Comprehensive Listing of Transactional Documents for Mortgagors, Mortgagees and Contractors

Forms and Documents

Document Name	Status
Form 9444-ORCF Transactional Documents for Mortgagees and Contractors Form and Instruction	Unchanged
Signed OMB 83-C Form for OMB 2502-0605, 10-4-19.pdf Justification for No Material/Nonsubstantive Change	2019-11-12
92476C_orcf_redline.docx Justification for No Material/Nonsubstantive Change	2019-10-22
OMB 83-C Form_92476C.docx Justification for No Material/Nonsubstantive Change	2019-10-22
Signed OMB 83-C Form for OMB 2502-0605, 10-4-19.pdf Justification for No Material/Nonsubstantive Change	2019-10-04
2502-0605 Supporting Statement .docx Supporting Statement A	2019-03-25
2502-0605 - PTA (Signed by Privacy Office).pdf Supplementary Document	2018-12-21
Re-Published 15-Day FRN for Collection 2502-0605, 6-29-18.pdf Supplementary Document	2018-12-21
Published 30 Day FRN for Collection 2502-0605, 4-10-2018.pdf Supplementary Document	2018-12-21
Published 60 FRN for Collection 2502-0605, 5-19-2017.pdf Supplementary Document	2018-12-21
12 US CODE 1713.pdf Supplementary Document	2018-12-21
12 US CODE 1715n.pdf Supplementary Document	2018-12-21
12 US CODE 1715.pdf Supplementary Document	2018-12-21
12 USC 1701.pdf Supplementary Document	2018-12-21
48 Stat. 1246.pdf Supplementary Document	2018-12-21
Public Law 73-479, National Housing Act.pdf Supplementary Document	2018-12-21

IC Document Collections

IC ID	Document Title	Status
204773	Transactional Documents for Mortgagees and Contractors Form and Instruction	Unchanged

ICR Details

OMB Control No: 2502-0605	ICR Reference No: 201911-2502-002
Status: Historical Active	Previous ICR Reference No: 201910-2502-002
Agency/Subagency: HUD/OH	Agency Tracking No:
Title: Comprehensive Listing of Transactional Documents for Mortgagors, Mortgagees and Contractors
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/06/2020
	Date Received in OIRA: 11/12/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2022	06/30/2022	06/30/2022
Responses	26,125	0	26,125
Time Burden (Hours)	49,226	0	49,226
Cost Burden (Dollars)	0	0	0

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Abstract: Information provided includes documents comprising the application for FHA mortgage insurance of residential care facilities, and for servicing of the mortgages. The information is submitted from HUD-approved mortgagees, sponsors, mortgagors and contractors. The included documents are necessary for the application, review, commitment, initial/final endorsement, administration, servicing, technical oversight and audit of the Office of Residential Care Facilities projects pursuant to FHA programs 232, 241, 223(f) and 223(a)(7).

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Authorizing Statute(s): US Code: 12 USC 1715 Name of Law: Housing for Moderate and Displaced Families
   US Code: 12 USC 1701 Name of Law: Rental Supplement Payments
   US Code: 12 USC 1715n Name of Law: Misc Housing Insurance
   US Code: 12 USC 1713 Name of Law: Rental Housing Insurance
  

