OMB Number: 4040

- 0004 Expiration Date: 01/31/2009 

### Ap **plication for Federal Assistance SF -** **424** Version 02 *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: *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** :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 o n 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 bes t 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 subj ect me to criminal, civil, or administrative penalties. (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 R epresentative:**  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) Prescribed by OMB Circular A

- 102OMB Number: 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 Applica nt organization is delinquent of any Federal Debt.

### U.S. DEPARTMENT OF EDUCATION **BUDGET INFORMATION NON**  **- CONSTRUCTION PROGRAMS**  OMB Control Number: 1894

- 0008 Expiration Date: 02/28/2011
Name of I nstitution/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 b efore 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) **Indir ect Cost Inform**  **ation (To Be Completed 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 specif y): __________________________ The Indirect Cost Rate is _________% (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 76.564(c)(2)? The Restricted Indirect Cost Rate is _________% ED 524

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

- year grants should complete all applicable columns. Please read all instructions before completing form.
**SECTION B -**  **BUDGET 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. 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) 

### SECTION C

**– BUDGET NARRATIVE**  (see instructions)

# Instructions for ED 524
General I nstructions This form is used to apply to individual U.S. Department of Education (ED) di scretionary grant programs. Unless directed otherwise, provide the same budget information for each year of the multi

-year funding request. Pay attention to applicable program specific instructions, if attached. You may access the Education Department General Administrative Regulations, 34 CFR 74

– 86 and 97

- 99, on ED’s website at: http://www.ed.gov/policy/fund/reg/edgarReg/edgar.html **You must consult with your Business Office prior t o ubmitting this**  **form.** Section A

- Budget Summary

U.S. Department of Education Funds All applicants must complete Section A and provide a break

- down by the applicable budget categories shown in lines 1

- 11. Lines 1

- 11, columns (a)

- (e): For each projec t year for which dunding is requested, show the total amount requested for each applicable budget category. Lines 1

- 11, column (f): Show the multi

-year total for each budget category. If funding is requested for only one project year, leave this column blank. Line 12, columns (a)

- (e): Show the total budget request for each project year for which funding is requested. Line 12, column (f): Show the total amount requested for all project years. If funding is requested for only one year, leave this space blank. Indirect Cost I

nformation : If you are requesting reimbursement for indirect costs on line 10, this information is to be completed by your Business Office. (1): I

ndicate whether or not your organization has an Indirect Cost Rate Agreement that wa s approved by the Federal government. If you checked “no,” ED generally will authorize grantees to use a temporary rate of 10 percent of budgeted salaries and wages subject to the following limitations:

(a) The grantee must submit an indirect cost propo sal to its cognizant agency within 90 days after ED issues a grant award notification; and

(b) If after the 90

- day period, the grantee has not submitted an indirect cost proposal to its cognizant agency, the grantee may not charge its grant for indirect c osts until it has negotiated an indirect cost rate agreement with its cognizant agency.

(2): If you checked “yes” in (1), indicate in (2) the beginning and ending dates covered by the I ndirect Cost Rate Agreement. I n addition, indicate whether ED, another Federal agency (Other) or State agency issued the approved agreement. If you check “Other,” specify the name of the Federal or other agency that issued the approved agreement. (3): If you are applying for a grant under a Restricted Rate Program (34 CFR 75.563 or 76.563), indicate whether you are using a restricted indirect cost rate that is included on your approved I ndirect Cost Rate Agreement or whether you are using a restricted indirect cost rate that complies with 34 CFR 76.564(c)(2). Note: State or Local government agencies may not use the provision for a restricted indirect cost rate specified in 34 CFR 76.564(c)(2). Check only one response. Leave blank, if this item is not applicable.

