OMB Number: 4040-0004

Expiration Date: 01/31/2009

Application 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 application:

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

Application for Federal Assistance SF-424 Version 02

*9. Type of Applicant 1: Select Applicant Type:

 

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

Application 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 Any 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 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 announcement or 

agency specific instructions

Authorized Representative:

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-102
OMB Number: 4040-0004

Expiration Date: 01/31/2009

Application 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 Federal Debt. 


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 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 specify): __________________________ 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 for 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 Instructions

This form is used to apply to individual U.S. Department of Education 

(ED) discretionary 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 to 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 project 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 Information: If you are requesting reimbursement for 

indirect costs on line 10, this information is to be completed by your 

Business Office. (1): Indicate whether or not your organization has an 

Indirect Cost Rate Agreement that was 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 proposal 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 costs 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 Indirect Cost Rate Agreement. In 

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 Indirect 

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 justification 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 specific 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. In 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. 

Specify the estimated amount of the base to which 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" programs) 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 

regarding 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 the 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 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 collection of 

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 (0348-0040), Washington, DC 20503

PLEASE DO NOT RETURN YOUR COMPLETED 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 application.

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 the 

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 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. Will comply 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 the 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 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 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 made; and (j) the requirements 

of any other nondiscrimination statute(s) which may apply to 

the application.

7. Will 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 

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 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.
9. Will comply, as applicable, with the provisions of the DavisBacon 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 applicable, 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. 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) Implementation 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 Safe 

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 research, 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 

blooded 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 construction 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 1996 and OMB Circular No. A-133, 

Audits of States, Local Governments, and Non-Profit 

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

APPLICANT ORGANIZATION 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 requirements 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 Workplace 

(Grants)." The certifications shall be treated as a material 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 

implemented 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 making 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 cooperative 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 award 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 

RESPONSIBILITY 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 preceding 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 indicted 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 this 

application had one or more public transaction (Federal, State, 

or local) terminated for cause or default; and 

B. Where 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 Workplace 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. The 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 workplace;

(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 workplace;

(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 of 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 provide 

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), Washington, DC 20202-4248. Notice shall include the 

identification 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 such 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. The 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 Workplace 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 Maryland Avenue, S.W. (Room 

3652, GSA Regional Office Building No. 3), Washington, 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 applicant will comply with the above certifications.

NAME OF APPLICANT PR/AWARD NUMBER AND / OR PROJECT NAME

PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

SIGNATURE DATE

ED 80-0013 12/98

 
14

Certification Regarding Debarment, Suspension, Ineligibility and

Voluntary Exclusion -- Lower Tier Covered Transactions

This certification is required by the Department 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 signing 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 entered 

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 originated 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 participant 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," " person," 

"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 enter 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 originated.

6. The prospective lower tier participant further agrees by submitting 

this proposal that it will include the clause titled Certification

Regarding Debarment, Suspension, Ineligibility, and Voluntary 

Exclusion-Lower Tier Covered Transactions,without modification, in

all lower tier covered transactions 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 required 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 transaction 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 department 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 principals are presently debarred, 

suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal 

department or agency.

(2) Where 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

Complete 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 material change only:

Year _______ quarter _______

Date of last report___________

 

4. Name 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: 

 Congressional District, if known: 

6. Federal Department/Agency: 7. Federal Program Name/Description: 

CFDA Number, if applicable: ____________

8. 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: _______

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 employee 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 of 

a covered Federal action.

2. Identify the status of the covered Federal action.

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 code 

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 covered 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 of 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 20503
OMB 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 Education's General 

Education Provisions Act (GEPA) that applies to 

applicants for new grant awards under Department 

programs. This provision is Section 427 of GEPA, enacted 

as part of the Improving 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 Statelevel uses. In addition, local school districts or other 

eligible applicants that apply to the State for funding need 

to provide this description in their applications to the State 

for funding. The State would 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?

Section 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. This 

provision allows applicants discretion in developing the 

required description. The statute highlights six types of 

barriers that can impede 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 your students, 

teachers, etc. from such access or participation in, the 

Federally-funded project or activity. The description in 

your application of steps to be taken to overcome these 

barriers need not be lengthy; you may provide a clear and 

succinct description of how you plan to address those 

barriers that are applicable to your circumstances. In 

addition, 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. Consistent with 

program requirements 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 examples may help illustrate how 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, might 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 students who are blind.

(3) An applicant that proposes to carry out a model 

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 

implementing 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 Statement 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 

valid 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, gather 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.