### 52 B Number: 4040
- 0004 Expiration Date: 01/31/2009



### Version 02 **Application for Federal Assistance SF -** **424** *1. Type of Submission: Preapplication Application Changed/Corrected Application *2. Type of Application New Continuation Revision * If Revision, select appropriate letter(s) *Other (Specify)

3. Date Received : 4. Applicant Identifier: 5a. Federal Entity Identifier: *5b. Federal Award Identifier: **State Use Only :**  6. Date Received by State: 7. State Application Identifier: **8. APPLICANT INFORMATION:** *a. Legal Name: *b. Employer/Taxpayer Identification Number (EIN/TIN): *c. Organizational DUNS:
**d. Address:** *Street 1: Street 2: *City: County: *State: Province: *Country: *Zip / Postal Code **e. Organizational Unit:** Department Name: Division Name: **f. Name and contact information of person to be contacted on matters involving this appli cation:**  Prefix: *First Name: Middle Name: *Last Name: Suffix: Title: Organizational Affiliation: *Telephone Number: Fax Number:

### 52

*Email: OMB Number: 4040
- 0004 Expiration Date: 01/31/2009 

### Ap **plication for Federal Assistance SF -** **424** Version 02 ***9. Ty pe o** **f Applicant 1: Select Applicant Ty pe:**  Type of Applicant 2: Select Applicant Type: Type of Applicant 3: Select Applicant Type: *Other (Specify) ***10 Name of Federal Agency: 11. Catalog of Federal Domestic Assistance Number**  :

CFDA Title:

***12 Funding Opportunity Number**  :

*Title:

**13. Competition Identification Number** :

Title:

**14. Areas Affected by Project (Cities, Counties, States, etc.):** 

***15. Descriptive Title of Applicant’s Project** :

### 52 OMB Number: 4040
- 0004 Expiration Date : 01/31/2009 

### Ap **plication for Federal Assistance SF -** **424** Version 02 **16. Congressional Districts Of:** *a. Applicant: *b. Program/Project: **17. Proposed Project** : *a. Start Date: *b. End Date: **18. Estimated Funding ($):** *a. Federal *b. Applicant *c. State *d. Local *e. Other *f. Program Income *g. TOTAL ***19. Is Application Subject to Review By State Under Executive Order 12372 Process?**  a. This application was made available to the State under the Executive Order 12372 Process for review on b. Program is subject to E.O. 12372 but has not been selected by the State for review. c. Program is not covered by E. O. 12372 ***20. Is the Applicant Delinquent On An y**  **Federal Debt? (If “Yes”, provide explanation.)**  Yes No 21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative p enalties. (U. S. Code, Title 218, Section 1001) ** I AGREE ** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announc ement or agency specific instructions **Authorized Re presentative:**  Prefix: *First Name: Middle Name: *Last Name: Suffix: *Title: *Telephone Number: Fax Number: * Email: *Signature of Authorized Representative: *Date Signed: Authorized for Local Reproduction Standard Form 424 (Revised 10/2005)

### 52 Prescribed by OMB

Circular A
- 102
OMB Numb er: 4040
- 0004 Expiration Date: 01/31/2009 

### Ap **plication for Federal Assistance SF -** **424** Version 02 ***Applicant Federal Debt Delinquency Explanation**  The following should contain an explanation if the Applicant organization is delinquent of any Fed eral Debt.

### 52



## SUPPLEMENTAL INFORMATION REQUIRED FOR DEPARTMENT OF **EDUCATION 1.**  **Project Director :**  Prefix: *First Name: Middle Name: *LastName: Suffix:

Address: * Street1: Street2: * City: County: * State * Zip Code: * Country: * Phone Number (give area code) Fax Number (give area code)
Email Address:

**2. Ap**  **plicant Experience:** Novice Applicant Yes No Not applicable to this program **3. Human Subjects Research:**  Are any research activities involving human subjects planned at any time during the proposed project Period? Yes No 

## Are ALL the research activities proposed designated to be exempt from the regulations? Yes Provide Exemption(s) #: No Provide Assurance #, if available: **Please attach an explanation Narrative:**

OMB Control No. 1894

- 0007 Add Attachment Delete Attachment View Attachment

### 52 

### ASSURANCES **- NON** **- CONSTRUCTION PROGRAMS** 

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the co llection of information. S end comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348
-0040), Wa shington, DC 20503 

### PLEA**SE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE O F MA** **NA GEMENT A** **ND BUDGET. SEND IT TO THE**  **ADDRESS PROVIDED BY THE SPONSORING A GENCY.** 

