1 **U.S. DEPARTMENT OF EDUCATION** FORM APPROVED **WASHINGTON, DC 20202 -**  **6244** OMB NO. 1810
- 0657 EXPIRATION DATE: 

### IMPACT AID PROGRAM **INSTRUCTIONS FOR COMPLETING APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM, SECTION 8007(b), ELEMENTARY AND SECONDARY**  **EDUC ATION ACT** 
**Public 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 4.5 hours 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 (20 USC 7707(b) Elementary and Secondary

Education Act, as amended) . 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, Impact Aid Program, U.S. Department of Education, 400 Maryland Ave., S.W., Washington, D.C. 20202
- 6244 or email IC DocketMgr@ed.gov and reference the OMB Control Number 1810
- 0657
. Please read these instructions and the application notice carefully before you complete the application. You should also review the authorizing statute (section 8007(b) of the Elementary and Secondary

Education Act) and regulations (34 CFR Part 222), which provide detailed eligibility requirements, definitions of terms, and the specific requirements of various sections of the law. The authorizing legislation and regulations are available on the Impact Aid Program (IAP) Internet web site, www.ed.gov/offices/OESE/ImpactAid , or from the IAP. If you need further assistance in preparing this application please call the IAP at 202/260

- 3858. **WHO MAY APPLY** A limited number of local educational agencies (LEAs) that are eligible for funding under the Impact Aid Program and that meet certain fiscal capacity and effort requirements may a ppl y for assistance under the discretionary c onstruction program. S ee the program regulations at 34 CFR 222.170 for complete eligibility requirements. **HOW AND WHEN TO APPLY The deadline for submitting this electronic application is 4:30 p.m., Washington, D.C. time,** 

**__________________________ .**  Also, fax the original signed copies of the application cover page to the U.S. Department of Education Impact Aid Program by 4 :30 p.m., Washington, D.C. time, on the deadline date. An applicant for an emergency grant must also submit by f ax a signed certification by a l ocal2

official, on letter

head, that the deficiency in the school facility

i dentified in the application threatens the health or safety of the occupants or prevents the use of all or a portion of the building. An application cannot be considered timely f iled and eligible for consi deration for funding unless all of these documents are received by the application deadline. **The fax number for the Application Control Center is (866) 799**  **- 1272**  When an LEA submits the application to the U.S. Department of Education, it must forward a complete cop y of the application to its state educational agency ( SEA). At the same time, if its state participates in the Executive Order 12372 review process, it must submit a copy o f the application to its state's designated single point of contact.

**CO VER PAGE**  **(PAGE 1) Emergency Grant**  An applicant that wishes to appl y for funding for more than one school facility must submit a separate application for each school facility

. **Federal Debt Delinquency** Check Yes if the applicant’s organization is delinquent on any F ederal debt. ( This question refers to the applicant’s organization and not to the person who signs as the authorized representative. C ategories of debt include delinquent audit disallowances, loans and taxes.) Otherwise, check No. **Applican t’s**  **DUNS Number**  Enter the LEA’s DUNS number that is used on the LEA’s section 8003 or section 8002 application. This number also may be found on any

Impact Aid pay

ment voucher the LEA has received since 1999
. **Applicant’s Taxpayer Identification Number** Enter the LEA’s taxpayer identification number as assigned b y the Internal Revenue Service
. **Applicant’s Impact Aid Number** Enter the LEA’s Impact Aid Number that is used on the LEA’s section 8003 or section 8002 application. This number also may b e found on any

Impact Aid pay

ment voucher the LEA has received.3

**LEA Identification and Address** Make corrections to the LEA name and address information that is displayed, if necessary
. **Contact Person** Enter the name, title, phone and fax numbers, and e

- mail address of the appropriate person to be contacted at the LEA if there are questions regarding this application. **Name of School Facility** Enter the name of the school facility f or which funding is requested. An applicant that wishes to apply f or funding for more than one school facility must submit a separate application for each school facility
. **Enrollment** Enter the total enrollment in this school facility for school ye ar 2010
- 2011 as of the survey date reported on the local educational agency ’s fiscal year 200 8 application for section 8003
. **Executive Order 12372 Review** Enter the date the LEA’s application was submitted to its state for review. If the applicant’s state does not participate in this review process or has not selected this program for review, enter N/A (for not a pplicable). See the appendix for additional information

. **Authorized Representative Certification** Enter the name and title of the LEA’s authorized representative. The representative must sign and date the cover page of the a pplication, the Impact Aid Program Assurances and Certifications page, the Assurances for Construction Programs, and the Additional Department of Education Construction Assurances. The IAP c annot consider an application for funding unless it is complete and timely f iled. This means that the forms must be submitted electronically and the signature pages must be faxed by the application deadline.