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:
	82 FR 23058	05/19/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 15396	04/10/2018
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Transactional Documents for Mortgagees and Contractors	94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94001-ORCF-RI, 94001-ORCF-RI, 94001-ORCF-RI, 94001-ORCF-RI, 92080-ORCF, 92211A-ORCF, 90010-ORCF, 90011-ORCF, 92211-ORCF, 92331-ORCF, 92333-ORCF, 92335-ORCF, 92337-ORCF, 92339-ORCF, 92466-ORCF, 9250-ORCF, 92117-ORCF, 92228-ORCF, 92266-ORCF, 92417-ORCF, 93333-ORCF, 93479-ORCF, 93480-ORCF, 91125-ORCF, 91127-OCRF, 91129-ORCF, 92408-ORCF, 92412-ORCF, 92441-ORCF, 92441a-ORCF, 92442-ORCF, 92452-ORCF, 92452A-ORCF, 90020-ORCF, 92322-ORCF, 91725CERT-ORCF, 91725INST-ORCF, 92325-ORCF, 2-ORCF, 91110-ORCF, 91112-ORCF, 91126-ORCF, 91710-ORCF, 92070 - ORCF, 92223-ORCF, 92466A-ORCF, 94000-ORCF, 94001-ORCF, 93332-ORCF, 93481-ORCF, 93486-ORCF, 95379-ORCF, 9443-ORCF, 91128-ORCF, 92414-ORCF, 92464-ORCF, 92476-ORCF, 92476B-ORCF, 9001-ORCF, 9003-ORCF, 9002-ORCF, 9004-ORCF, 9005-ORCF, 9005a-ORCF, 9006-ORCF, 9007-ORCF, 9007a-OCRF, 9009-ORCF, 9444-ORCF, 92333A-ORCF, 92342-ORCF, 92071-ORCF, 92324-ORCF, 92330-ORCF, 92330A-ORCF, 94000B-ORCF, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 92485-ORCF, 935.2D-ORCF, 92000-ORCF, 90023-ORCF, 94000-ORCF-ADD, 94000-ORCF-ADD, 92343-ORCF, 92334-ORCF, 92336-ORCF, 92435-ORCF, 92468-ORCF, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 90030-ORCF, 90031-ORCF, 90033-ORCF, 92266A-ORCF, 92324A-ORCF, 94000-ORCF-ADD, 94000-ORCF-ADD, 91071-ORCF, 92476C-ORCF, 92327-ORCF, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 92334A-ORCF, 92467-ORCF, 94001A-ORCF, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 92340-ORCF, 9445-ORCF, 90012-ORCF, 90013-ORCF, 90015-ORCF, 90016-ORCF, 90017-ORCF, 90018-ORCF, 90019-ORCF, 90022-ORCF, 91118-ORCF, 91130-ORCF, 92434-ORCF, 92479-ORCF, 92456-ORCF, 92554-ORCF, 93305-ORCF, 92450-ORCF, 9442-ORCF, 91123-ORCF, 91124-ORCF, 92023-ORCF, 92415-ORCF, 90014-ORCF, 92455-ORCF, 91725-ORCF, 941-ORCF, 2205a-ORCF, 9839-ORCF, 90024-ORCF, 91111-ORCF, 91116-ORCF, 90021-ORCF, 92328-ORCF, 92403-ORCF, 92437-ORCF, 92448-ORCF, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 94000-ORCF-ADD, 92341-ORCF, 94001-ORCF-RI, 2537-ORCF, 90029-ORCF, 92266-ORCF, 93334-ORCF, 91116A-ORCF, 92338A-ORCF, 94001-ORCF-RI, 92467A-ORCF, 1044-D-ORCF, 92340A-ORCF, 92441B-ORCF, 93335-ORCF, 2747-ORCF, 9807-ORCF, 90032-ORCF, 92266B-ORCF, 92323A-ORCF, 92434A-ORCF, 94000A-ORCF, 91117-ORCF, 92264a-ORCF, 92323-ORCF, 92420-ORCF	Lender Narrative Supplement – Cost Certification ,   Lender Narrative - Fire Safety Equipment Installation, with Existing HUD-Insured Mortgage ,   Lender Narrative – Operating Loss Loan ,   Master Lease Addendum ,   Cross-Default Guaranty of Subtenants ,   Master Lease Subordination, Non-Disturbance and Attornment Agreement ,   Guide for Opinion of Master Tenant’s Counsel ,   Healthcare Regulatory Agreement – Master Tenant ,   Lender Narrative – Substantial Rehabilitation 2 Stage Initial Firm Submission ,   Lender Narrative Substantial Rehabilitation 2 Stage, Final Firm Submission ,   Lender Narrative - Fire Safety Equipment Installation, without Existing HUD-Insured Mortgage ,   Master Tenant Estoppel Certificate ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - KS) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - LA) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - MA) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - MD) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - ME) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - MI) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - MN) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - MO) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - MS) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - MT) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - NC) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - NE) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - NH) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - NJ) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - NM) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - NV) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - NY) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - OH) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - OK) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - OR) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - PA) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - RI) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - SC) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - SD) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - TN) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states -TX) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - UT) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - VA) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - VI) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - VT) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - WA) ,   Contractor's and/or Mortgagor's Cost Breakdown ,   Application for Insurance of Advance of Mortgage Proceeds ,   Request for Construction Changes on Project Mortgages ,   Contractor's Requisition ,   Permission to Occupy ,   Affirmative Fair Housing Marketing Plan – 232 ,   Appraisal Sockets ,   Master Tenant Assignment of Leases and Rents ,   Subordinate Cross-Default Guaranty of Subtenants ,   Termination and Release of Cross-Default Guaranty of Subtenants ,   Amendment to HUD Master Lease (Partial Termination and Release) ,   Limited Guaranty and Security Agreement ,   Management Agreement Addendum ,   Operator Assignment of Leases and Rents ,   Mortgagor's Certificate of Actual Cost ,   Contractor's Certificate of Actual Cost ,   Lender's Certification - Insurance Coverage ,   Healthcare Regulatory Agreement – Fire Safety ,   Rider to Security Instrument - LIHTC ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - AK) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - AL) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - AR) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - AZ) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - CA) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - CNM) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - CO) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - DE) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - FL) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - GA) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - GU) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - HI) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - IA) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - ID) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - IL) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - IN) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - WI) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - WV) ,   