Application for Small, Rural School Achievement Program

CFDA 84.358A

**U.S. Department of Education**

**Applicant Information** Organizational Unit

**1.** Name of
LEA/District:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_ - \_\_\_\_\_\_\_\_

City State County ZIP Code + 4

**2.** Applicant's D-U-N-S Number
\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|

**3.** Applicant's T-I-N \|\_\_\_\|\_\_\_\| -
\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\| **6.** Is the
applicant delinquent on any Federal debt? ­\_\_\_Yes \_\_\_No

**4.** Applicant's NCES LEA ID Number
\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|\_\_\_\|

**5.** LEA Contact:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_

City State Zip code + 4

Tel. #: ( ) \_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_ Fax #: (
)\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_

E-Mail Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**7.** Is application subject to review by Executive Order 12372
process?

\_\_\_ Yes (*Date made available to the Executive Order 12372*

*process for review):* \_\_\_\_/\_\_\_\_/\_\_\_\_\_\_\_\_\_

\_\_\_ No *(If "No," check appropriate box below.)*

\_\_\_ Program is not covered by E.O. 12372.

\_\_\_ Program has not been selected by State for review.

**8.** The LEA, through the signature of its authorized representative,
provides the assurances and certifications required in the following
documents that are incorporated by reference into this application:

-   The assurances in Standard Form 424B (Assurances -- Non-Construction
    Programs).

-   The certifications in ED-Form 80-0013 regarding lobbying,
    debarment/suspension/responsibility status, and drug-free workplace.

With respect to the Certification Regarding Lobbying, the LEA certifies
that no Federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee
of any agency, a Member of Congress, an officer or employee of Congress,
or an employee of a Member of Congress in connection with the making or
renewal of Federal grants under this program; that the LEA shall
complete and submit Standard Form-LLL, \"Disclosure Form to Report
Lobbying,\" when required (34 C.F.R. Part 82, Appendix B); and that the
LEA shall require the full certification, as set forth in 34 C.F.R. Part
82, Appendix A, in the award documents for all subawards at all tiers.

**Authorized Representative Information**

**9.** To the best of my knowledge and belief, all data in this
application are true and correct. The document has been duly authorized
by the governing body of the applicant and the applicant will comply
with the attached assurances if the assistance is awarded.

**a.** Authorized Representative (*Please type or print name clearly*.)

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**b.** Title:
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**c.** Tel. #: ( ) \_\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_\_\_\_\_ Fax #: ( )
\_\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_\_\_\_\_

E-Mail Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**e. Signature of Authorized Representative:**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:\_\_\_/\_\_\_\_/\_\_\_\_\_\_

**INSTRUCTIONS**

> **1.** **Name of LEA/District.** Enter the name of the applicant
> district or the primary organizational unit that will undertake the
> assistance activity.
>
> **2.** **D-U-N-S Number.** Enter the applicant's D-U-N-S Number. If
> your organization does not have a D-U-N-S Number, you can obtain the
> number by calling 1-800-333-0505 or by completing a D-U-N-S Number
> Request Form. The form can be obtained via the Internet at the
> following URL: **http://www.dnb.com.**
>
> **3. Tax Identification Number.** Enter the taxpayer's identification
> number as assigned by the Internal Revenue Service.

4.  **NCES LEA ID Number.** Enter the NCES LEA ID number. If you don't
    know it, go to

> http://www.nces.ed.gov/ccdweb/school/index.asp. Please make sure you
> review eligibility requirements for this program.

5.  **LEA Contact.** Name, address, telephone and fax numbers, and
    e-mail address of the person to be contacted on matters involving
    this application.

6.  **Federal Debt Delinquency.** Check **"Yes"** if the applicant's
    organization is delinquent on any Federal debt. (This question
    refers to the applicant's organization and not to the person who
    signs as the authorized representative. Categories of debt include
    delinquent audit disallowances, loans and taxes.) Otherwise, check
    **"No."**

7.  **Executive Order 12372.** Check **"Yes"** if the application is
    subject to review by E.O. 12372. Also, please enter the month, day,
    and four (4) digit year (e.g., 12/12/2001). Otherwise, check
    **"No."** The purpose of Executive Order 12372 is to foster an
    intergovernmental partnership and strengthen federalism by relying
    on State and local processes for the coordination and review of
    proposed Federal financial assistance and direct Federal
    development. The application notice, as published in the Federal
    Register, informs the applicant as to whether the program is subject
    to the requirements of E.O. 12372. In addition, the application
    package contains information on the State Single Point of Contact.
    An applicant is still eligible to apply for a grant or grants even
    if its respective State, Territory, Commonwealth, etc. does not have
    a State Single Point of Contact. For additional information on E.O.
    12372 go to <http://www.cfda.gov/public/eo12372.htm>.

> **8. Incorporation by reference of assurances and certifications.**
> This application incorporates the references the assurances and
> certifications listed on the form and the applicant, through the
> signature of its authorized representative, hereby provides those
> assurances and certifications.
>
> **9. Authorized representative information and signature.** Provide
> the listed information and have the application signed by the
> authorized representative of the applicant. A copy of the governing
> body's authorization for you to sign this application as official
> representative must be on file in the applicant's office. Be sure to
> enter the telephone and fax number and e-mail address of the
> authorized representative. Also, in item 15e, please enter the month,
> day, and four (4) digit year (e.g., 12/12/2001) in the date signed
> field.

Paperwork Burden Statement. **According to the Paperwork Reduction Act
of 1995, no persons are required to respond to a collection of
information unless such collection displays a valid OMB control number.
The valid OMB control number for this information collection is**
1810-XXXX**. The time required to complete this information collection
is estimated to average 20 minutes per response, including the time to
review instructions, search existing data resources, gather the data
needed, and complete and review the information collection.** If you
have any comments concerning the accuracy of the estimate(s) or
suggestions for improving this form, please write to: **U.S. Department
of Education, Washington, D.C. 20202-4651.** If you have comments or
concerns regarding the status of your individual submission of this form
write directly to: Mr. Charles Lovett, Office of School Support and
Technology Programs, U.S. Department of Education, 400 Maryland Avenue,
S.W., Rm. 3E241, Washington, D.C. 20202-6400.