### 80 **A p**  **p l**  **i ca**  **t i**  **o n**  **fo r**  **F e**  **d e**  **r a**  **l A** **ssis t**  **a n**  **ce S**  **F -**  **424** O M B N um b er : 4 04 0 - 00 0 4 E xpi r ati on D at e : 8 /3 1 / 2 016

* 1
. Ty p e o f S u b mi s s i on: * 2
. Ty p e o f A pp l i c a t i o n: * If R e v is i on , se l ec t app rop r i at e le t t e r( s ): Pr eap p l i ca t i on A pp l ica t ion N e w C on t i nua t ion * O t he r (S pe c i f y ): C han g ed /C o rr e c t e d A p p l i ca t i on R e v isi o n * 3
. D a te R ec e i v ed : 4
. A p p li c an t I de n t i f i e r: C o m p l eted by G r a n ts.gov u pon sub m i ssion 5a . F ede r a l E n t i ty I de n t i f i e r: * 5b
. F e de r a l Awa rd I den t i f i e r: **St a**  **te U**  **s e**  **O n**  **l y**  **:** 6
. D a te R ec e i v e d b y St a t e : 7 . St a t e A p p l i ca t i o n I d en t i f ie r: **8 .**  **A PPLICANT**  **INF O**  **R M**  **A T**  **I O**  **N:**

* a . Le g a l N a me:
* b
. E m p lo y e r/ T a x pa y e r I den t i f ica t io n N u m b e r (EIN/ T IN): * c . O rga n i z a t i o na l DUNS: **d. A** **ddr ess**  **:** *Str ee t 1: Str ee t 2: *C i t y : C oun t y/P a r i sh : *St a t e : Pro v in c e: *C oun try : *Z i p / P o s t a l C od e: **e .**  **O rg**  **a n**  **i za**  **tio n**  **a l**  **Unit:** D epa rt m en t N a me : D i v isio n N am e : **f. N**  **am e**  **a nd**  **c ont**  **a c**  **t infor m**  **a tion**  **of p**  **e r** **s on**  **t o**  **be c**  **ont ac** **t e**  **d on**  **m a**  **tt e**  **rs in**  **v ol**  **v ing**  **this a**  **ppli c**  **a ti**  **o n:**  Pr e f i x : *F i rs t N a me : M iddl e N ame : * Las t N a me : S u ff i x : T i t le :

### 81 O rgani z a t i on a l Aff i lia t ion:

* T elephon e N u m be r: F a x N umbe r: *E mai l: 

### A **p p**  **l i**  **ca t**  **i o**  **n fo**  **r F**  **e d**  **e r** **a l**  **A ssis**  **t a**  **n ce**  **S F**  **- 424**  **9 .**  **T y** **pe of**  **A ppli**  **ca nt**  **1 :**  **S e**  **l e**  **c t**  **A ppli**  **ca nt**  **T y** **p e:**  Ty p e o f A ppl i can t 2 : S el e c t A ppl i can t Ty pe: Ty p e o f A ppl i can t 3 : S el e c t A ppl i can t Ty pe:

* O t he r (S pe c i f

y )

***** **1 0**  **N am**  **e of F**  **e d**  **e r** **a l**  **A g**  **e n**  **c y**  **: 11**  **. C**  **a t**  **a l**  **og of**  **F e**  **d e**  **r a**  **l Do**  **m e**  **s tic**  **A ss**  **i s**  **t a**  **n c**  **e Nu**  **m b**  **e r**  :
CFDA T i t le :

***** **1 2**  **Fun d**  **ing O**  **pport u**  **ni t**  **y N**  **u m**  **b e**  **r** :

* T i t le :

**13 .**  **Co m**  **p e**  **tition Id**  **e n**  **t ifi**  **ca t**  **i o**  **n Nu**  **m b**  **e r**  :

T i t le :

### 82 **14 .**  **A r**  **ea s**  **A**

**ff ec**  **t e**  **d b**  **y Proj**  **ec t (Citi**  **es ,**  **Co u**  **nti e**  **s ,**  **St a**  **t e**  **s ,**  **e t**  **c .):** 

***** **15 .**  **D e**  **s c**  **ripti v** **e Title**  **of A**  **ppli ca**  **nt ’**  **s Proj**  **ec t**  :

Att a c h s uppor

t i n g do c u m e n t s a s spe c i f i e d in age n c y i n st ruc t i o n s .



### A **p p**  **l i**  **ca t**  **i o**  **n fo**  **r F**  **e d**  **e r** **a l**  **A ssis**  **t a**  **n ce**  **S F**  **- 424**  **16 .**  **Congr e**  **ss io**  **n a**  **l Di**  **s tr**  **i c**  **ts O**  **f:**

* a . A pp l ic a n t: * b
. Prog r a m /Pro je c t: Att a c h a n add i t i ona l l i s t o f P rogra m /P ro j e c t Congres s i ona l D i st r i ct s i f needed. **17 .**  **Prop o**  **se d**  **Pro**

**j ec**  **t** :
* a . St a rt D a t e : * b
. E n d D a t e: **18 .**  **E s**  **t i**  **ma t**  **e d**  **Fund i**  **ng (**  **$ ):** 