Security Instrument/Mortgage/Deed of Trust Addenda (various states - WY) ,   Healthcare Facility Note - Rider (various states - AK) ,   Healthcare Facility Note - Rider (various states - LA) ,   Healthcare Facility Note - Rider (various states - ME) ,   Healthcare Facility Note - Rider (various states - OR) ,   Healthcare Facility Note - Rider (various states - VT) ,   Healthcare Facility Note - Rider (various states - WA) ,   Escrow Agreement for Off-site Facilities ,   Escrow Agreement for Debt Service Reserves ,   Consolidated Operator Opinion [Single State] ,   Multifamily Insurance Branch Claim ,   Application for Insurance Benefits ,   Mortgagee's Application for Partial Settlement ,   Insurance Termination Request ,   232 Healthcare Portal Access ,   Lender Narrative, Requests to Release or Modify Original Loan Collateral ,   Lender Narrative, Accounts Receivable ,   Lender Narrative, Loan Modification ,   Loan Modification Lender Certification ,   Mortgage Record Change - 232 ,   Application for Change of Ownership ,   Lender Narrative, Change of Operator/Lessee ,   Lender Narrative, Change of Management Agent ,   Servicer's Notification to HUD of Risks to Healthcare Project ,   Operator's Notification to HUD of Threats to Permits and Approvals ,   Supplemental Addendum to Operating Lease ,   Supplemental Master Lease Addendum ,   Supplemental Operator Security Agreement ,   Supplemental Operator Assignment of Leases and Rents ,   Supplemental Master Lease SNDA ,   Supplemental Master Tenant Assignment of Leases and Rents ,   Supplemental Healthcare Regulatory Agreement – Master Tenant ,   Supplemental Master Tenant Security Agreement ,   Supplemental Lender's Certificate for 241(a) ,   Supplemental Building Loan Agreement for 241(a) ,   Supplemental Healthcare Regulatory Agreement – Borrower ,   Supplemental Healthcare Regulatory Agreement – Operator ,   Supplemental Security Instrument/Mortgage/Deed of Trust ,   Supplemental Healthcare Facility Note ,   Funds Authorization ,   Borrower’s Certification- Full or Partial Completion of Non-Critical Repairs ,   Model Form - Bill of Sale ,   Application for Transfer of Physical Assets ,   Personal Financial and Credit Statement ,   Certification of Exigent Health & Safety (EH&S) Issues ,   Certification of Physical Condition Compliance ,   Monthly Report for Establishing Net Income ,   Schedule B - Schedule of Disbursements ,   Schedule C - Schedule of Accounts Payable ,   Computation of Surplus Cash, Distributions and Residual Receipts ,   Previous Participation Certification – Controlling Participant ,   Early Commencement/Early Start – Borrower Certification ,   Memo Requesting Post-Commitment Early Start of Construction ,   Design Professional’s Certification of Liability Insurance ,   Design Architect’s Certification ,   Forecasted Staffing Schedule ,   Financial Statement Certification-General Contractor ,   Lender Certification for New Construction, Cost Certifications ,   Request for Final Endorsement of Credit Instrument ,   HUD Amendment to AIA Document B108 ,   Escrow Agreement for Working Capital ,   Request for Permission to Commence Construction ,   Building Loan Agreement ,   Building Loan Agreement Supplemental ,   Construction Contract ,   Performance Bond - Dual Obligee ,   Payment Bond ,   Request for Endorsement of Credit Instrument & Certificate of Lender, Borrower & General Contractor ,   Escrow Agreement for Incomplete Construction ,   Off-Site Bond – Dual Obligee ,   Supplementary Conditions of the Contract for Construction ,   Agreement and Certification ,   HUD Representative’s Trip Report ,   Minor Movable Equipment Escrow Agreement ,   Initial Operating Deficit Escrow Calculation ,   Escrow Agreement For Latent Defects ,   Request for Approval of Advance/Release of Escrow Funds ,   Escrow Agreement for Non-critical, Deferred Repairs ,   Escrow Agreement For Operating Deficits ,   Lender Narrative – Section 232/223(a)7 Refinance ,   Lender Narrative-Section 232/223(f) Refinance ,   Lender Narrative – Section 232/241(a) ,   Lender Narrative – New Construction Single Stage ,   Lender Narrative – New Construction 2 Stage, Initial Firm Submission ,   Lender Narrative – New Construction 2 Stage, Final Firm Submission ,   Lender Narrative – Substantial Rehabilitation Single Stage ,   Master Tenant Security Agreement ,   Certification of Outstanding Obligations - Section 232/223(f) ,   Consolidated Certifications – Lender ,   Consolidated Certifications – Borrower ,   Consolidated Certifications – Principal of Borrower ,   Consolidated Certifications – Operator ,   Consolidated Certifications - Parent of the Operator ,   Consolidated Certifications – Management Agent ,   Consolidated Certifications – Contractor ,   Auditor Certification ,   Certification for Submission of Electronic Firm Application ,   Borrower's Certification - Completion of Critical Repairs ,   Building Code Certification ,   Lender’s Certificate ,   Completion of Assurance ,   Healthcare - Facility Note ,   Accounts Receivable Financing Certification ,   Intercreditor Agreement ,   Operator Estoppel Certificate ,   Guide for Opinion of Borrower’s Counsel ,   Exhibit A to Opinion of Borrower’s Counsel - Certification ,   Instructions to Guide for Opinion of Borrower’s and Operator’s Counsel ,   Guide for Opinion of Operator’s Counsel, and Certification ,   Request for Waiver of Housing Directive ,   Lender’s FHA Number Request ,   Borrower’s Certificate of Actual Cost ,   Management Certification—Residential Care Facility ,   Contact Sheet ,   Subordination, Non-Disturbance and Attornment Agreement of Operating Lease (SNDA) ,   Survey Instructions and Borrower'’s Certification ,   Refund Request for Overpayment of Firm Application Exam Fee ,   Addendum to Operating Lease ,   Financial Statement Certification-Borrower ,   Residual Receipts Note (Nonprofit Borrowers) ,   Lease Addendum ,   Surplus Cash Note ,   Maximum Insurable Loan Calculation ,   Operator Security Agreement ,   Subordination Agreement Financing ,   Healthcare Regulatory Agreement – Borrower ,   Healthcare Regulatory Agreement – Operator ,   Security Instrument/ Mortgage/Deed of Trust