Section B

- Budget Summary Non

- Federal Funds If you are required to provide or volunteer to provide cost

- sharing or matching funds or other non

- Federal resources to the project, these should be shown for each applicable budget category on lines 1

- 11 of Section B. Lines 1

- 11, columns (a)

- (e): For each project year, for which matching funds or other contributions are provided, show the total contribution for each applicable budget category. Lines 1

- 11, column (f): Show the multi

-year total for each budget category. If non

- Federal contributions are provided for only one year, leave this column blank. Line 12, columns (a)

- (e): Show the total matching or other contribution for each project year. Line 12, column (f): Show the total amount to be contributed for all years of the multi

-year project. If non

- Federal contributions are provided for only one year, leave this space blank. Section C

- Budget Narrative [Attach separate sheet(s)] Pay attention to applicable program specific instructions,

if attached. 1. Provide an itemized budget breakdown, and justificati on by project year, for each budget category listed in Sections A and B. For grant projects that will be divided into two or more separately budgeted major activities or sub

-projects, show for each budget category of a project year the breakdown of the sp ecific expenses attributable to each sub

-project or activity. 2. For non

- Federal funds or resources listed in Section B that are used to meet a cost

- sharing or matching requirement or provided as a voluntary cost

- sharing or matching commitment, you must include: a. The specific costs or contributions by budget category; b. The source of the costs or contributions; and c. I n the case of third

-party in

- kind contributions, a description of how the value was determined for the donated or contributed goods or services. [Please review ED’s general cost sharing and matching regulations, which include specific limitations, in 34 CFR 74.23, applicable to non - governmental entities, and 80.24, applicable to governments, and the applicable Office of Management and Budget (OMB) cost principles for your entity type regarding donations, capital assets, depreciation and use allowances. OMB cost principle circulars are available on OMB’s website at: http://www.whitehouse.gov/omb/circulars/index.html] 3. If applicable to this program, provide the rate and base on which fringe benefits are calculated. 4. If you are requesting reimbursement for indirect costs on line 10, this information is to be completed by your Business Office. S pecify the estimated amount of the base to whi ch the indirect cost rate is applied and the total indirect expense. Depending on the grant program to which you are applying and/or your approved Indirect Cost Rate Agreement, some direct cost budget categories in your grant application budget may not be included in the base and multiplied by your indirect cost rate. For example, you must multiply the indirect cost rates of “Training grants" (34 CFR 75.562) and grants under programs with “Supplement not Supplant” requirements ("Restricted Rate" program s) by a “modified total direct cost” (MTDC) base (34 CFR 75.563 or 76.563). Please indicate which costs are included and which costs are excluded from the base to which the indirect cost rate is applied. When calculating indirect costs (line 10) for "Training grants" or grants under "Restricted Rate" programs, you must refer to the information and examples on ED’s website at: http://www.ed.gov/fund/grant/apply/appforms/appforms.html

. You may also contact (202) 377

- 3838 for additional information reg arding calculating indirect cost rates or general indirect cost rate information. 5. Provide other explanations or comments you deem necessary.

**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 **1894 -**  **0008** . The time required to complete this information collection is estimated to vary from 13 to 22 hours per response, with an average of 17.5 hours per response, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection. If you have any comments concerning t he accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202

-4537. If you have comments or concerns regarding the status of your individual submission of this form, write directly to (insert program office), U.S. Department of Education, 400 Maryland Avenue, S.W., Washington, D.C. 20202.**Previous Edition Usable Standard Form 424B (Rev. 7**  **- 97)**  **Authorized for Local Reproduction Prescribed by OMB Circular A** **- 102**  **OMB Approval No. 0348 -**  **0040** 

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

Public reporting burden for this collection of information i s 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), Washington, DC 20503 

### PLEASE DO NOT RETURN YOUR COMPLETE **D FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.** 

**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 a pplication. 2. Will give 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 establish a proper accounting system in accordance with generally accepted accounting standards or agency directives. 3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents th e appearance of personal or organizational conflict of interest, or personal gain. 4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. 5. Will comply with the Intergovernmental Personn el 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. Will 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 1 964 (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 Discrimination Act of 197 5, 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 Alcoh ol 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 1912 (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, rental or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being ma de; and (j) the requirements of any o ther nondiscrimination statute(s) which may apply to the application. 7. Will co mply, 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 displaced 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. Will comply, as applicable, with the pro visions of the Hatch Act (5 U.S.C. 1501

- 1508 and 7324

- 7328) which limit the political activities of em

ployees whose principal employment activities are funded in whole or in part with Federal funds.9. Will 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. Will comply, if

a pplicabl e, 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 c ost of insurable construction and acquisition is $10,000 or more. 11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National 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 with 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 Federal actions to State (Clear Air) Im plementation Plans under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. 7401 et seq.); (g) protection of underground sources of drinking water under the Saf e Drinking Water Act of 1974, as amended, (P.L. 93

- 523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93

- 205). 12 Will comply with the Wild 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. Will 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. Will 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. Will comply with the Laboratory Animal Welfare 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. Will 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. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act Amendments of

1 996 and OMB Circular No. A

- 133, Audits of States, Local Governments, and Non

- P rofit Organizations. 18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program.