* a . F e d e r al

* b
. A pp l i c ant

* c . St a t e
* d
. L o cal

* e . O t her *f. Prog r a m I n c o m e * g . T O T AL

***** **19 .**  **Is A**  **ppli c**  **a tion**  **S u**  **bj ec**  **t t**  **o R**  **e v**  **i e**  **w B**  **y St**  **a te**  **Und e**  **r E x**  **ec uti**  **v e**  **O rd**  **e r**  **12 3**  **7 2**  **Pro c**  **e s**  **s?** a . T hi s ap p li c a t i o n wa s m ad e a v aila b l e t o t h e St a t e u n de r th e E x ecu t i v e O rde r 1 2 37 2 P ro c es s fo r r e v ie w o n b
. Pro g r a m i s s u bj e c t to E. O
. 1237 2 bu t h a s no t be e n s el e c t e d b y t h e St a te fo r re v ie w . c . Pro g r a m i s no t co v e r e d b y E. O
. 123 7 2.

### 83 ***** **20 .**  **Is t**  **he A**  **ppli ca**  **nt D**  **e lin**  **q u**  **e nt**  **O n**  **A n**  **y F**  **e d**  **e r** **a l**  **D e**  **bt? (If**  **“ Y**  **e s**  **,” pro**  **v ide**  **ex p**  **l a**  **n a**  **t io**  **n in**  **at t**  **a c**  **h m**  **e nt.)**  Ye s No If “ Yes ”, p ro v i d e e x plana t io n a n d a t t ac h
. **21 .**  ***** **B y**  **s igning**  **this a**  **ppl i**  **ca t**  **i on,**  **I c**  **e rti**  **f y**  **( 1**  **) to the**  **s t**  **a t**  **em e**  **nts c**  **o nt**  **a i**  **n e**  **d in**  **t he**  **l i**  **s t of**  **ce rtifi**  **ca t**  **ion s**  ****** **a n**  **d (**  **2 ) t**  **h a**  **t t**  **he s**  **t a**  **t em**  **e nts**  **h e**  **r e**  **in a**  **re tru**  **e ,**  **c o**  **m pl**  **e te**  **a nd**  **acc u**  **r a**  **te to**  **t he**  **b es**  **t of m**  **y k**  **no w**  **l e**  **dg e**  **. I**  **a l**  **s o**  **pro v**  **ide the**  **r e**  **quir e**  **d ass**  **u r** **a n**  **ces** ****** **a nd**  **a gr** **e e**  **to c**  **o m**  **p l**  **y w**  **ith a**  **n y**  **r es**  **ulting t**  **e r**  **m s**  **if I ac**  **c e**  **pt a**  **n a** **w a**  **rd. I**  **a m**  **a w**  **a re**  **th a**  **t a**  **n y**  **f a**  **l se**  **, fi**  **c titiou**  **s ,**  **or fr a**  **u du**  **l e**  **nt s**  **t a**  **t em**  **e nts**  **or c**  **l a**  **i m**  **s m**  **a y**  **s ubj**  **ec t**  **m e**  **to c**  **r im**  **i n**  **a l,**  **c i**  **v il,**  **or a**  **d m**  **in i**  **s tr** **a ti**  **v e**  **p e**  **n a**  **lti e**  **s .**  **(U. S.**  **Cod e**  **, T**  **itle 218**  **, S**  **ec ti**  **o n**  **100 1**  **)  I A G REE **  T h e lis t o f c e rt i fic a t io n s a n d as s u r a n ce s , o r a n i n t e r n e t s i te w he re y o u ma y ob t ai n t h i s l is t , i s co n t ai n e d i n t h e a n no u n c e men t or age n c y sp e ci fi c in s tr u c t i o ns . **A uthori**  **ze d**  **R e**  **pr es**  **e nt**  **a ti**  **v e**  **:** Pr e f i x : *F i rs t N a me : M iddl e N ame :
* Las t N a me : S u ff i x :

* T i t le :

* T elephon e N um b e r: F a x N umbe r: * E mai l: *S igna t u re o f A u t h o r i z e d R ep r ese n t a t i v e: C o m p l e t e d b y G ra n ts . go v u po n s u b m issi on *D a te S ig n ed: C o m p l e t e d b y G ra n ts . go v u po n s u b m issi on

# U. **S. D**  **ep a**  **rt m**  **ent o**  **f Educ a**  **t i**  **o n**  **Supp l**  **e m**  **ent a**  **l I**  **n f** 

**o r**  **m a**  **t io**  **n f** 

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## Addre ss: * S tr e e t 1: S tr e et 2: * C ity : C ounty : 

### * S t at e : * Z i p C ode: C ountry : * Phone Num

ber ( g i v e ar ea co d e ) : Fax Num ber ( g i v e ar ea co d e ) : * E ma i l A ddr e s s: 

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r ch a c ti viti es i nvo l vi ng human s ub j ec t s p l anned at any ti me d u ri ng the p r o p o s ed P r o

j e c t P e ri od? Y es No b. Ar e AL L the r e se a

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u l at i o n s? Y es P r o vi de E xe m

p ti o n ( s ) # (s ) : 1 2 3 4 5 6 N o P r o vi de A s s ur an ce # ( s ) , i f av a il ab l e:

c. I f app l i cab l e, p l e a se att ach your “ E xe m pt R e s ea rc h ” or “N o nexe m

pt R e s earc h ” nar

r ati v e t o th i s f

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### U **. S**  **. D**  **E P**  **AR T**  **M E**  **N T**  **O F**  **E DUCA**  **T I**  **O N**  **B UD**  **G ET**  **IN F**  **O R**  **M A**  **T I**  **O N**  **N O**  **N -**  **C O**  **N S**  **T RUC**  **T I**  **O N**  **P R**  **O G**  **RA M**  **S** OM B C on t r o l N u m b e r : 1894 - 00 0 8 E x p i ra t io n D a t e : 0 6/ 30

