OMB Control No. 1820-0625

Exp. Date: XX-XX-XXXX

REHABILITATION SERVICES ADMINISTRATION

SECTION 509 -- PAIR ASSURANCES

Yes An eligible system

(1) has in effect a system to protect and advocate for the rights of eligible individuals with

disabilities;

(2) has the same general authorities, including access to records and program income, as are 

set forth in part C of the Developmental Disabilities Assistance and Bill of Rights Act of 

2000 (42 U.S.C. 6041 et seq.);

(3) has the authority to pursue legal, administrative, and other appropriate remedies or 

approaches to ensure the protection of, and advocacy for, the rights of eligible individuals 

with disabilities within the State or the American Indian Consortium;

(4) provides information on and makes referrals to programs and services addressing the 

needs of individuals with disabilities in the State or the American Indian Consortium, 

including individuals with disabilities who are exiting from public school programs;

(5) develops a statement of objectives and priorities on an annual basis, and a plan for 

achieving these objectives and priorities; 

*(6) provides to the public, including individuals with disabilities and, as appropriate, their 

representatives, an opportunity to comment on the objectives and priorities established by, 

and activities of, the eligible system including -

*(A) the objectives and priorities for the activities of the eligible system for each year and the 

rationale for the establishment of such objectives and priorities; and

*(B) the coordination of programs provided through the eligible system with the advocacy 

programs of the Client Assistance Program under Section 112 of the Rehabilitation Act of 

1973, as amended, the State Long-Term Care Ombudsman program established under the 

Older Americans Act of 1965 (42 U.S.C. 3001-3030), Part C of the Developmental 

Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 6041 et seq.), and the 

Protection and Advocacy of Individuals with Mental Illness Act (42 U.S.C. 10801 et seq.):

*(7) establishes a grievance procedure for clients or prospective clients of the eligible system 

to ensure that individuals with disabilities are afforded equal access to the services of the 

eligible system;

(8) uses the funds made available to the PAIR program to supplement and not supplant the 

non-Federal funds that would otherwise be made available for the purpose for which Federal 

funds are provided;

(9) implements procedures designed to ensure that, to the maximum extent possible, 

mediation (and other alternative dispute resolution) procedures, which include good faith 

negotiation, are used before resorting to formal administrative or legal remedies; and

(10) assures that direct payment of funds under the PAIR program is not prohibited by nor 

inconsistent with State law, regulation or policy.

As a duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above assurances.

Name of Applicant:

Printed name and title of authorized representative:

Signature: Date:

* Applicants should attach the information (marked with an asterisk above) to the application 

package in the order in which the information is presented in the above Assurances. Applicants 

should label the attachments clearly according to the applicable Assurance.
OMB Control No. 1820-0625

Exp. Date: XX-XX-XXXX

Paperwork Reduction Act 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. Public 

reporting burden for this collection of information is estimated to average 10 minutes per 

response, including time for reviewing instructions, searching existing data sources, gathering 

and maintaining the data needed, and completing and reviewing the collection of information. 

The obligation to respond to this collection is required to obtain or retain benefit pursuant to 

Section 509 of the Rehabilitation Act of 1973, as amended, and its implementing federal 

regulations at 34 CFR Part 381. Send comments regarding the burden estimate or any other 

aspect of this collection of information, including suggestions for reducing this burden, to the 

U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email 

ICDocketMgr@ed.gov and reference the OMB Control Number 1820-0625. Note: Please do not 

return the completed Rehabilitation Services Administration Section 509 PAIR Assurances form

to this address.