**ADDITIONAL INFORMATION (PAGE 2)**  **Interest in School Facility** Check **Own, Lease**  or **Other**
. I f you check **Leas e**  , enter the expiration date of the lease. I f you check **Other** , provide additional information describing the arrangement for use of the building.4

**Type of Special District** If the applicant is a charter school, Alaskan Rural Education Attendance Area, or coterminous district, please check the appropriate box. **Age of School Facility** Enter the ye ar the facility was built. If this building has had major renovations or additions since the original construction, enter the ye ar and describe the nature of the renovation (e.g., replacement of roof, replacement of heating, ventilation and air conditioning system, construction of additional classrooms). **Acreage in LEA** Enter the total acres of land within the boundaries of the LEA. Enter the total acres of nontaxable Federal property within the boundaries of the LEA. Applicants may include Federal property that is not eligible for payments under section 8002 in the second figure. **Bonded Indebtedness** Enter the maximum bonding capacity of the LEA. Enter the amount of bonded debt owed by the LEA. Both these amounts must be as of the end of the LEA ’s 2003
- 2007 school ye ar. **Assessed Value** For each taxing jurisdiction within the LEA, enter the total assessed value of the real property (land and improvements) in the LEA that was taxed for school purposes for school ye ar 2010
- 2011
. M ost LEAs have a single taxing jurisdiction and may u se just one line on this form to enter their data. S ome LEAs contain multiple jurisdictions such as townships or are located in more than one jurisdiction such as two counties and must use multiple lines on this form.

**PROJECT NARRATIVE FOR EMERGENCY GRANT APPLICATION (PAGE 3)**  Enter the proposed start and end dates for the project. Prepare a complete but succinct description of the proposed project that includes the following information:

 Detailed description of the nature and scope of the emergency condition
 Identify

which mechanical systems are impacted
 How much of the building is involved5

 Identify

the population affected (students, teachers, administrators, etc.)
 Identify

the proportion of the building occupants affected by the condition. Describe how the emergency c ondition adversel y affects the health, safety and well

-being of the occupants of the school facility
. Describ e any actions the applicant has taken to respond to the emergency c ondition, and why

the applicant has been unable to resolve the condition. Describe how the proposed project will address the emergency c ondition, and indicate the potential effects of delaying the project, including increased future costs. Describe the proposed project in detail. Provide information on how the proposed project will address the emergency

c ondition. Include a timeline of major activities such as design, contract solicitati on and award, and construction begin and end dates. Report other resources available to the LEA that can be used for this project. Include anticipated receipts such as state construction grants, which the LEA has not actually yet received. Limit the l ength of the project narrative to the space provided on the form. Do not include supplemental drawings, photographs, or other extraneous materials relating to the proposed project as the reviewers will not consider them.

**INDEPENDENT CERTIFICATION FOR E MERGENCY GRANT APPLICATION**  **(PAGE 4)** Enter the name, title and organization of the certifying local official. An application for an emergency

grant must include a signed statement on this form from a n appropriate certifying official certifying that the de ficiency described in the narrative for the proposed project threatens the health or safety of the occupants or prevents the use of all or a portion of the building. The certifying official must either use the form provided or submit a report on official letterhead. Appropriate certifying officials may include individuals such as fire marshals, state building inspectors, local zoning officials, military installation officials, Indian Health Services officials, or other individuals who are responsible for inspecting school facilities and identifying health and safety deficiencies. Certifying officials may not be a staff member of the applicant LEA.6 **JUSTIFICATION FOR REBUILDING**

**(PAGE 5)** An applicant that believes that rebuilding would be less expensive or more cost effective than repairing or renovating the existing facility must provide a detailed justification, including cost estimates for both alternatives. The applicant may propose rebuilding only if the LEA holds title to the existing facility

for which funding is requested. Limit the length of this project narrative to the space provided on the form. Do not include drawings, designs, or other extraneous documents regarding proposed projects because reviewers will not consider them.