/ 201 7 Na m e o f I n s t i t u t ion / Org a n iz

at io n A pp lican t s r e qu e s t i n g f und i n g f o r on l y on e y ear s h ou ld c o m

p le t e t h e c o l

u m n und e r " Pr oj ec t Y ea r 1 . " A pp lican t s re qu e s t i n g f und i n g f o r m u l t i - y ear g ran t s s hou ld c o m p le t e a l l app licab le c o l

u m n s . P lea s e rea d a ll i

n s t r u c t ion s b e f

o re c o m p le t i n g f o r m . **S E**  **C T** **I O**  **N A**  **- B**  **U**

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rec t Co s t s ( li

n e s 1 - 8) 10 . I nd i rec t Co s t s * 11 . Tra i n i n g S t i p e nd s 12 . T o t a l Co s t s ( li

n e s 9 - 11) ***** **I n**  **d i**  **rec t**  **C o**  **s t**  **I**

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n g re i m bu r s e m e n t f o r i nd i rec t c o s t s o n li

n e 10 , p lea s e an s we r t h e f o llo w i n g qu e s t ion s : ( 1 ) D o yo u h a v e an I

nd i rec t Co s t R

a t e A g ree m

e n t app r ov e d b y t h e F e d e ra l gov e r n m e n t ?

____ Y

e s

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e n t : Fr o m :

___ /

___ /

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___ /

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__ _ I s i n c l ud e d i n yo u r app r

ov e d I nd i rec t Co s t R

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e n t ? o r

___ C o m

p lie s w i t h 3 4 CFR 76 . 564 ( c )(2 ) ? Th e R e s t r ic t e d I n d i rec t Co s t R

a t e i s

_________ % E D 524

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e o f I n s t i t u t ion / Org a n iz

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p le t e t h e c o l

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u m n s . P lea s e rea d a ll in s t r u c t ion s b e f

o re c o m p le t i n g f o r m . **S E**  **C T** **I O**  **N B**  **- B**  **U**

**D G** **E T**  **S U** 

**MM AR**  **Y N**  **O N** **- F**  **E D**  **E RA**  **L F** 

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rec t Co s t s ( L i n e s 1 - 8) 10 . I nd i rec t Co s t s 11 . Tra i n i n g S t i p e nd s 12 . T o t a l Co s t s ( L i n e s 9 - 11) 

### S **E C**  **T I**  **O N**  **C**
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**E** ( s e e i ns t r uc ti ons ) E D 524

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c ti o n s T h i s f o r m i s us e d t o app ly t o i n d i v i du a l U . S. D e p a rtm

e n t o f E du c a t i o n ( E D ) d i s c r e t i o n a r y g r a n t p r og r a ms . Un l e

s s d i r ec t e d o t he r w i s e , p r ov i d e t h e s am e budge t in f

o r m ati o n f o r ea c h y e a r o f t he m u

lt i - y ea r f u n d i n g r e que st . P a y a tt e n

ti o n t o ap p li c a

b l e p r og r a m sp ec i f

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e Re gu l a t i o n s , 3 4 C F R 7 4

– 8 6 an d 9 7 -9 9 , o n E D ’ s w e b s i t e a t : h t t p :// www . e d . gov / po li c y / f u n d /r e g / e dga r Re g

/ e dga r . h t m l **Y o**  **u m**  **u s**  **t c**  **o n**  **s u**  **l t**  **w i**  **t**

**h yo**  **u r**  **B u**  **s i**  **n e**  **s s**  **O f** 

**f i**  **c e**  **p r**  **i o**  **r t**  **o s**  **ubm i**  **t t** 

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u mm a r y U . S. D e p a r t m

e n t o f E du cati o n Fu n ds A l l app li can t s m us

t c o m p l e t e S ec t i o n A a n d p r o v

i d e a br eak -

d o w n by t h e app li cab l e budge t cat e g o r i e s sho w n i n lin e s 1 - 1 1 . L i n e s 1 - 11 , c olu

m ns ( a ) - ( e ) : F o r eac h p r

o j e c t y e a r f o r w h i c h f u n d i ng i s r e que st e d

, sho w t h e t o

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u n d i n g i s r e que st e d f

o r on l y o ne p r o j e c t y ea r , l ea v e t h i s c o lu m n b l a nk . L i n e 12 , c o l