**Note:** Certain of these assurances may not be 

## applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified. As the duly authorized representative of the applicant I certify that the applicant: 1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including funds sufficient to pay the non - Federal share of project cost) to ensure proper planning, management, and completion of the project described in this application. 2. Wi ll g ive the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establis h a proper accounting system in accordance with generally accepted accounting standards or agency directives. 3. Wi ll establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of person al or organizational conflict of interest, or personal gain. 4. Wi ll initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. 5. Wi ll comply with the Intergovernmental Personnel Act of 1970 (42 U.S .C. 4728
-4763) relating to prescribed standards for merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A of OPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F). 6. Wi ll co mply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88
- 352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of th e Education Amendments of 1972, as amended (20 U.S.C. 1681
- 1683, and 1685
- 1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimi nation Act of 1975, as amended (42 U.S.C. 6101
- 6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92
-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91
- 616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) 523 and 527 of the Public Health Service Act of 191 2 (42 U.S.C. 290 dd
- 3 and 290 ee 3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. 3601 et seq.), as amended, relating to nondiscrimination in the sale, ren tal or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and (j) the requirements of any other nondiscrimination statute(s) which may apply to the appli cation. 7. Wi ll comply, or has already complied, with the requirements of Titles II and III of the uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91
- 646) which provide for fair and equitable treatment of persons dis placed or whose property is acquired as a result of Federal or federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases. 8. Wi ll comply, as appli cable, with the provisions of the Hatch Act (5 U.S.C. 1501
- 1508 and 7324
- 7328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds.

### 52

9. Wi ll comply, as applicable, with the provisions of the Davis
- Bacon Act (40 U.S.C. 276a to 276a
- 7), the Copeland Act (40 U.S.C. 276c and 18 U.S.C. 874) and the Contract Work Hours and Safety Standards Act (40 U.S.C. 327
- 333), regarding labor standards for federally assisted construction subagreements. 10. Wi ll comply, if applica ble, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93
-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more. 11. Wi ll comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the Nationa l Environmental Policy Act of 1969 (P.L. 91
- 190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance wi th EO 11988; (e) assurance of project consistency with the approved State management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. 1451 et seq.); (f) conformity of F ederal actions to State (Clear Air) Implementation Plans u nder Section 176(c) of the Clear Air Act of 1955, as a mended (42 U.S.C. 7401 et seq.); (g) protection of u nderground sources of drinking water under the Safe D rinking Water Act of 1974, as amended, (P.L. 93
- 523); and (h) protection of endangered species under the Endangered S pecies Act of 1973, as amended, (P.L. 93
-205). 12 Wi ll comply with the W ild and Scenic Rivers Act of 1968 (16 U.S.C. 1721 et seq .) related to protecting components or potential components of the national wild and scenic rivers system. 13. Wi ll assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. 470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. 469a
- 1 et seq.). 14. Wi ll comply with P.L. 93
- 348 regarding the protection of human subjects involved in rese arch, development, and related activities supported by this award of assistance. 15. Wi ll comply with the Laboratory Animal We lfare Act of 1966 (P.L. 89
- 544, as amended, 7 U.S.C. 2131 et seq.) pertaining to the care, handling, and treatment of warm bl ooded animals held for research, teaching, or other activities supported by this award of assistance. 16. Wi ll comply with the Lead
- Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.) which prohibits the use of lead
- based paint in constructio n or rehabilitation of residence structures. 17. Wi ll cause to be performed the required financial and compliance audits in accordance with the Single Audit Act Amendments of 1996 and OMB Circular No. A
- 133, Audits of States, Local Governments, and Non
- P rofit Organizations. 18. Wi ll comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program

**Standard Form 424B (Rev. 7 -** **97) Back** SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE

APPLICANT ORGANIZATION DATE S UBMITTED

### 52 

### U.S. DEPARTMENT OF EDUCATION BUDGET INFORMATION NON

-CONSTRUCTION PROGRAMS OMB Control Number: 1894

-0008 Expiration Date: 02/28/2011 Name of Institution/Organization Applicants requesting funding for only one year should complete the column under "Project Year 1." Applicants requesting funding for multi

-year grants should complete all applicable columns. Please read all instructions before completing form. **SECTION A**  **- BUDGET SUMMARY**  **U.S. DEPARTMENT OF EDUCATION FUNDS** Budget Categories Project Year 1 (a) Project Year 2 (b) Project Year 3 (c) Project Year 4 (d) Project Year 5 (e) Total (f) 1. Personnel 2. Fringe Benefits 3. Travel 4. Equipment 5. Supplies 6. Contractual 7. Construction 8. Other 9. Total Direct Costs (lines 1

- 8) 10. Indirect Costs* 11. Training Stipends 12. Total Costs (lines 9

- 11) ***Indirect Cost Information (To Be C**  **ompleted by Your Business Office ):**  If you are requesting reimbursement for indirect costs on line 10, please answer the following questions: (1) Do you have an Indirect Cost Rate Agreement approved by the Federal government? ____Yes ____ No (2) If yes, please provide the following information: Period Covered by the Indirect Cost Rate Agreement: From: ___/___/______ To: ___/___/______ (mm/dd/yyyy) Approving Federal agency: ____ ED ____ Other (please specify): ________________________

__ (3) For Restricted Rate Programs (check one)

-- Are you using a restricted indirect cost rate that: ___ Is included in your approved Indirect Cost Rate Agreement? or ___ Complies with 34 CFR 6.564(c)(2)?