**COST ESTIMATE TABLE**  **(PAGE 6)**
The data entered on this table should be based on actual estimates
. The estimates should take into consideration the delay

between the application for funds and actual construction. On line (a), provide an estimate of the direct costs as sociated with this project. While there are no indirect costs allowed for these projects, a district may be reimbursed for direct costs that are necessary and reasonable to the grant. Examples of acceptable direct costs are supplies, equipment, advertising, and travel. On line (b) provide an estimate for the planning and design phase of the project. Examples of associated costs are construction feasibility study, building plan s and specifications, the creation of bid documents, and engineering services. On line (c) provide the estimated cost of construction. Examples of costs related to construction are the independent construction manager, labor, materials, and equipment costs. On line (d) provide estimates for state and local permits, compliance monitoring, taxes , contingency

planning, and any

other miscellaneous costs. On line (e) sum lines (a) through (d) and place the sub totals in each column. On line (f) identify

any other available resources from local or state sources. S ubtract line (f) f

rom line (e) and place the result on (g)
.7

**CHILDREN WHO ATTENDED THIS SCHOOL FACILITY AND WHO WERE INCLUDED ON TABLES 1 THROUGH 5 OF THE APPLICANT’S SECTION 8003**  **APPLICATION (PAGES 7 THROUGH 10)**  Report on these pages those children included on Tables 1 through 5 of the applicant’s section 8003 FY 20 12 (school year 20 10
- 20 11 ) application who attended the school facility for which funding is requested.

**ASSURANCES AND CERTIFICATIONS (PAGES 11**  **AND SF -**  **424D)** The authorized representative for the LEA should review these assurances and certifications and then sign and date each form. The signature of the LEA’s representative commits the applicant to the assurances contained in the application, including the assurance that the applicant meets all statutory, regulatory

and administrative requirements.

**FINANCIAL INFORMATION** The Impact Aid Program will request audited financial reports for the preceding three ye ars from highl y ranked applicants before final award decisions are made. These reports will be use d to verify the amount of available funds that could be used for this project. In cases where matching funds are required, additional documentation of in

- kind contributions will be requested at that time
. The IAP may

contact state officials to verify dat a provided b y an LEA in this application or in any additional data request, including funds that an LEA may receive from a state school construction program.

**CONSTRUCTION FEASIBILITY STUDY**

For selected applicants requesting funding for new construction , the Impact Aid Program will request a feasibility

o f construction study

prior to making an award determination. The independent third party study should demonstrate that the area upon which the construction will occur is suitable for construction and wil l be able to sustain the new facility or addition. This study should include information to show that the soil it stable and suitable for construction, that the existing infrastructure can serve and sustain the new facility
.8 Appendix A The list below, prepared by the U.S. Department of Education is an unofficial version of the State Single Point of Contact (SPOC) Li st published by the Office of Management and Budget (OMB). The Department has made every effort to ensure the accuracy of the information c ontained in this unofficial version. Itreflects those changes made by O MB as of 08/15/01. The only official and up to date version of the State Single Point of Contact (SPOC) Li st is posted on the Grants Management section of the OMB web site: http://www. whitehouse.gov/omb/grants/spoc.html. You may review and/or download the Adobe pdf (portable document format) version of this document at the aforementioned site. Please include this statement in any reproduction of this unofficial list. You are strongly encouraged to access the Intergovernmental Review (SPOC Li st) link to the Grants Management Information section of the OMB web page regularly in the course of completing grant applications to be submitted to yo ur designated State Single Point of Contact (S POC). I f you do not have access to the Internet, please use the list below to contact the office or individual listed in order to confirm the State Single Point of Contact (SPOC).

**STATE SINGLE POINTS OF CONTACT (SPOCs)** It is estimated that in 2001, the Federal Government will outlay $ 305.6 billion in grants to State and local governments. Executive Order 12372, “Intergovernmental Review of Federal Programs,” was issued with the desire to foster the intergovernmental partnership and strengthen federalism by

rel ying on State and local processes for the coordination and review of proposed Federal financial assistance and direct Federal development. The Order allows each State to designate an entity to perform this function. Below is the official list of those entities. For those States that have a home page for their designated entity, a direct link has been provided on the official version http://www.whitehouse.gov/omb/grants/spoc.html. States that are not listed on this page have chosen not to participate in the intergovernmental review process, and therefore do not have a SPOC. If you are located within one of these States, yo u may still send application material directl y to a Federal awarding agency. Contact information for Federal agencies that awar9 **ARKANSAS** Tracy L . Copeland Manager, State Clearinghouse Office of Intergovernmental Services Department of Finance and Administration 1515 W. 7 th Street, Room 412 Little Rock, Arkansas 72203 Telephone: (501) 682