u m ns ( a ) -( e ) : S

ho w t h e t o t a

l budge t r e que st f

o r e a c h p r o j ec t y e a r f o r w h i c h f und i n g i s r e qu

e st e d . L i n e 12 , c o l

u m n (f) : S ho w t h e t o

t a l am o un t r e que st e d f o r a l l p r o j ec t y ea r s . I f f

u n d in g i s r e que st e d f

o r o n ly o ne y e a r , l ea v e th i

s s p ac e b l a nk . I n d i r ec t C o st I n f

o r m a ti o n : I f y o

u a r e r e que st in

g r e i m bu r s e m e n t f o r in d i r ec t c o s t s o n li n e 1 0 , t

h i s in f o r m ati o n i s t o b e c o m

p l e t e d by yo u

r B usin e s s O ff

i ce . ( 1 ) : I nd

i cat e w h e the r o r no t y ou

r o r ga n i z ati o n h a s a n I n d i r ec t C o st R

a t e Ag r e e m e n t th a t w a s app r o v e d by t he F e de r a l gov e r n m e n

t . I f yo u c h ec k e d “ no , ” E D ge n e r a l ly w il l au t ho r i z e g r a n t ee s t o us e a t e m po r a r y r a t e o f 1 0 p e r c

e n t o f budge t e d s a l a r i e s a n d w a ge s sub j e c t t o t h e f o ll o w i n g li m it a ti on s : ( a ) T h e g r a n t e e m ust s ub m i t an in d

i r e c t c o st p r op o s a l t o i

t s c o g n i za n t a ge n c y w

i t h i n 9 0 d a y s a f t e r E D i ssue s a g

r an t a w a r d no t i f i cati on; a n d ( b) I f a f t e r t he 9 0 - d

a y p e r i od, t he g

r an t e e h a s n o

t subm i tt e d a n i n d i r ec t c o st p r op o s a l t o it s c o g n i z a n t a ge n c y , t he g r a n t e e m a y n o

t c h a r ge i t s g

r a n t f o r in d i r e c t c o s t s u n ti l i t h a s n e go

ti at e d an i n d

i r e c t c o st r a t e a g

r ee m e n t w i t h it s c o g n i z an t a ge n c y. ( 2 ) : I f yo u c h ec k

e d “ y e s ” i n ( 1 ) , i n d

i c a t e in ( 2 ) t he b e g i nn in g an d e n d

in g d a t e s c ov e r

e d b y t h e I nd i r e c t C o st R a t e A g r ee m e n t . I n a dd

i t i o n, in d i c a t e w h e th e r E D , ano the r F e d

e r a l a ge n c y ( O t h e r ) o r S

t a t e a ge n c y i ssue d t h e ap pr ov e d a g r ee m e n t . I f yo u c h e c

k “ O t h e r , ” s p ec i f y t he n a m e o f t he F e de r a

l o r o the r a ge n c y t hat i ssue d t h e app r ov

e d a g r ee me n t . ( 3 ) : I f yo u a r e ap p ly i n

g f o r a g r a n t u n d e r a R e st r i c t e d R a t e P r o g r a m ( 3 4 C F R 75 . 5 6 3 o r 7 6 . 5 6 3 ) , in d i cat e w h e the r y o u a r e usi n g a r e st r i c t e d i n d i r e c t c o st r at e t hat i s in c l

ud e d o n yo u r ap pr ov e d I n d i r e c t C o st R

a t e A g r ee m e n t o r w h e t he r yo u a r e usi n g a r e st r i c t e d i n d i r ec t c o st r a t e th at c o

m p li e s w i t h 3 4 C F R 76 . 564 (

c )( 2 ) . N o t e : S t a t e o r L o ca l g ov e r n m e n t a ge n c i e s m a y no t us e t h e p r o

v i s i o n f o r a r e s t r i c t e d in d i r ec t c o st r at e s

p ec i f i e d in 3 4 C F R 76 . 5 64 ( c )( 2 ) . Ch ec k on ly o ne r e spon s e . L ea v

e b l a n k, i f t h

i s i t e m i s no t ap p li c a

b l e . S ec t i o n B - Budge t S

u mm a r y N o n - F e d e r a l Fu n ds I f yo u a r e r e qu

i r e d t o p r o v

i d e o r vo lun t ee r t o p r o

v i d e c o st - sh a r i n g o r m a t c h in g f u n ds o r o t he r no n-

F e d e r a l r e s o u r c e s t o t he p r o

j e c t , t he s e sho u l d b e sho w

n f o r eac h ap p li cab l e budge t cat e g o r y o n lin e s 1 - 1 1 o f S ec t i o n B . L i n e s 1 - 11 , c olu

m ns ( a ) - ( e ) : F o r eac h p r

o j e c t y e a r , f o r w h i c h m a t c h in g f u n ds o r o t he r c o n

tr ibu ti o ns a r e p r

o v i d e d , sho w t he t o

t a l c on t r i bu t i o n f o r eac h app l i

cab l e budg

e t ca t e go r y. L i n e s 1 - 11 , c olu

m n (f) : S ho w t h e m u

lt i - y e a r t o t a l f o r eac h budge t ca t e go r y . I f n o

n - F e d e r a l c o n tr ibu ti o ns a r e p r

o v i d e d f o r on ly o ne y ea

r , l ea v e t h i s c o lu

m n b l a nk . L i n e 12 , c o l

u m ns ( a ) -( e ) : S

h o w t h e t o t a

l m at c h in g o r o th e r c on t r i bu t i o n f o r eac h p r o

j ec t y e a r . L i n e 12 , c o l

u m n (f) : S ho w t h e t o

t a l am o un t t o b e c on tr i

bu t e d f o r a l l y ea r s o f t h e m u

lt i - y e a r p r o j e c t . I f no n - F

e d e r a l c o n tr ibu t i ons a r e p r ov i d e d f o r o n ly o ne y e a

r , l ea v e th i s sp a c

e b l a n k . S ec t i o n C - Budge t N a rr at i v e [ At t ac h s e p a r a t e sh ee t ( s ) ] P a y a t t e n t i o n t o app li cab l e p r o g r a m sp ec i f

