Community Services Block Grant (CSBG) Program Model Plan Applications

Forms and Documents

Document Name	Status
Form 1 ACSI CSBG Eligible Entity Survey Form and Instruction	New
Form 1 CSBG Model Plan Application - States and Territories Form	Modified
PRA supporting statement for CSBG Model State Plan FY2017 (4).docx Supporting Statement A	2017-05-24
IM 128 Application for FY 2013 Indian Tribes and Tribal Organizations.docx Supplementary Document	2013-05-29
IM 127 Application for FY 2013 State and U_S_ Territories.mht Supplementary Document	2013-05-29

IC Document Collections

IC ID	Document Title	Status
226996	ACSI CSBG Eligible Entity Survey Form and Instruction	New
192928	CSBG Model Plan Application - States and Territories Form	Modified

ICR Details

OMB Control No: 0970-0382	ICR Reference No: 201705-0970-008
Status: Historical Active	Previous ICR Reference No: 201505-0970-004
Agency/Subagency: HHS/ACF	Agency Tracking No: ocs
Title: Community Services Block Grant (CSBG) Program Model Plan Applications
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/01/2017
	Date Received in OIRA: 05/25/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2018	36 Months From Approved	07/31/2018
Responses	1,091	0	56
Time Burden (Hours)	2,366	0	1,848
Cost Burden (Dollars)	0	0	0

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Abstract: The CSBG Model Plan Application will be used as the plan submitted to ACF by States, Territories, Tribes and Tribal Organizations for the receipt of Federal funds to administer a CSBG program. The information collected is required by the CSBG Statute for the receipt of CSBG program funds.

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Authorizing Statute(s): PL: Pub.L. 105 - 286 676 Name of Law: CSBG Program
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 3967	01/26/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 23010	05/19/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
CSBG Model Plan Application - States and Territories	1	CSBG State Plan Information Collection Instrument
ACSI CSBG Eligible Entity Survey	1	ACSI Survey of Eligible Entities

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,091	56	0	1,035	0	0
Annual Time Burden (Hours)	2,366	1,848	0	518	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: An IC was added.

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Annual Cost to Federal Government: $13,750

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/25/2017

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