### 52



### Name of Institution/Organization Applicants requesting funding for only one year should complete the column under "Project Year 1." Applicants requesting funding for multi

-year grants should complete all applicable columns. Please read all instructions before completing form. 

## SECTION B **- BUD**  **GET SUMMARY NON** **- FEDERAL FUNDS**  Budget Categories Project Year 1 (a) Project Year 2

(b) Project Year 3

(c) Project Year 4

(d) Project Year 5

(e) Total

(f) 1. Personnel 2. Fringe Benefits 3. Travel 4. Equipment 5. Suppli es 6. Contractual 7. Construction 8. Other 9. Total Direct Costs (Lines 1

- 8) 10. Indirect Costs 11. Training Stipends 12. Total Costs (Lines 9

- 11) **SECTION C**

**– BUDGET NARRATIVE**  (see instructions) 

## ED 5 24

### 52



# CERTIFICATION REGARDING LOBBYING Certification for Contracts, Grants, Loans and Cooperative Agreements. The undersigned certifies, to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, 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 awarding of any Federal contract, the making of any Federal grant, the making of any Federal Loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan or co operative agreement. (2) If any funds other 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 Mem ber of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loam or cooperative agreement, the undersigned shall complete and submit Standard Form

– LLL, “Disclosure of Lobbying Activities,” in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or enteri ng into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Statement for Loa n Guarantees and Loan Insurance. The undersigned states, to the best of his or her knowledge and belief, that: If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or em ployee or any agency, a me mb er of Congress, an officer or employee of Congress or an employee of a Member of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form
- LLL, “Disc losure of Lobbying Activities,” in accordance with its instructions. Submission of this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required stateme nt shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Applicant’s Organization

Printed Name of Authorized Representative Printed Title of Authorized Representative
Signatu re Date

ED 80
- 0013 08/05

### 52 OMB No. 1890

-0014, Exp. 02/28/09



# Survey on Ensuring Equal Opportunity for Applicants

**Ap plicant’s (Organization) Name:** 

**____________________________________________________________ Ap**  **plicant’s DUNS Number:**

______________________________________________________ ___________ **Federal Program: ________________________________________________CFDA Number:** 

**___________**
1. Has the applicant ever received a grant or contract from the Federal government? Yes No
2. Is th e applicant a faith
- based organization? Yes No
3. Is the applicant a secular organization? Yes No 4. Does the applicant have 501(c)(3) status? Yes No 5. Is the applicant a local affiliate of a national organ ization? Yes No 6. How many full
-time equivalent employees does the applicant have? (Check only one box). 3 or Fewer 15
- 50 4
- 5 51
- 100 6
- 14 over 100
7. Wh at is the size of the applicant’s annual budget? (Check only one box.) Less Than $150,000 $150,000
- $299,999 $300,000
- $499,999 $500,000
- $999,999 $1,000,000
- $4,999,999 $5,000,000 or more **Purpose:** The Federal government is committed to ensuring that all qualified applica nts, small or large, non
- religious or faith
- based, have an equal opportunity to compete for Federal funding. In order for us to better understand the population of applicants for Federal funds, we are asking nonprofit private organizations (not including private universities) to fill out this survey. Upon receipt, the survey will be separated from the application. Information provided on the survey will not be considered in any way in making funding decisions and will not be included in the Federal gra nts database. W hile yo ur help in this data collection process is greatly appreciated, completion of this survey is voluntary. 

# Instructions for Submitting the Survey: If you are applying using a hard copy application, please place the comp leted survey in an envelope labeled “Applicant Survey.” Seal the envelope and include it along with your

### 52 Approved by OMB 0348
- 0046 

## Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pu rsuant to 31 U.S.C. 1352

(See reverse for public burden disclosure)
1. Type of Federal Action: a. contract ____ b. grant c. cooperative agreement d. loan e. loan guarantee f. loan insurance 2. Status of Federal Action: a. bid/offer/application _____ b. initial award c. post
- award 3. Report T yp e: a. initial filing _____ b. material change For material change only: Year _______ q uarter _______ Date of last report___________ 4. Name and Address of Reporting Entity: ____ Prime _____ Subawardee Tier______, if Known:

Congressional District, if kn own: 5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime:

Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, if applicable: _______________

___ 7. Federal Action Number, if known: 9. Award Amount, if known: $ 10. a. Name and Address of Lobbying Registrant (if individual, last name, first name, MI): b. Individuals Performing Services (including address if different from No. 10a) (last name, first name, MI):

11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi

- annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Signature: __________________________________ Print Name: _____ Title: _____ Telephone No.: ____________ Date: _______

**Fe deral Use Only**  **Au thorized for Local Reproduction**  **Standard Form -**  **LLL (Rev. 7 -** **97)**