i c in st ru c t i on s , i f at t ac h e d. 1 . P r ov i d

e a n i t e m i z e d budge t br ea k d

o w n , an d j ust i f

i cati o n by p r o j ec t y e a r , f o r eac h budge t cat e g

o r y li s t e d in S ec t i o ns A a n d B . F o r g r a n t p r o j ec t s t h a t w il l b e d i v i d e d i n t o t w

o o r m or e s e p a r a t e ly budge t e d m a

j o r ac ti v iti e s o r su b - p r o j e c t s , sh o w f o r eac h budge t ca t e g

o r y o f a p r o

jec t y e a r t he br eakd

o w n o f t he sp ec i f i c e xp e ns e s a t tr

ibu t ab l e t o ea c

h sub - p r o j e c t o r ac ti v it y . 2 . F o r no n - F e d

e r a l f u n ds o r r e s ou

r ce s li st e d i n S ec t i o n B t h at a r e us e d t o m ee t a c o st - sh

a r i n g o r m a t c h in g r e qu i r e m e n t o r p r o v i d e d a s a vo lu n t a r y c o st - sh a r

i n g o r m at c h

in g c o m m it m e n t , y o u m u st i n c lude :

a . T h e sp ec i f

i c c o st s o r c o n

tr i bu ti o ns by budge t ca t e go r

y ; b . T h e s o u

r c e o f t he c o st s o r c o

n tr i bu t i ons ; a n d c . I n t h e ca s e o f t h

i r d- p a rty i n - k i n d c on tr ibu t i o n s , a d e s c r i p ti o n o f ho w t h e v a lue w

a s de t e r m ine d f

o r t he d on at e d o r c o n tr i bu t e d g oo ds o r s e r v i ce s . [ P l ea s e r e v i e w E D ’ s ge n e r a l c o st sh a r

in g an d m a t c h

i ng r e gu l a t i on s , w

h i c h i n c lud

e s p ec i f i c li m it a ti o ns , in 3 4 C F R 74 .23 , app li cab l e t o n o

n - g o v e r n m e n t a l e n titi e s , an d 8 0 . 24 , ap p li c a

b l e t o g ov e r n m e n

t s , an d t he ap

p li c ab l e O ff i c e o f M a n a ge m e n t a n d B udge t ( O M B ) c o st p r in c i p l e s f o r y ou r e n tity ty p e r e ga r

d i n g d on a t i o ns , cap it a

l a ss e t s , d e p r ec i a ti o n an d us e a ll o w

a n ce s . O M B c o st p r in c ip l e c i r c u l a r s a r e a v a

il ab l e o n O M B ’ s w

e b s i t e a t : h t t p :// www . w h i t e ho us e . go

v / o m b / c i r c u l a r s/ind e x . h tm l ] 3 . I f app li cab l e t o t

h i s p r o g r a m , p r ov i d e t he r at e a n d ba s e o n w

h i c h fr i n ge b e n e f

i t s a r e c a l c

ul a t e d . 4 . I f yo u a r e r e que st i n g r e i m bu r s e m e n t f o r i n d i r ec t c o st s o n li n e 10 , t h i s in f

o r m ati o n i s t o b e c o m p l e t e d by yo u r B usin e s s O ff

i ce . S p ec i f y t h e e st i m

at e d a m ou

n t o f t he ba s e t o w

h i c h t he i n d

i r e c t c o st r a t e i s app li e

d an d t h e t o

t a l in d i r e c t e x p e n s e. D e p e nd

in g o n t h e g r a n t p r o g r a m t o w h i c h yo u a r e ap

p ly i n g an d / o r yo u r app r ov e d I n d i r ec t C o st R

a t e Ag r ee m e n t , s o m e d i r ec t c o st bud

g e t ca t e go r i e s i n yo u

r g r a n t ap p li c a

ti o n budge t m a y n o

t b e i n c lude d in t h e b a s e an d m u

lt i p li e d by yo u

r in d i r e c t c o st r at e . F o r e x a m p l e , y o

u m ust m u

lti p ly th e i n d

i r ec t c o st r at e

s o f “ T r a i n i ng g r a n t s " ( 3 4 C F R 75 . 5 6 2 ) an d g r an t s u n d e r p r og r a ms w i t h “ S u pp l e m e n t n o

t S u pp l a n t ” r e qu

i r e m e n t s ( " Re str i c t e

d R a t e " p r o g r a m s ) by a “ m

o d i f i e d t o t a l d i r ec t c o st ” ( M

T D C ) ba s e ( 3 4 C F R 75 . 56 3 o r 7 6 . 56 3 ) . P l ea s e i n d i c a t e w h i c h c o s t s a r e in c l ud e d an d w h i c h c o st s a r e e x c lud

e d fr o m t he b a s e t o w

h i c h t h e i n d i r ec t c o st r at e i s app li e

d . W h e n ca l c u

l atin g i n d i r e c t c o st s ( li n e 10 ) f

o r " T r a in in g g r a n t s " o r g r a n t s u n d e r " Re st r i c

t e d R a t e " p r o g r a m s , y o u m us t r e f e r t o t he in f o r m ati o n an d e x am

