7 CFR 1776, "Household Water Well System Grant Program"

2024-2025 Information Collection Supplement

OMB NO. 0572-0139

Non-Form

The following non-form items are cleared as part of the information collection and details on each item are included in the attached supplemental statement:

Initial Application/Application Processing (Non-Form/Written):

• SAM Registration.

• Identify Relationship with Rural Development Employee(s).

• Organizational Documents - Evidence of Legal Authority and Existence.

• List of Directors and Officers.

• Evidence of Tax-Exempt Status.

• Work Plan (Project Proposal, Scope of Work, and Budget Justification).

• Statement of Experience.

• Pro-forma Balance Sheets and Financial Statements.

• Prior year Audit or Financial Statements.

• Pro-forma Income Statement and Cash Flow.

Post Application (Non-Form/Written)

• SAM Registration Maintenance.

• Audit.

• Project Performance Report.

• Request for Written Approval of Work Plan Changes.

• Grant Agreement.

ITEMS CLEARED IN OTHER PACKAGES BUT INCLUDED IN BURDEN

• 1940-1, Request for Obligation of Funds (cleared under multiple packages).

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