80

Application for Federal Assistance SF-424

OMB Number: 4040-0004

Expiration Date: 8/31/2016

*1. Type of Submission: *2. Type of Application: * If Revision, select appropriate letter(s):

Preapplication

Application

New

Continuation

*Other (Specify):

Changed/Corrected Application Revision

* 3. Date Received: 4. Applicant Identifier:

Completed by Grants.gov upon submission

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/Parish:

*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:
81

Organizational Affiliation:

*Telephone Number: Fax Number:

*Email:

Application for Federal Assistance SF-424

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:
82

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

*15. Descriptive Title of Applicant’s Project:

Attach supporting documents as specified in agency instructions.

Application for Federal Assistance SF-424

16. Congressional Districts Of:

*a. Applicant: *b. Program/Project:

Attach an additional list of Program/Project Congressional Districts if needed.

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.
83

*20. Is the Applicant Delinquent On Any Federal Debt? (If “Yes,” provide explanation in attachment.)

Yes No

If “Yes”, provide explanation and attach.

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: Completed by Grants.gov upon submission *Date Signed: Completed by Grants.gov upon submission
U.S. Department of Education

Supplemental Information for the SF-424

1. Project Director:

Prefix: * First Name: Middle Name: * Last Name: Suffix:

Address:

* Street1: 

Street2:

* City: 

County:

* State: * Zip Code: Country:

* Phone Number (give area code): Fax Number (give area code):

* Email Address:

2. Novice Applicant:

Are you are a novice applicant as defined in the regulations in 34 CFR 75.225 (and included in the 

definitions page in the attached instructions)?

Yes No

3. Human Subjects Research:

a. Are any research activities involving human subjects planned at any time during the 

proposed Project Period?

Yes No

b. Are ALL the research activities proposed designated to be exempt from the regulations?

Yes Provide Exemption(s) # (s): 1 2 3 4 5 6

No Provide Assurance #(s), if available:

c. If applicable, please attach your “Exempt Research” or “Nonexempt Research” narrative to this form 

as indicated in the definitions page in the attached instructions.

OMB Number: 1894-0007

Expiration Date: 8/31/2017
U.S. DEPARTMENT OF EDUCATION 

BUDGET INFORMATION

NON-CONSTRUCTION PROGRAMS

OMB Control Number: 1894-0008

Expiration Date: 06/30/2017

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 EDUCATIO N 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 In direct 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)

ED 524
Instructions for ED 524

General Instructions

Thisform is used to apply to individual U.S. Department of Education 

(ED) discret ionary grant programs. Unless direct ed otherwise, provide 

the same budget information for each year ofthe multi-year funding 

request . Pay attention to applicable program specific instructions, if

attached. You may access the Education Department General

Administ rative Regulat ions, 34 CFR 74 – 86 and 97-99, on ED’s

websit e at:

http://www.ed.gov/policy/fund/reg/edgarReg/edgar.html

You must consult with your Business Office prior to submitting 

this form.

Section A - Budget Summary

U.S. Depart ment 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 funding 

is request ed, showthe total amount requested for each applicable 

budget category.

Lines 1-11, column (f): Show the multi-year total for each budget

category. If funding isrequest ed 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 isrequest ed.

Line 12, column (f): Show the total amount request ed for all project 

years. If funding isrequest ed for only one year, leave this space 

blank.

Indirect Cost Information: If you are request ing reimbursement for 

indirect costs on line 10, thisinformation isto 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 budget ed 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 St ate 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 isincluded 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 theprovision for a restricted 

indirect cost rate specified in 34 CFR 76.564(c)(2). Check only one 

response. Leave blank, if thisitem 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 contribut ed for all 

years of the multi-year project. If non-Federal contribut ions are 

provided for only one year, leave thisspace blank.

Section C - Budget Narrat ive [Attach separat e 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 

separat ely budget ed major activities orsub-projects, showfor 

each budget category of a project year the breakdown ofthe 

specific expenses attribut able 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 volunt ary cost-sharing or matching commitment, you must 

include:

a. The specific costs or contributions by budget category;

b. The source ofthe costs or contribut ions; and

c. In the case of third-party in-kind contribut ions, a description 

of how the value was det ermined for the donated or contributed 

goods or services.

[Please review ED’s general cost sharing and matching

regulat ions, 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 

donat ions, capital assets, depreciation and use allowances. OMB

cost principle circulars are available on OMB’s websit e at:

http://www.whit ehouse.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 request ing reimbursement forindirect costs on line

10, thisinformation isto be completed by your Business Office. 