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE

AP PLICANT ORGANIZATI ON DATE SUBMITTED

**Standard Form 424B (Rev. 7 -** **97) Back**

## 12 **CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS; AND DRUG**  **- FREE WORKPLACE REQUIREMENTS**  Applicants should refer to the regulations cited below to determine the certification to which they are required to attest. Applicants should also review the instructions for certification included in the regulations before completing this form. Signature of this form provides for compliance with certification req uirements under 34 CFR Part 82, "New Restrictions on Lobbying," and 34 CFR Part 85, "Government
-wide Debarment and Suspension (Nonprocurement) and Government
-wide Requirements for Drug
- Free W orkplace (Grants)." The certifications shall be treated as a mat erial representation of fact upon which reliance will be placed when the Department of Education determines to award the covered transaction, grant, or cooperative agreement.
1. **LOBBYING** As required by Section 1352, Title 31 of the U.S. Code, and im plemented at 34 CFR Part 82, for persons entering into a grant or cooperative agreement over $100,000, as defined at 34 CFR Part 82, Sections 82.105 and 82.110, the applicant certifies that: (a) 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 mak ing of any Federal grant, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal grant or cooperative agreement; (b) If any funds other than 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 this Federal grant or co operative agreement, the undersigned shall complete and submit Standard Form
- LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions; (c) The undersigned shall require that the language of this certification be included in the awa rd documents for all subawards at all tiers (including subgrants, contracts under grants and cooperative agreements, and subcontracts) and that all subrecipients shall certify and disclose accordingly.
2. **DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILIT** **Y MATTERS** As required by Executive Order 12549, Debarment and Suspension, and implemented at 34 CFR Part 85, for prospective participants in primary covered transactions, as defined at 34 CFR Part 85, Sections 85.105 and 85.110
-- A. The applicant certifies that it and its principals: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency; (b) Have not within a three
- year period preced ing this application been convicted of or had a civil judgement rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) Are not presently in dicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (2)(b) of this certification; and (d) Have not within a three
- year period preceding t his application had one or more public transaction (Federal, State, or local) terminated for cause or default; and B. W here the applicant is unable to certify to any of the statements in this certification, he or she shall attach an explanation to this application.
3. **DRUG -**  **FREE WORKPLACE (GRANTEES OTHER THAN INDIVIDUALS)**  As required by the Drug
- Free W orkplace Act of 1988, and implemented at 34 CFR Part 85, Subpart F, for grantees, as defined at 34 CFR Part 85, Sections 85.605 and 85.610
- A. T he applicant certifies that it will or will continue to provide a drug
-free workplace by: (a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the grantee's workplace and specifying the actions that will be taken against employees for violation of such prohibition; (b) Establishing an on
- going drug
-free awareness program to inform employees about: (1) The dangers of drug abuse in the workplac e; (2) The grantee's policy of maintaining a drug
-free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance programs; and (4) The penalties that may be imposed upon employees for drug abuse violations occurring in the wo rkplace; (c) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph (a); (d) Notifying the employee in the statement required by paragraph (a) that, as a condition o f employment under the grant, the employee will: (1) Abide by the terms of the statement; and (2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction;

## 13

(e) Notifying the agency, in writing, within 10 calendar days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must p rovide notice, including position title, to: Director, Grants Policy and Oversight Staff, U.S. Department of Education, 400 Maryland Avenue, S.W . (Room 3652, GSA Regional Office Building No. 3), W ashington, DC 20202
- 4248. Notice shall include the identifi cation number(s) of each affected grant; (f) Taking one of the following actions, within 30 calendar days of receiving notice under subparagraph (d)(2), with respect to any employee who is so convicted: (1) Taking appropriate personnel action against suc h an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; (g) Making a good faith effort to continue to maintain a drug
-free workplace through implementation of paragraphs (a), (b), (c), (d), (e), and (f). B. Th e grantee may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant: Place of Performance (Street address. city, county, state, zip code)

