Annual Representations and Certification

Representations and Certifications

Documents and Forms

Document Name Document Type
Form Reps and Certs Annual Representations and Certification Form and Instruction
Reps and Certs Annual Reps and Certs Annual Reps and Certs Form 7_27_15.doc Form and Instruction
Supporting Statement annual reps and certs.docx Supporting Document IC Document
Public Comment.docx Public Comments IC Document
Reps Certs Fact Sheet.docx Fact Sheets IC Document

Information Collection (IC) Details

IC Title:	Annual Representations and Certification	Agency IC Tracking Number:	0013

Is this a Common Form? Yes		IC Status: Removed

Obligation to Respond: Mandatory

CFR Citation: 41 CFR 51-4.3 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Reps and Certs	Annual Reps and Certs	Annual Reps and Certs Form 7_27_15.doc		Yes	No	Printable Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title: Annual Representations and Certification	FR Citation: 80 FR 27930

Number of Respondents: 559	Number of Respondents for Small Entity: 559

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-559	559
Annual IC Time Burden (Hours)	-4,472	4,472
Annual IC Cost Burden (Dollars)	-178,880	178,880

Documents for IC

Title	Document	Date Uploaded
Supporting Document	Supporting Statement annual reps and certs.docx	08/10/2015
Public Comments	Public Comment.docx	08/10/2015
Fact Sheets	Reps Certs Fact Sheet.docx	08/10/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.