p l e s o n E D ’ s w

e b s i t e a t : h t t p :// www . e d . gov / f u n d / g r a n t/ ap p l y / ap p f or ms/ app f

o r m s .h t m l . Y o u m a y a l s o c on t ac t ( 2 0 2 ) 3 7 7 - 38 3 8 f o r a dd i t i o na l i n f

or m a t i o n r e ga r d i n g ca l c u l a t in g in d i r ec t c o st r a t e s o r ge n e r

a l in d i r e c t c o st r a t e i n f o r m a ti o n . 5 . P r ov i d

e o t h e r e x p l a n ati ons o r c o mm

e n t s yo u d ee m n e ce ss a r y. **P a**  **p e**  **r w**  **o r**  **k B**  **u r**  **d e**  **n S**  **t a**  **t e**  **m e**  **n t**  A cc o r d i n g t o t he P ap e r w

o r k Re du c t i o n A c t o f 1 99 5 , n o p e r

s o ns a r e r e qu i r e d t o r e spon d t o a c o ll e c ti o n o f in f

o r m ati o n u n l e s s suc h c o ll ec t i o n d

i s p l a y s a v a li d O M B c o n

t r ol n u m b e r. T he v a li d O M B c on t r o l n u

m b e r f o r t h i s in f o r m ati o n c oll ec ti o

n i s **189 4**  **- 0**  **0 08**  . T he t i m e r e qu i r e d t o c o m

p l e t e t h i s in f o r m a ti o n c o ll e c ti o n i s e st i m at e d t o v a r y fr o m 1 3 t o 2 2 h ou

r s p e r r e spo

n s e , w i t h an a v e r a ge o f 1 7 . 5 h ou

r s p e r r e spon s e , i n c lud

in g t he t i m

e t o r e v i e w i n stru c ti o n s , s ea r c h e x i s

t i ng d a t a s o u r ce s , g a t h e r t he d

a t a n e e d e d, a n d c o m

p l e t e an d r e v i e w t h e in f o r m ati o n c o ll e c ti o n . I f yo u h a v

e an y c o mm e n t s c o n ce r n i n g t he acc u r ac y o f t he t i m

e e sti m a t e ( s ) o r sugge st i o ns f

o r i m p r o v in g t h i s f o r m , p l ea s e w

r i t e t o : U . S. D e p a r t

m e n t o f E du ca ti on, W a sh

ing t on, D . C . 2020 2 -

4 5 37 . I f yo u h a v

e c o mm e n t s o r c o n ce r n s r e ga r d in g t he st a t us o f yo u

r i n d i v i du a l subm i ssi o n o f t h

i s f o r m , w r i t e d i r ec tly t o ( i n s e r t p r og

r a m o f f i ce ) , U . S. D e p a r

t m e n t o f E du cati o n, 4 00 M a r y

l a n d Av e n ue , S. W . , W a s

h i n g t o n , D . C . 20 202 .O M B C ont r o l N o . 1 8 94 - 0 0 0 5 (E x

p . 0 3 / 31 /2 0 17 ) 

## NO **T ICE**  **T O A**  **L L**  **A P**  **P L**  **ICAN T**  **S** T h e p urpo s e o f th is e n cl o s ur e is to i n f o r m y o u abo ut a n e w pro v i s i o n i n th e De p art m e nt o f Edu c a ti on ' s Ge n e r al Edu cati o n P ro v i s i o n s Act ( G E P A) th at app lies to app licants f

o r n e w gr ant a ward s un d er De p art me nt pro gr a ms . T h is pro v i s i o n is Secti o n 427 o f G E P A , e n acted as p art o f th e I m pro v i n g Am e r ic a ' s Sc h oo ls Act o f 199 4 ( P u

b lic L a w ( P . L . ) 103 - 382) . **T o Wh**  **o m**  **D o**  **es T**  **his P**  **r ov**  **i s**  **i o**  **n** 

### Appl **y?** Secti o n 42 7 o f G E P A a f

f ec t s app licants f

o r n e w gr ant a w ard s un d er th is pro gr a m . **A L**  **L A**  **PP L**  **I CA**  **N T**  **S FO**  **R N**  **E W**  **A W**  **ARDS M**  **UST I**  **N C**  **L U**  **D E**  **I N**  **FO R** **M A**  **TI O**  **N I**  **N T**  **H E**  **I R**  **A PP**  **L I**  **C A**  **TI O**  **NS T**  **O AD**  **D R** **E SS**  **T H**  **I S**  **N E**  **W P**  **R O**  **V I**  **S I**  **O N**  **I N**  **O RD**  **E R**  **T O**  **R E**  **C EI**  **V E**  **F U**  **ND I**  **N G**  **UN D**  **E R**  **T H**  **I S**  **P R**  **O G**  **RA M**  **.** (I f th is pro gr a m is a S tate - f o r m u la gr ant pro gr a m , a State n ee d s to pro v i d e th is d e s c r i p ti o n o n l y f or pr o j ects o r acti v ities th at it carr ies o ut wi th fun d s r e s e rv ed f

o r State - l e v el us e s . I n a dd iti o n , l o cal s c h oo l d i s tr icts o r o th er eli g i b le app licants th at app l y to th e St a te f

o r f un d i n g n eed to pro v i d e th i s d e s c r i p ti o n in th eir app lica t i o n s to th e S tate f o r f un d i ng . T h e State wou ld b e r e s po ns i b le f o r e n s ur i n g th at th e s c h oo l d i s tr ict o r o th er l o cal e nti t y h a s su b mitted a s uf

f ici e nt s ect i o n 42 7 s tate me nt as d e s c r i b ed b el o w . ) **Wh a**  **t D**  **o es**  **T h**  **i s**  **P r**  **ov i**  **s i**  **o n**  