- 1074 FAX: (501) 682

- 5206 tlcopeland@dfa.state.ar.us **CALIFORNIA** Grants Coordination State Clearinghouse Office of Planning and Research P.O. Box 304 4, Room 222 Sacramento, California 95812

- 3044 Telephone: (916) 445

- 0613 FAX: (916) 323

- 3018 S tate.clearinghouse@opr.ca.gov
**DELAWARE** Charles H. Hopkins Executive Department Office of the Budget 540 S. Dupont Highway

, 3 rd Floor Dover, De laware 19901 Telephone: (302) 739

- 3323 FAX: (302) 739

- 5661 chopkins@state.de.us **DISTRICT OF COLUMBIA** Luisa Montero

- Diaz Office of Partnerships and Grants Development Executive Office of the Mayor District of Columbia Government 414 4 th Street, NW, Suite 530 South Washington, DC 20001 Telephone: (202) 727

- 8900 FAX: (202) 727

- 1652 Opgd.eom@dc.gov **FLORIDA** Cindy Cranick Florida State Clearinghouse 3900 Commonwealth Boulevard Douglas Building, Mail Station 47 Tallahassee, Florida 32399

- 2100 Telephone: (850) 922

- 5438 FAX: (850) 414

- 0479 clearinghouse@dca.state.fl.us **GEORGIA** Georgia State Clearinghouse 270 Washington Street, SW Atlanta, Georgia 30334 Telephone: (404) 656

- 3855 FAX: (404) 656

- 7901 gach@mail.opb.state. ga.us10 **ILLINOIS** Virginia Bova Department of Commerce and Community Affairs James R. Thompson Center 100 West Randolph, Suite 3

- 400 Chicago, Il linois 60601 Telephone: (312) 814

- 6028 FAX: (312) 814

- 8485 vbova@commerce.state.il.us **IOWA** Steven R. M cCann Division of Community

and Rural Development Io wa Department of Economic Development 200 East Grand Avenue Des Moines, Iowa 50309 Telephone: (515) 242

- 4719 FAX: (515) 242

- 4809 S teve.mccann@ided.state.ia.us **KENTUCKY** Ron Cook Department for Local Government 1024 Capital Center Drive, Suite 340 Frankfort, Kentucky 40601 Telephone: (502) 573

- 2382 FAX: (502) 573

- 2512 ron.cook@mail.state.ky. us **MAINE** Joyce Benson State Planning Office 184 State Street 38 State House Station Augusta, Maine 04333 Telephone: (207) 287

- 3261 Telephone: (207) 287

- 1461 (direct) FAX: (207) 287

- 6489 J oyce.benson@state.me.us **MARYLAND** Linda Janey Manager, Clearinghouse and Plan Review Unit Maryland Office of Planning 301 West Preston Street

– Room 1104 Baltimore, Maryland 21201

- 2305 Telephone: (410) 767

- 4490 FAX: (410) 767

- 4480 linda@mail.op.state.md.us **MICHIGAN** Richard Pfaff Southeast Michigan Council of Governments 535 Griswold, Suite 300 Detroit, Michigan 48226 Telephone: (313) 961

- 4266 FAX: (313) 961

- 4869 pfaff@semcog.org11 **MISSISSIPPI** Cathy Mallette Clearinghouse Officer Department of Finance and Administration 1301 Woolfolk Building, Suite E 501 North West Street Jackson, Mississippi 39201 Telephone: (601) 359

- 6762 FAX: (601) 359

- 6758 **MISSOURI** Angela Boessen Federal Assistance Clearinghouse Office of Administration P.O. Box 809 Truman Building, Room 840 Jefferson City, Missouri 65102 Telephone: (573) 751

- 4834 FAX: (573) 522

- 4395 igr@mail.oa.state.mo.us kirchhofft@mail.oa.state.mo.us **NEVADA** Heather Elliott Department of Administration State Clearinghouse 209 E. Musser Street, Room 200 Carson City, Nevada 89701 Telephone: (775) 684

- 0209 FAX: (775) 684

- 0260 Helliot@govmail.state.nv.us **NEW HAMPSHIRE** Jeffrey H. Taylor Director New Hampshire Office of State Planning Attn: Intergovernmental Review Process Mike Blake 21⁄2 Beacon Street Concord, New Hampshire 03301 Telephone: (603) 271

- 2155 FAX: (603) 271

- 1728 Jtaylor@osp.state.nh.us **NEW MEXICO** Ken Hughes Local Government Division Room 201, Bataan Memorial Building Santa Fe, New Mexico 87503 Telephone: (505) 827

