |
(Col. d & e) |
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KEEPER |
HOURS |
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DENT |
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(Col. i & j) |
| (a) |
(b) |
(c) |
(d) |
(e) |
(f) |
(g) |
(h) |
(i) |
(j) |
(k) |
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| 1753 |
Equipment Contract |
395 |
28 |
1.7 |
47.6 |
1.50 |
71.40 |
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| Subpart E, H |
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| 1753.3 and 6 |
Borrower's non-conformance request letter |
Written |
1 |
1 |
1 |
1.00 |
1.00 |
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| Subpart A |
(construction, design, materials, equipment, etc..) |
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| 1753.37, 38, |
Certificate of Completion, Equipment Contract |
395a |
9 |
1.4 |
12.6 |
0.50 |
6.30 |
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| 39, 68 |
(Including Installation) |
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| 1753.37, 38, |
Certificate of Completion, Equipment Contract |
395b |
11 |
1.4 |
15.4 |
0.50 |
7.70 |
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| 39, 68 |
(Not Including Installation) |
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| 1753.37, 38, |
Certificate of Contractor and Indemnity Agreement |
395c |
9 |
1 |
9 |
0.50 |
4.50 |
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| 39, 68 |
(Use only for installation contracts) |
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| 1753.37, 38, |
Report in writing, including all measurements, any |
395d |
19 |
1 |
19 |
0.75 |
14.25 |
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| 39, 68 |
acceptance test report and other information required under |
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Part II of applicable specifications |
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| 1753 |
Certification Regarding Debarment, Suspension, Ineligibility |
AD1048 |
28 |
1 |
28 |
0.25 |
7.00 |
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| Subpart E, H |
and Voluntary Exclusion - Lower Tier Covered Transactions |
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| 1753 |
Lobbying Certification (Telephone Version 3, 8/11) |
Written |
28 |
1 |
28 |
0.05 |
1.40 |
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| Subpart E, H |
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TOTALS |
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28 |
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161 |
0.71 |
114 |
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FORMS APPROVED UNDER OTHER OMB NUMBERS |
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| 1753 |
Certificate ("Buy American") |
213 |
20 |
1 |
20 |
0.016 |
0.32 |
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0572-0107 |
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| 1753.11, |
Construction or Equipment Contract Amendment |
238 |
13 |
2.2 |
28.6 |
0.016 |
0.46 |
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| 28, 38, 68 |
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0572-0107 |
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| 1784.21(b)(7) |
Disclosure of Lobbying Acitivities |
SF LLL |
1 |
1 |
1 |
0.25 |
0.25 |
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(0348-0046) |
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Total burden associated with OTHER packages |
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50 |
0.02 |
1 |
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Total burden hours associated with THIS package |
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161 |
0.71 |
114 |
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COMBINED burden associated with this package |
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210 |
0.55 |
115 |
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