Check **[ ]** if there are workplaces on file that are not identified here. **DRUG -**  **FREE WORKPLACE (GRANTEES WHO ARE INDIVIDUALS)**  As required by the Drug
- Free W orkplace Act of 1988, and implemented at 34 CFR Part 85, Subpart F, for grantees, as defined at 34 CFR Part 85, Sections 85.605 and 85. 610
- A. As a condition of the grant, I certify that I will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant; and B. If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant activity, I will report the conviction, in writing, within 10 calendar days of the conviction, to: Director, Grants Policy and Oversight Staff, Department of Education, 400 Maryl and Avenue, S.W . (Room 3652, GSA Regional Office Building No. 3), W ashington, DC 20202
-4248. Notice shall include the identification number(s) of each affected grant.

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

NAME OF APPLICANT PR/A WA RD NUMBER AND / OR PROJE CT NAME

PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

SIGNATUR E DATE

ED 80
- 0013 12/98

## 14 **Certification Regarding Debarment, Suspension, Ineligibility and**  **Voluntary**

**Exclusion --**  **Low er Tier Covered Transactions** 
This certification is required by the Depa rtment of Education regulations implementing Executive Order 12549, Debarment and Suspension, 34 CFR Part 85, for all lower tier transactions meeting the threshold and tier requirements stated at Section 85.110. **Instructions for Certification** 1. By sig ning and submitting this proposal, the prospective lower tier participant is providing the certification set out below. 2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was ente red into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originat ed may pursue available remedies, including suspension and/or debarment. 3. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier particip ant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 4. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," " perso n," "primary covered transaction," " principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations. 5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly e nter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction or iginated. 6. The prospective lower tier participant further agrees by submitting this proposal that it will include the clause titled C e r t i fi c at i o n Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion
- Lower Tier Covered Transactions, w i t h o u t m o d i fi c a t i o n , i n all lower tier covered transa ctions and in all solicitations for lower tier covered transactions. 7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may but is not require d to, check the Nonprocurement List. 8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transacti on knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the departmen t or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

**Certification** (1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its princ ipals are presently debarred,

suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (2) Wh ere the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall

attach an explanation to this proposal. NAME OF APPLICANT PR /AWARD NUMBER AND/OR PROJECT NAME

PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

SIGNATURE DATE

ED 80
- 0014, 9/90 (Replaces GCS
- 009 (REV.12/88), which is obsolete)

### Approved by OMB 0348

- 0046 

## Disclosure of Lobbying Activities Com plete this form to disclose lobbying activities pursuant 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 Type:**  a. initial filing _____ b. material change **For m aterial change only:**  Year _______ quarter _______ Date of last report___________ **4. Nam** **e and Address of Reporting Entity:** ____ Prime _____ Subawardee

Tier______, if Known:

**Congressional District**

**,** if known **: 5.**  **If Reporting Entity in No. 4 is Subawardee,** Enter Name and Address of Prime:

**Congr essional District** 

**,** if known **: 6.**  **Federal Departm ent/Agency:**  **7. Federal Program**  **Name/Description:** CFDA Number, if applicable : ____________ 8. **Federal Action Number,** if known: 9. **Award Am ount**  , if known: **$ 10. a. Nam** **e and Address of Lobbying Registr ant**  (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**  **wa s made or entered into. This disclosure is required**  **pursuant to 31 U.S.C. 1352. This informa tion will be reported**  **to the Congress sem i** **- 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 fail** **ure.** 

### Signature: __________________________________ **Print Nam e: _____**  **Title: _____ Telephone No.: ____________ Date: _______** 
**Federal Use Only Authorized for Local Reproduction**  **Standard Form -**  **LLL (Rev. 7 -**  **97)**

### INSTRUCTIONS FOR COMPLETION OF SF **- LLL,**  **DISCLOSURE OF LOBBYING ACTIVITIES** This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or em ployee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome o f a covered Federal action. 2. Identify the status of the covered Federal acti on. 3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks “Subawardee,” then enter the full name, address, city, State and zip c ode of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the c overed Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., “RFP