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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	26,125	26,125	0	0	0	0
Annual Time Burden (Hours)	49,226	49,226	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: This is a reinstatement, with changes, to a previously approved collection of the existing collection 2502-0605, which has expired. HUD has clarified the extent to which the documents may be submitted electronically. There have also been changes made to the forms that have now been effective for four years. Changes include those suggested by industry stakeholders as well as HUD staff, to more efficiently and effectively explain and clarify the nature of the documents and requirements there. New documents have also been added to the collection as part of this revision, to provide standardized methods for submitting information requests to HUD that were previously being done, but not in a standard way, via an OMB form. The additions are effectuating already existing program requirements. Further, there have been documents added to the collection that were previously listed under various Multifamily Housing collections and were inadvertently omitted from the original ORCF collection as being applicable specifically to ORCF participants. Please note that the forms are still available in the original Multifamily collections, for use by Multifamily participants, and the forms added to this healthcare collection are similar versions but related specifically to healthcare transactions. These additions do create an overall increase to the burden hours noted in the collection, as provided in section 12 above; however, in most cases, these were burden hours already being realized by the participants, since those forms from Multifamily were still being collected by ORCF to verify the necessary submission information, and the requirements for prior HUD approval of certain procedures (such as changing the collateral of a project or the addition of accounts receivable financing) also entailed providing ORCF with documented information, but not in a standardized form. Multifamily was not counting these burden hours in their collection, since they were not aware of the forms being used for healthcare transactions; thus, no duplication of hours was being counted.

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Annual Cost to Federal Government: $5,667,253

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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:  Yes

Description/Changes for Common Form Usage: 

Approved RCFs using this ICR

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

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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: 11/12/2019

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