# PAPERWORK REDUCTION ACT SUBMISSION

+-----------------+------------------+----------+-----------+---------+
| Please read the |                  |          |           |         |
| instructions    |                  |          |           |         |
| before          |                  |          |           |         |
| completing this |                  |          |           |         |
| form. For       |                  |          |           |         |
| additional      |                  |          |           |         |
| forms or        |                  |          |           |         |
| assistance in   |                  |          |           |         |
| completing this |                  |          |           |         |
| form, contact   |                  |          |           |         |
| your agency's   |                  |          |           |         |
| Paperwork       |                  |          |           |         |
| Clearance       |                  |          |           |         |
| Officer. Send   |                  |          |           |         |
| two copies of   |                  |          |           |         |
| this form, the  |                  |          |           |         |
| collection      |                  |          |           |         |
| instrument to   |                  |          |           |         |
| be reviewed,    |                  |          |           |         |
| the supporting  |                  |          |           |         |
| statement, and  |                  |          |           |         |
| any additional  |                  |          |           |         |
|                 |                  |          |           |         |
| **documentation |                  |          |           |         |
| to: Office of   |                  |          |           |         |
| Information and |                  |          |           |         |
| Regulatory      |                  |          |           |         |
| Affairs, Office |                  |          |           |         |
| of Management   |                  |          |           |         |
| and Budget,     |                  |          |           |         |
| Docket Library, |                  |          |           |         |
| Room 10101, 725 |                  |          |           |         |
| 17^th^ Street** |                  |          |           |         |
|                 |                  |          |           |         |
| **NW,           |                  |          |           |         |
| Washington, DC  |                  |          |           |         |
| 20503.**        |                  |          |           |         |
+-----------------+------------------+----------+-----------+---------+
| 1\.             |                  | 2\. OMB  |           |         |
| A               |                  | Control  |           |         |
| gency/Subagency |                  | Number   |           |         |
| originating     |                  | b. None  |           |         |
| request         |                  |          |           |         |
|                 |                  | a\.      |           |         |
| ## U.S. Agency  |                  | [041     |           |         |
|  for Internatio |                  | 2]{.unde |           |         |
| nal Development |                  | rline} - |           |         |
|                 |                  | [        |           |         |
|                 |                  |    ]{.un |           |         |
|                 |                  | derline} |           |         |
+-----------------+------------------+----------+-----------+---------+
| 3\. Type of     |                  | 4\. Type |           |         |
| information     |                  | of       |           |         |
| collection      |                  | review   |           |         |
| *(check one)*   |                  | r        |           |         |
|                 |                  | equested |           |         |
| a\. New         |                  | *(check  |           |         |
| Collection      |                  | one)*    |           |         |
|                 |                  |          |           |         |
| b\. Revision of |                  | a\.      |           |         |
| a currently     |                  | Regular  |           |         |
| approved        |                  | Su       |           |         |
| collection      |                  | bmission |           |         |
|                 |                  |          |           |         |
| c\. Extension   |                  | b\.      |           |         |
| of a currently  |                  | E        |           |         |
| approved        |                  | mergency |           |         |
| collection      |                  | --       |           |         |
|                 |                  | Approval |           |         |
| d\.             |                  | r        |           |         |
| Reinstatement,  |                  | equested |           |         |
| without change, |                  | by       |           |         |
| of a previously |                  |          |           |         |
| approved        |                  | c\.      |           |         |
| collection for  |                  | D        |           |         |
| which approval  |                  | elegated |           |         |
| has expired     |                  |          |           |         |
|                 |                  |          |           |         |
| e\.             |                  |          |           |         |
| Reinstatement,  |                  |          |           |         |
| with change, of |                  |          |           |         |
| previously      |                  |          |           |         |
| approved        |                  |          |           |         |
| collection for  |                  |          |           |         |
| which approval  |                  |          |           |         |
| has expired     |                  |          |           |         |
|                 |                  |          |           |         |
| f\. Existing    |                  |          |           |         |
| collection in   |                  |          |           |         |
| use without an  |                  |          |           |         |
| OMB control     |                  |          |           |         |
| number          |                  |          |           |         |
|                 |                  |          |           |         |
| For b -- f,     |                  |          |           |         |
| note Item A2 of |                  |          |           |         |
| Supporting      |                  |          |           |         |
| Statement       |                  |          |           |         |