- DE

- 90

- 001.” 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (MI). 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB control Number. The valid OMB control number for this information collection is OMB No. 0348

- 0046. 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 o f information. Send 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

- 0046), Washington, DC 20503OMB Control No. 1894

- 0005 (Exp. 01/31/2011)


## NOTICE TO ALL APPLICANTS The purpose of this enclosure is to inform you about a new provision in the Department of E ducation's General Education Provisions Act (GEPA) that applies to applicants for ne w grant awards under Department programs. This provision is Section 427 of GEPA, enacted as part of the Im

proving America's Schools Act of 1994 (Public Law

(P.L.) 103

- 382). **To Whom Does This Provision Apply?** Section 427 of GEPA affects applicants for new grant awards under this program. **ALL APPLICANTS**  **FOR NEW**  **AWARDS MUST**  **INCLUDE INFORMATION**  **IN THEIR**  **APPLICATIONS TO**  **ADDRESS THIS**  **NEW PROVISION**  **IN ORDER**  **TO RECEIVE**  **FUNDING UNDER THIS PROGRAM.** (If this program is a State

- formula grant program, a State needs to provide this description only for projects or activities that it carries out with funds reserved for State

level uses. In addition, local school districts or other eligible applicants that apply to the State for funding need to provide this des cription in their applications to the State for funding. T he State wo uld be responsible for ensuring that the school district or other local entity has submitted a sufficient section 427 statement as described below .)

**What Does This Provision Require?** S ection 427 requires each applicant for funds (other than an individual person) to include in its application a description of the steps the applicant proposes to take to ensure equitable access to, and participation in, its Federally

- assisted program for students, teachers, and other program beneficiaries with special needs. T his provision allows applicants discretion in developing the required description. T he statute highlights six ty pes of barriers that can im

pede equitable access or participation: gender, race, national origin, color, disability, or age. Based on local circumstances, you should determine whether these or other barriers may prevent yo ur students, teachers, etc. from such access or participation in, the Federally

- funded project or activity. T he description in yo ur application of steps to be taken to overcome these barriers need not be lengthy; yo u may provide a clear and succinct description of how yo u plan to address those barriers that are applicable to your circumstances. In additio n, the information may be provided in a single narrative, or, if appropriate, may be discussed in connection with related topics in the application. Section 427 is not intended to duplicate the requirements of civil rights statutes, but rather to ensure that, in designing their projects, applicants for Federal funds address equity concerns that may affect the ability of certain potential beneficiaries to fully participate in the project and to achieve to high standards. C onsistent with program requirement s and its approved application, an applicant may use the Federal funds awarded to it to eliminate barriers it identifies. **What are Examples of How an Applicant Might Satisfy**

**the Requirement of This Provision?** The following exam

ples may help illustrate ho w an applicant may comply with Section 427. (1) An applicant that proposes to carry out an adult literacy project serving, among others, adults with limited English proficiency, mi ght describe in its application how it intends to distribute a brochure about the proposed project to such potential participants in their native language. (2) An applicant that proposes to develop instructional materials for classroom use might describe how it will make the materials available on audio tape or in braille for st

udents who are blind. (3) An applicant that proposes to carry out a mo del science program for secondary students and is concerned that girls may be less likely than boys to enroll in the course, might indicate how it intends to conduct "outreach" efforts to girls, to encourage their enrollment. We recognize that many applicants may already be im plementing effective steps to ensure equity of access and participation in their grant programs, and we appreciate your cooperation in responding to the requirements of this provision.

**Estimated Burden Statem ent for GEPA Requirements**  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 v alid OMB control number for this information collection is **1894 -**  **0005.** The time required to complete this information collection is estimated to average 1.5 hours per response, including the time to review instructions, search existing data resources, gathe r the data needed, and complete and review the information collection. **If you**  **have any**  **comments concerning**  **the accuracy of the time estimate(s) or suggestions for improving this form, please write to:**  U.S. Department of Education, 400 Maryland Avenue, S.W. , Washington, D.C. 20202

- 4537.