### Require? Secti o n 42 7 r e qu i r es each ap p licant f o r f un d s (o t h er th an a n i n d i v i du al p e r s on ) to i n clu d e in its app licati o n a d e s c r i p ti o n o f th e s te p s th e app licant pro p o s es to tak e to e nsur e e qu itab le acce s s t o , an d p articip ati o n i n , its Fe d e r al l y - a ss i s ted pro gr a m f or s t u d e nt s , teac h e r s , an d o th er pro gr am b e n e f iciar ies wi t h s p ecial n ee d s . T h is pro v i s i o n all o w s app licants d i s c r eti o n i n d e v el op i n g t h e r e qu i r ed d e s c r i p ti o n . T h e s tat ute h i g h l i g hts s ix t yp es o f b arr ie r s th at c an i m p e d e e qu itab le acce s s o r p articip ati o n : g e n d e r , r ace, n ati o n al or i g i n , c o l or , d i s ab ili t y, o r a g e. B a s ed o n l o cal c i r c um s t a n ce s , yo u s h o u ld d ete r m i n e w h e t h er th e s e o r o th er b arr i e r s ma y pr e v e nt yo ur s t u d e nt s , tea c h e r s , etc. f r o m su c h acce s s o r p articip ati o n i n , th e Fe d e r al l y - fun d ed pro j ect or acti v i t y . T h e d e s c r i p ti o n in y o ur app licati o n o f s te p s to b e tak en to o v e r c o m e th e s e b arr ie r s n eed n o t b e le n g thy ; y

o u m a y pro v i d e a clear an d su cci n ct d e s c r i p ti o n o f h o w y o u p lan t o a ddr e s s th o s e b arr ie r s th at ar e app licab le to y o ur ci r c ums t an ce s . I n a dd iti o n , th e i n f

o r mati o n ma y b e pro v i d ed in a s i n g le n arr ati v e, or , if appropr iate, m a y b e d i s c u s s ed in c o nn ecti o n wi t h r elated t op ics in th e app licati o n . Secti o n 42 7 is n o t i nt e nd ed to du p licate th e r e qu i r e me nts o f c i v il r i ghts s tat ut e s , b ut r ath er to e n s ur e th a t, in d e s i gn i n g th eir pr o j ect s , app licants f

o r Fe d e r al f un d s a ddr e s s e qu i t y c o n ce rn s th at ma y a f f ect th e ab ili t y o f ce rtain po te nti a l b e n e f iciar i e s to f

u l l y p articip ate in th e pro

j ect a n d to ac h ie v e to h i g h s tan d ard s . C o ns i s t e nt wi t h p r o gr a m r e qu i r e m e nts a nd its appro v ed app licati o n , an app licant m a y us e t h e Fe d e r al f un d s a ward ed to it to el i m i n ate b arr ie r s it i d e nt i f ie s . **Wh a**  **t a**  **re Ex**  **a m** **pl e**  **s o**  **f H**  **o w**  **a n**  **Applic a**  **nt** 

### M **i g**  **ht S**  **at i**  **s f**  **y t**  **he Requir**  **e m**  **ent o**  **f T**  **h i**  **s P**  **r ov**  **i s**  **i o**  **n?** T h e f o ll o w i n g e x a m p les ma y h elp il l us tr ate h o w an app licant ma y c o m

p l y wi t h S e cti o n 427 . (1 ) A n app licant th at propo s es to carry out an a du lt lite r a c y pro

j ect s e rv i n g , a mo n g o th e r s , a du lts wi t h l i mi ted En g l i s h pro f icie n c y, m i ght d e s c r i b e in its app licati o n h o w it i nte n d s to d i s tr i b ute a bro c hur e abo ut th e pr o po s ed p r o j ect to su c h po te nti a l p articip ants i n th eir n at i v e lan g u a g e. (2 ) An app licant th at propo s es to d e v el op i ns tru cti o n a l mate r ia l s f o r c l a ss ro o m us e mi g ht d e s c r i b e h o w it wi l l ma k e th e mate r ials a v ailab le o n au d io tap e o r in br aille f o r s t u d e nts w h o ar e b li n d . (3 ) A n app lic ant th at prop os es to carr y o ut a mod el s ci e n ce pro gr a m f o r s ec o n d ar y s t

u d e nts an d is c o n ce rn ed th at g i r ls m a y b e le s s l i k e l y th an b o y s to e nro ll in th e c our s e, mi ght i n d icate h o w it i nt e n d s to c o n du ct " o utr eac h " e f f orts to g i r l s , to e n c o ur a g e th eir e nro l l m e nt. (4 ) An app licant th at propo s es a pro j ect to i n c r ea s e s c h oo l s a f