| instructions    |                  |          |           |         |
+-----------------+------------------+----------+-----------+---------+
|                 |                  | 5\.      |           |         |
|                 |                  | Small    |           |         |
|                 |                  | entities |           |         |
|                 |                  |          |           |         |
|                 |                  | Will     |           |         |
|                 |                  | this     |           |         |
|                 |                  | inf      |           |         |
|                 |                  | ormation |           |         |
|                 |                  | co       |           |         |
|                 |                  | llection |           |         |
|                 |                  | have a   |           |         |
|                 |                  | sig      |           |         |
|                 |                  | nificant |           |         |
|                 |                  | economic |           |         |
|                 |                  | impact   |           |         |
|                 |                  | on a     |           |         |
|                 |                  | sub      |           |         |
|                 |                  | stantial |           |         |
|                 |                  | number   |           |         |
|                 |                  | of small |           |         |
|                 |                  | e        |           |         |
|                 |                  | ntities? |           |         |
|                 |                  | Yes No   |           |         |
+-----------------+------------------+----------+-----------+---------+
|                 |                  | 6\.      |           |         |
|                 |                  | R        |           |         |
|                 |                  | equested |           |         |
|                 |                  | ex       |           |         |
|                 |                  | piration |           |         |
|                 |                  | date     |           |         |
|                 |                  |          |           |         |
|                 |                  | a\.      |           |         |
|                 |                  | Three    |           |         |
|                 |                  | years    |           |         |
|                 |                  | from     |           |         |
|                 |                  | approval |           |         |
|                 |                  | date b.  |           |         |
|                 |                  | Other    |           |         |
|                 |                  | Specify: |           |         |
|                 |                  |          |           |         |
+-----------------+------------------+----------+-----------+---------+
| 7\. Title       |                  |          |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
+-----------------+------------------+----------+-----------+---------+
| 8\. Agency form |                  |          |           |         |
| number(s) *(if  |                  |          |           |         |
| applicable)*    |                  |          |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
+-----------------+------------------+----------+-----------+---------+
| 9\. Keywords    |                  |          |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
+-----------------+------------------+----------+-----------+---------+
| 10\. Abstract   |                  |          |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
+-----------------+------------------+----------+-----------+---------+
| 11\. Affected   |                  | 12\.     |           |         |
| public *(Mark   |                  | Ob       |           |         |
| primary with    |                  | ligation |           |         |
| "P" and all     |                  | to       |           |         |
| others that     |                  | respond  |           |         |
| apply with      |                  | *(check  |           |         |
| "x")*           |                  | one)*    |           |         |
|                 |                  |          |           |         |
|                 |                  | a\.      |           |         |
|                 |                  | V        |           |         |
|                 |                  | oluntary |           |         |
|                 |                  |          |           |         |
|                 |                  | b\.      |           |         |
|                 |                  | Required |           |         |
|                 |                  | to       |           |         |
|                 |                  | obtain   |           |         |
|                 |                  | or       |           |         |
|                 |                  | retain   |           |         |
|                 |                  | benefits |           |         |
|                 |                  |          |           |         |
|                 |                  | c\.      |           |         |
|                 |                  | M        |           |         |
|                 |                  | andatory |           |         |
+-----------------+------------------+----------+-----------+---------+
| a\. Individuals | d\. Farms        |          |           |         |
| or households   |                  |          |           |         |
|                 | e\. Federal      |          |           |         |
| b\. Business or | Government       |          |           |         |
| other for       |                  |          |           |         |
| profit          | f\. State, Local |          |           |         |
|                 | or Tribal        |          |           |         |
| c\.             | Government       |          |           |         |
| Not-for-profit  |                  |          |           |         |
| institutions    |                  |          |           |         |
+-----------------+------------------+----------+-----------+---------+
| 13\. Annual     |                  | 14\.     |           |         |
| recordkeeping   |                  | Annual   |           |         |
| and reporting   |                  | r        |           |         |
| burden          |                  | eporting |           |         |
|                 |                  | and      |           |         |
| a.  Number of   |                  | recor    |           |         |
|     respondents |                  | dkeeping |           |         |
|                 |                  | cost     |           |         |
|                 |                  | burden   |           |         |
