FORM APPROVED OMB No. 1840
- 0564 Expiration Date:

Page **1** of **5 U.S. DEPARTMENT OF EDUCATION,**  **OFFICE OF POSTSECONDARY EDUCATION FINANCIAL REPORT FOR**  **M UNDER THE**  **ENDOWMENT CHALLENGE GRANTS PROGRAM (Title III, Part C)** 

**AND ENDOWMENT**  **ACTIVITIES UNDER THE**  **TITLE III PART**  **S A & B**  **AND TITLE V PROGRAM**  **S**

**NOTE TO ENDOWMENT CHALLENGE GRANT RECIPIENTS ONLY.**  If you received your initial ECG award prior to 1987, your grant number will begin with GOO. After 1987, your grant number will begin with P031G. If your institution has been awarded more than one Endowment Ch allenge G rant (ECG) , you must report on **each grant separately**  , by completing this form using the respective project award and/or grant numbers. **NOTE TO TITLE III AND TITLE V GRANTEES THAT HAVE ENDOWMENT AS AN ACTIVITY:**  Th e Endowment Fund Corpus amount may change from y ear to ye ar if y ou elected to use F ederal funds for endowment building more than one y ear of yo ur five y ear grant period and added to the original corpus rather than creating a different account for each drawdown. For example, if in y ear one y ou raised and matched $50,000 of Federal funds, and you invested $100,000 to form the endowment corpus, then in year two you elected to raise and match $25,000 of Federal funds for a total of $50,000 and decided to add this $50,000 to the orig inal $100,000, y our corpus then changes from $100,000 to $150,000. However, if y ou have chosen to develop a separate endowment corpus for each year, you must report on each individual investment sep a ra t ely , by

completing t h is form for each

. NAME OF IN STITUTION:_________________________________________________ ADDRESS :_________________________________________________ CI TY AND STATE :_________________________ ZIP CODE :____________

_ GRANT NUMBER :________

_________________________________________ CONTACT PERSON :_________________________________________________ E
- MAIL :_________________________________________________ TEL EPHONE NUMBER :__________________

_______________________________ FAX :_________________________________________________FORM APPROVED OMB No. 1840
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Page **2** of **5** 1. Enter the initial f

iscal y ear (FY) this grant was awarded: FY

______ 2. Enter the amount of the institution’s original Endo wment Fund Corpus : $_______ 3. In which fiscal ye ar did the institut ion submit the “initial” financial repor t: FY_____ 4. Enter your institution’s fiscal y ear or budget period covered by this report: From ____________________ to ____________________ Month/Day

/Year Month/Day /Year 5. This is rep ort number _____ of 20 **INVESTMENT DISTRIBUTION S**  **- FOR CORPUS ONLY**  Reference: Section 628.43 of the program regulations TYPE OF SAVINGS Amount Name of ACCOUNT OR SECURITY Financial Institution (a) A federall y insured bank savings account: $____________ ________

_______________ (b) A compatible interest bearing account: $____________ _______________________ (c) A money

market fund: $____________ _______________________ (d) Certificate s of deposit: $____________ _____________________

__ (e) Mutual f

und s : $____________ _______________________ (f) Stock s : $____________ _______________________ (g) Bond s : $____________ _______________________ (h) Other (please specify ty pe of investment account):

________________

_____ $____________ _______________________

_ _____________________ $____________ ________________________ _____________________ $____________

________________________FORM APPROVED OMB No. 1840
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Page **3** of **5 TOTAL INVESTED**  **(a -**  **h) :**  $____________ **INCOME EARNED** Enter the amount of the endowment fund income earned during the 12

- month period covered b y th is financial report. $______________ Enter the cumulative (aggregate) amount (to date) of all endowment fund income earned since the initial investment

. $

______________ **INCOME USED** Enter in the appropriate space(s) below, the amo unt of endowment fund income used , both for the 12

- month period covered by this report, and the aggregate, for the following purposes: CURRENT AGGREGATE a) Oper ations and maintenance: $______________ $_____________ b) Administration and management of the endowment fund : $______________ $_____________ c) Bu yi ng and selling securities: $______________ $_____________
d ) Academic and support personnel: $______________ $_____________

e ) Construction and renovation: $______________ $_____________ f ) Community

and student services programs and technical assistance : $______________ $_____________ g ) Other (Please specify

below) : ___________________________ $______________ $_____________ ___________________________ $______________ $_____________

**TOTAL (a**  **- g):**  $______________ $_____________FORM APPROVED OMB No. 1840
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Page **4** of **5 CERTIFICATION**  I certify that:

- No part of the endowment fund corpus has been invested in real estate (Section 628.43 of the regulat ions);

- No part of the endowment fund corpus has been withdrawn and/or expended (Section 628.44 of the regulations);

- Not more than fift y percent of aggregate endowment fund income has been withdrawn and/or expended (Section 628.45 of the regulations). President (or Certified Official):

**_________________________________ ______________________** 

(Signature) (Date)

( Name
- Ty

pe or Print ) (Title

- Ty pe or Print ) (E

- mail

– Ty

pe or Print ) (Phone Number) **WARNING:** An y person who knowingl y makes a false statement or misrepresentation on this form is subject to penalties which may include fines and/or imprisonment under the United States Criminal Code. **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 display s a valid OMB control number. The valid OMB control number for this information collection is 1840

- 0564. The time required to complete this information collection is estimat ed to average 3 hours 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 time estima te(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:**  U.S. Departmen t of Education, Office of Postsecondary Education, Institutional Development and Undergraduate Education Service. Attention: Karen W. Johnson, 1990 K Street, NW, 6 th Floor, Washington, D.C. 20006.FORM APPROVED OMB No. 1840
- 0564 Expiration Date:

Page **5** of **5** This financial reporting form will be utilized for Titl e III, Part A, Title III Part B, Title V Program Endowment Activities , and Title III Part C Endowment Challenge Grant Programs. The purpose of this Annual Financial Report is to have the grantees report annually the kind of investments that have been made, the income earned and spent, and whether an y part of the Endowment Fund Corpus has been spent. This information allows us to give technical assistance and determine whether the grantee has compiled with the statutory and regulatory

investment requirements

. Responses to the collection of information are required consistent with the provisions of P.L . 98
- 95 Section 331 under the Endowment Challenge Grant, HEA 1965, as amended. As these materials contain no confidential information, these application material s will become part of ED’s public records once submitted and approved in accordance with the regulations promulgated under the Paperwork Reduction Act (5 CFR 1320.8(b)(3)(v)).