- 4370 FAX: (505) 827

- 4948 khughes@dfa.state.nm.us **NORTH CAROLINA** Jeanette Furney Department of Administration 1302 Mail Servic e Center Raleigh, North Carolina 27699

- 1302 Telephone: (919) 807

- 2323 FAX: (919) 733

- 9571 jeanette.furney@ncmail.net **NORTH DAKOTA** Jim Boyd Division of Community

Services 600 East Boulevard Ave, Dept 105 Bismarck, North Dakota 58505

- 0170 Telephone: (701) 328

- 2094 FAX: (701) 328

- 2308 jboyd@state.nd.us **RHODE ISLAND** Kevin Nelson Department of Administration Statewide Planning Program One Capitol Hill Providence Rhode Island 02908

- 5870 Telephone: (401) 222

- 2093 FAX: (401) 222

- 208 3 knelson@doa.state.ri.us12 **SOUTH CAROLINA** Omeagia Burgess Budget and Control Board Office of State Budget 1122 Ladies Street

– 12 th Floor Columbia, South Carolina 29201 Telephone: (803) 734

- 0494 FAX: (803) 734

- 0645 aburgess@budget.state.sc.us **TE XAS**  Denise S. Francis Director, State Grants Team Governor’s Office of Budget and Planning P.O. Box 12428 Austin, Texas 78711 Telephone: (512) 305

- 9415 FAX: (512) 936

- 2681 dfrancis@governor.state.tx.us **UTAH** Caroly n Wright Utah State Clearinghouse Governor’s Office of Planning and Budget State Capitol, Room 114 Salt Lake City, Utah 84114 Telephone: (801) 538

- 1535 FAX: (801) 538

- 1547 cwright@gov.state.ut.us **WEST VIRGINIA** Fred Cutlip, Director Community

Development Division West Virgini a Development Office Building #6, Room 553 Charleston, West Virginia 25305 Telephone: (304) 558

- 4010 FAX: (304) 558

- 3248 fcutlip@wvdo.org **WISCONSIN** Jeff Smith Section Chief, Federal/State Relations Wisconsin Department of Administration 101 Eas t Wilson Street

– 6 th Floor P.O. Box 7868 Madison, Wisconsin 53707 Telephone: (608) 266

- 0267 FAX: (608) 267

- 6931 jeffrey .smith@doa.state.wi.us **AMERICAN SAMOA** Pat M. Galea'i Federal Grants/Programs Coordinator Office of Federal Programs Office of the Governor/Department of Commerce American Samoa Government Pago Pago, American Samoa 96799 Telephone: (684) 633

- 5155 Fax: (684) 633

- 4195 pmgaleai@samoatelco.com **GUAM** Director Bureau of Budget and Management Research Office of the Governor P.O. Box 2950 Agana, Guam 96910 Telephone: 011

- 671
- 472
- 2285 FAX: 011
- 671
- 472
- 2825 jer@ns.gov.gu **PUERTO RICO** Jose Caballero / May

ra Silva Puerto Rico Planning Board Federal Proposals Review Office Minillas Government Center P.O. Box 41119 San Juan, Puerto Rico 00940

- 1119 Telephone: (787) 723

- 6190 FAX: (787) 722

- 678313

**NORTHERN MARIANA ISLANDS** Ms. Jacoba T. Seman Federal Programs Coordinator Office of Management and Budget Office of the Governor Saipan, MP 96950 Telephone: (670) 664

- 2289 FAX: (670) 664

- 2272 omb.jseman@saipan.com **VIRGIN ISLANDS** Ira Mills Director, Office of Management & Budget # 41 Norre Gade Emancipation Garden Station, Second Floor Saint Thomas, Virgin Islands 00802 Telephone: (340) 774

- 0750 FAX: (7 87) 776

- 0069 Irmills@usvi.org Changes to this list can be made only after OMB is notified by a S tate’s officially

d esignated representative. E
-mail messages can be sent to grants@omb.eop.gov. If you prefer, you may send correspondence to the following po stal address: Attn: Grants Management Office of Management and Budget New Executive Office Building, Suite 6025 725 17 th Street, NW Washington, DC 20503 Please note: Inquiries about obtaining a Federal grant should not be sent to the OMB e - mail or postal address shown above. The best source for this information is the Catalog of Federal Domestic Assistance (CFDA) [http://www.cfda.gov/].