| b.  Total       |                  | *(in     |           |         |
|     annual      |                  | t        |           |         |
|     responses   |                  | housands |           |         |
|                 |                  | of       |           |         |
|                 |                  | d        |           |         |
|                 |                  | ollars)* |           |         |
|  1.  Percentage |                  |          |           |         |
|         of      |                  | a        |           |         |
|         these   |                  | .  Total |           |         |
|                 |                  |     an   |           |         |
|       responses |                  | nualized |           |         |
|                 |                  |          |           |         |
| > collected     |                  |  capital |           |         |
| >               |                  | /startup |           |         |
|  electronically |                  |          |           |         |
| >               |                  |    costs |           |         |
|                 |                  |          |           |         |
| c.  Total       |                  |          |           |         |
|     annual      |                  |          |           |         |
|     hours       |                  | b        |           |         |
|     requested   |                  | .  Total |           |         |
|                 |                  |          |           |         |
|                 |                  |   annual |           |         |
| d.  Current OMB |                  |          |           |         |
|     inventory   |                  |    costs |           |         |
|                 |                  |          |           |         |
|                 |                  |    (O&M) |           |         |
| e.  Difference  |                  |          |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
| f.  Explanation |                  | c        |           |         |
|     of          |                  | .  Total |           |         |
|     difference  |                  |     an   |           |         |
|                 |                  | nualized |           |         |
|     1.  Program |                  |     cost |           |         |
|         change  |                  |     r    |           |         |
|                 |                  | equested |           |         |
|                 |                  |          |           |         |
| > 2\.           |                  |          |           |         |
| > Adjustment    |                  |          |           |         |
| >               |                  | d.       |           |         |
|                 |                  |  Current |           |         |
|                 |                  |     OMB  |           |         |
|                 |                  |     i    |           |         |
|                 |                  | nventory |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
|                 |                  | e.  Di   |           |         |
|                 |                  | fference |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
|                 |                  | f.  Exp  |           |         |
|                 |                  | lanation |           |         |
|                 |                  |     of   |           |         |
|                 |                  |     di   |           |         |
|                 |                  | fference |           |         |
|                 |                  |          |           |         |
|                 |                  |     1.   |           |         |
|                 |                  |  Program |           |         |
|                 |                  |          |           |         |
|                 |                  |   change |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
|                 |                  |   2.  Ad |           |         |
|                 |                  | justment |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
+-----------------+------------------+----------+-----------+---------+
| 15\. Purpose of |                  | 16\.     |           |         |
| information     |                  | F        |           |         |
| collection      |                  | requency |           |         |
| *(Mark primary  |                  | of       |           |         |
| with "P" and    |                  | recor    |           |         |
| all others that |                  | dkeeping |           |         |
| apply with      |                  | or       |           |         |
| "X")*           |                  | r        |           |         |
|                 |                  | eporting |           |         |
|                 |                  | (check   |           |         |
|                 |                  | all that |           |         |
|                 |                  | apply)   |           |         |
|                 |                  |          |           |         |
|                 |                  | a\.      |           |         |
|                 |                  | Recor    |           |         |
|                 |                  | dkeeping |           |         |
|                 |                  | b. Third |           |         |
|                 |                  | party    |           |         |
|                 |                  | di       |           |         |
|                 |                  | sclosure |           |         |
|                 |                  |          |           |         |
|                 |                  | c\.      |           |         |
|                 |                  | R        |           |         |
|                 |                  | eporting |           |         |
+-----------------+------------------+----------+-----------+---------+
| a\. ""          | e\. "" Program   | 1\. On   | 2\.       | 3\.     |
| Application for | planning or      | occasion | Weekly    | Monthly |
| benefits        | management       |          |           |         |
|                 |                  | 4\.      | 5\.       | 6\.     |
| b\. "" Program  | f\. "" Research  | Q        | Semi      | A       |
| evaluation      |                  | uarterly | -annually | nnually |
|                 | g\. ""           |          |           |         |
| c\. "" General  | Regulatory or    | 7\.      |           |         |
| purpose         | compliance       | Bi       |           |         |
| statistics      |                  | ennially |           |         |
|                 |                  |          |           |         |
| d\. "" Audit    |                  |          |           |         |
+-----------------+------------------+----------+-----------+---------+
|                 |                  |          | 8\. Other |         |