Specify the estimated amount ofthe base to which the indirect 

cost rate is applied and thetotal indirect expense. Depending on 

the grant program towhich 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 theindirect 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 "Rest ricted Rate" programs, you must refer to the 

information and examples on ED’s websit e at:

http://www.ed.gov/fund/grant/apply/appforms/appforms.html.

You may also contact (202) 377-3838 for additional information 

regarding calculat ing indirect cost rates or general indirect cost 

rate information.

5. Provide other explanations or comments you deem necessary.

Pape rwork Burden State ment

According to the Paperwork Reduct ion Act of 1995, no persons are 

required to respond to a collection of information unless such 

collect ion displays a valid OMB control number. The valid OMB 

control number for thisinformation collection is 1894-0008. The

time required to complete thisinformation 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, gatherthe data needed, and complete and review the 

information collection. If you have any comments concerning the 

accuracy of the time estimate(s) or suggest ions forimproving this 

form, please writeto: U.S. Department of Education, Washingt on, 

D.C. 20202-4537. If you have comments or concerns regarding the

status of your individual submission ofthisform, write directly to

(insert program office), U.S. Department ofEducation, 400 Maryland

Avenue, S.W., Washington, D.C. 20202.
OMB Control No. 1894-0005 (Exp. 03/31/2017)

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 State-level 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.

(4) An applicant that proposes a project to 

increase school safety might describe the special 

efforts it will take to address concern of lesbian, 

gay, bisexual, and transgender students, and 

efforts to reach out to and involve the families of 

LGBT students

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. Public reporting burden for this 

collection of information is estimated to average 1.5 hours per response, including time for reviewing 

instructions, searching existing data sources, gathering and maintaining the data needed, and completing and 

reviewing the collection of information. The obligation to respond to this collection is required to obtain or 

retain benefit (Public Law 103-382. Send comments regarding the burden estimate or any other aspect of this 

collection of information, including suggestions for reducing this burden, to the U.S. Department of Education,

400 Maryland Ave., SW, Washington, DC 20210-4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number

1894-0005.
CERTIFICATION REGARDING LOBBYING

Certification for Contracts, Grants, Loans, and Cooperative Agreements

The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any 

person for influencing or attempting to influence an officer or employee of an agency, a Member of 

Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with 

the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the 

entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or 

modification of any Federal contract, grant, loan, or cooperative agreement.

(2) 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 

contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard

Form-LLL, ''Disclosure of Lobbying Activities,'' in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award documents 

for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and 

cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification

is a material representation of fact upon which reliance was placed when this transaction was made or 

entered into. Submission of this certification is a prerequisite for making or entering into this transaction 

imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be 

subject to a civil penalty of not less than $10,00 0 and not more than $100,000 for each such failure.

Statement for Loan Guarantees and Loan Insurance

The undersigned states, to the best of his or her knowledge and belief, that:

If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer 

or 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 commitment providing for the United States to insure or 

guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, ''Disclosure of Lobbying 

Activities,'' in accordance with its instructions. Submission of this statement is a prerequisite for making or 

entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the 

required statement shall be subjec t to a civil penalty of not less than $10,000 and not more than $100,000 

for each such failure.

* APPLICANT'S ORGANIZATION

* PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

Prefix: * First Name: Middle Name:

* Last Name: Suffix:

* Title:

* SIGNATURE: * DATE:
ASSURANCES - NON-CONSTRUCTION PROGRAMS

OMB Approval No. 0348-0040

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 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.

Previous Edition Usable Standard Form 424B (Rev. 7-97)

Authorized for Local Reproduction Prescribed by OMB Circular A-102
9.

10.

11.

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.

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.

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 (Clean Air) Implementation Plans 

under Section 176(c) of the Clean 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.

13.

14.

15.

16.

17.

18.

Will comply with the Wild and Scenic Rivers Act of

1968 (16 U.S.C. §§1271 et seq.) related to protecting 

components or potential components of the national 

wild and scenic rivers system.

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.).

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.

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.

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.

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."

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
DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046

(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 a 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 b. Individuals Performing Services (including address if

(if individual, last name, first name, MI): 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 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 employeeof any agency, a Member of Congress, an officer or employee of 

Congress, or an employeeof a Member of Congress in connection with a coveredFederalaction. 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 appropriateclassification 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 previouslysubmitted 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 CongressionalDistrict, if known. Check the appropriateclassification 

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 organizationallevel 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; 

Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number 

assigned by the Federal agency). Include 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 PaperworkReduction 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 Managementand Budget, Paperwork Reduction Project (0348-0046), Washington, 

DC 20503.