e t y mi g ht d e s c r i b e th e s p ecial e ff ort s it wi ll tak e to a ddr e s s c o n ce rn o f le s b ian , g a y, b i s e xu al, an d tr an s g e nd er s t u d e nt s , an d e ff ort s to r each o ut to an d i nvo l v e th e f a m ili e s o f L G B T s t u d e nt s W e r ec o gn ize th a t ma ny app licant s ma y al r ea d y b e i m p l e m e nt i n g e f

f ect i v e s te p s to e n sur e e q u i t y o f acce s s an d p articip ati o n in t h eir gr ant pro g r a m s , an d w e appr eciate yo ur c oop e r ati o n i n r e s po n d i n g to th e r e qu i r e me nts o f th i s pro v i s i o n. **Est i**  **m a**  **t e**  **d B**  **u r**  **d e**  **n S**  **t a**  **t e**  **m e**  **n t**  **f o**  **r G**  **EPA R e**  **q u**  **i r**  **e m** **e n**  **t s**  **According to**  **the Paperwork**  **Reduction Act**  **of 1995,**  **no persons**  **are required**  **to r**  **espond 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, inc**  **l uding**  **time for**  **reviewing instructions,**  **searching existing**  **data sources,**  **gathering and**  **maintaining the**  **data n**  **eeded, and**  **completing and**  **reviewing the**  **collection of**  **information. The**  **obligation to**  **respond to**  **this collect**  **i on**  **is required**  **to obtain**  **or retain**  **benefit (Public**  **Law 103**  **- 382.**  **Send comments**  **rega r**  **ding the**  **burden estimate**  **or any**  **other aspect**  **of this**  **collection of**  **information, i**  **ncluding suggestions**  **for re**  **d ucing**  **this burden,**  **to the**  **U .**  **S. Department**  **of Education,**  **400 Maryland**  **Ave., SW,**  **Washi n**  **gton, DC**  **20210 -**  **4537 or**  **email ICDocketMgr@ed.gov**  **and refer**  **e nce**  **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 w ith 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 em ployee 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 agre em ents) 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 prerequi site for making or entering into this transaction im posed 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 f ailure. 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 emp loyee 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 submi t 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:

### ASSURA **NCES -**  **NON -**  **CONSTRUCTION PROGRA MS**  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), Wa shington, DC 20503. 

### PLEA**SE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MA NA**  **GEMENT A ND BUDGET.**  **SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING A** **GENCY. NOTE:**  Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified. As the duly authorized representative of the applicant, I certify that the applicant:

1. Has the legal authority to apply for Federal assistance and the institutional, managerial and financial capability (including funds sufficient to pay the non - Federal share of project cost) to ensure proper planning, management and completion of t he project described in this application. 2. Wi ll 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. Wi ll 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. Wi ll initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. 5. Wi ll comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. §§4728 - 4763) relating to prescribed standards for merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A of OPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F). 6. Wi ll 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 p rohibits 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, T reatment 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. Wi ll comply, or has already complied, with the requirements of Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91 - 646) which provide for fair and equitable treatment of persons 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. Wi ll 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. Wi ll comply, as applicable, wi th 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 Wo rk Hours and Safety Standards Act (40 U.S.C. §§327 - 333), regarding labor standards for federally - assisted construction subagreements. Wi ll 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. Wi ll 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 Ex ecutive 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 Ma nagement 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 Wa ter 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. Wi ll comply with the Wi ld 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. Wi ll assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. §470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§469a - 1 et seq.). Wi ll 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. Wi ll comply with the Laboratory Animal We lfare Act of 1966 (P.L. 89 - 544, as amended, 7 U.S.C. §§2131 et seq.) pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities supported by this award of assistance. Wi ll comply with the Lead - Based Paint Poisoning Prevention Act (42 U.S.C. §§4801 et seq.) which prohibits the use of lead - based paint in construction or rehabilitation of residence structures. Wi ll cause to be performed the required financial and compliance audits in accordance with the Single Audit Act Amendments of 1996 and OM B Circular No. A - 133, "Audits of States, Local Governments, and Non - Profit Organizations." Wi ll 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 A ction:**  a. contract b. grant c. cooperative agreement d. loan e. loan guarantee f. loan insurance **2. Status of Federal A ction:**  a. bid/offer/application b. initial award c. post - award **3. Report T ype:**  a. initial filing b. material change **For Material Change Only:** ye ar quarter date of last report **4. Name and A ddress of Reporting Entity:**  **Prime Subawardee** 



### Tier , if known :
**Congressional Distric t**  , if known : **5. If Reporting Entity in No. 4 is a Subawardee, Enter Name and A** **ddress of Prime:**

**Congressional Distric t**  , if known : **6. Federal Department/A gency:**  **7. Federal Program N a**  **me/Description:** CFDA Number, if applicable : **8. Federal A ction Number,**  if known **: 9.**  **Aw ard A**  **mount,** if known **:** $ **10. a. Name and A ddress 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.** Inform ation 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 A**  **CTIVITIES** 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 employe e of a Member of Congress in connection with a covered Federal action. Complete all items that apply for both the initial filing and ma terial 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 organizationa l 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 Dom estic 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 am ount 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 Nam e, First Nam e, 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), Wa shington, DC 20503.