|                 |                  |          | (         |         |
|                 |                  |          | describe) |         |
|                 |                  |          | [         |         |
|                 |                  |          |      ]{.u |         |
|                 |                  |          | nderline} |         |
+-----------------+------------------+----------+-----------+---------+
| Code of Federal |                  |          |           |         |
| Regulations,    |                  |          |           |         |
| Title 22 of FA  |                  |          |           |         |
| Act, Chapter V. |                  |          |           |         |
+-----------------+------------------+----------+-----------+---------+
| 17\.            |                  | 18\.     |           |         |
| Statistical     |                  | Agency   |           |         |
| Methods         |                  | Contact  |           |         |
|                 |                  | (person  |           |         |
| > Does this     |                  | who can  |           |         |
| > information   |                  | best     |           |         |
| > collection    |                  | answer   |           |         |
| > employ        |                  | q        |           |         |
| > statistical   |                  | uestions |           |         |
| > methods       |                  | r        |           |         |
| >               |                  | egarding |           |         |
| > Yes No        |                  | the      |           |         |
|                 |                  | content  |           |         |
|                 |                  | of this  |           |         |
|                 |                  | sub      |           |         |
|                 |                  | mission) |           |         |
|                 |                  |          |           |         |
|                 |                  | Name:    |           |         |
|                 |                  |          |           |         |
|                 |                  |          |           |         |
|                 |                  | Phone:   |           |         |
|                 |                  |          |           |         |
+-----------------+------------------+----------+-----------+---------+

OMB 83-I (10/95)

+------------------------------------------------------+---------------+
| 19. **Certification for Paperwork Reduction Act      |               |
|     Submissions**                                    |               |
|                                                      |               |
| On behalf of this Federal Agency, I certify that the |               |
| collection if information encompassed by this        |               |
| request complies with 5 CFR 1320.9                   |               |
|                                                      |               |
| > **NOTE:** The text of 5 CFR 1320.9, and the        |               |
| > related provisions of 5 CFR 1320.8(b)(3), appears  |               |
| > at the end of the instructions. *The certification |               |
| > is to be made with reference to those regulatory   |               |
| > provisions as set forth in the instructions*.      |               |
|                                                      |               |
| 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 used plain, coherent, and unambiguous         |               |
|     terminology that is understandable to            |               |
|     respondents;                                     |               |
|                                                      |               |
| (e) Its implementation will be consistent and        |               |
|     compatible with current reporting and            |               |
|     recordkeeping practices                          |               |
|                                                      |               |
| (f) It indicates the retention period for            |               |
|     recordkeeping requirements;                      |               |
|                                                      |               |
| (g) It informs respondents of the information called |               |
|     for under 5 CFR 1320.8(b)(3);                    |               |
|                                                      |               |
| > \(i\) Why the information is being collected;      |               |
|                                                      |               |
| ii. Use of information;                              |               |
|                                                      |               |
| iii. Burden estimate;                                |               |
|                                                      |               |
| iv. Nature of response (voluntary, required for a    |               |
|     benefit, mandatory);                             |               |
|                                                      |               |
| v.  Nature and extent of confidentiality; and        |               |
|                                                      |               |
| vi. Need to display currently valid OMB control      |               |
|     number;                                          |               |
|                                                      |               |
| ```{=html}                                           |               |
| <!-- -->                                             |               |
| ```                                                  |               |
| (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 (see note in Item 19 of          |               |
|     instructions);                                   |               |
|                                                      |               |
| (i) It uses effective and efficient statistical      |               |
|     survey methodology; and                          |               |
|                                                      |               |
| (j) It makes appropriate use of information          |               |
|     technology.                                      |               |
|                                                      |               |
| If you are unable to certify compliance with any of  |               |
| the provisions, identify the item below and explain  |               |
| the reason in Item 18 of the Supporting Statement.   |               |
+------------------------------------------------------+---------------+
| Signature of Senior Official or designee             | Date          |
+------------------------------------------------------+---------------+
|                                                      |               |
+------------------------------------------------------+---------------+

OMB 83-I