OMB Number: 4040

- 0004 Expiration Date: 0 3 /31/20 12 

### Ap **plication for Federal Assistance SF -**  **424** *1. Type of Submission: Preapplication Application Changed/Corrected Application *2. Type o f 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/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 applicatio n:**  Prefix: *First Name: Middle Name: *Last Name: Suffix: Title: Organizational Affiliation: *Telephone Number: Fax Number: Com pleted by Grants.gov upon s ubmission*Email:


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

CFDA Title:

***12 Funding Opportunity Number**  :

*Title:

**13. Competition Identification Number** :

Title:

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

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

Attach supporting documents as specified in agency instructions.

### Ap **plication for Federal Assistance SF -**  **424 16. Congressional Districts Of:**  *a. Ap plicant: *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

. ***20. Is the Applicant Delinquent On An y**  **Federal Debt? (If “Yes ,**  **” provide explanation in at**  **tachment .)**  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 an y**  **false, fictitious, or fraudulent statements or claims may**  **subject me to cri minal, civil, or administrative penalties. (U. S. Code, Title 218, Section 1001)**  ** I AGREE ** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announc ement or agency spe cific instructions

. **Authorized Representative:** Prefix: *First Name: Middle Name: *Last Name: Suffix: *Title: *Telephone Number: Fax Number: * Email:*Signature of Authorized Representative: *Date Signed:


### INSTRUCTIONS FOR THE SF **- 424**  This is a standard form required for use as a cover sheet for submission of pre
- applications and applications and related information under discretionary programs. Some of the items are required and some are optional at the discretion of the applicant or the federa l agency (agency). Requir ed fields on the form are identified with an asterisk (*) and are also specified as “Required” in the instructions below. In addition to these instructions, applicants must consult agency instructions to determine other specific requirements. Item Entry: Item: Entry: 1. **Type of Submission:** (Required) Select one type of submission in accordance with agency instructions. • Pre
- application • Application • Changed/Corrected Application

– Check if this submission is to change or correct a previously submitted application. Unless requested by the agency, applicants may not use this form to submit changes after the closing date. 10. **Name Of Federal Agency** : (Required) Enter the name of the federal agency from which assistance is being requested with this applicat ion. 11. **Catalog Of Federal Domestic Assistance Number/Title:** Enter the Catalog of Federal Domestic Assistance number and title of the program under which assistance is requested, as found in the program announcement, if applicable. 2. **Type of Applicat ion**  : (Required) Select one type of application in accordance with agency instructions. • New

– An application that is being submitted to an agency for the first time. • Continuation
- An extension for an additional funding/budget period for a project with a projected completion date. This can include renewals. • Revision
- Any change in the federal government’s financial obligation or contingent liability from an existing obligation. If a revision, enter the appropriate letter(s). More than one may be sele cted. If "Other" is selected, please specify in text box provided. A. Increase Award D. Decrease Duration B. Decrease Award E. Other (specify) C. Increase Duration 12. **Funding Opportunity Number/Title:** (Required) E nter the Funding Opportunity Number (FON) and title of the opportunity under which assistance is requested, as found in the program announcement. 13. **Competition Identification Number/Title:** Enter the competition identification number and title of the competition under which assistance is requested, if applicable.
14. **Areas Affected By Project:** This data element is intended for use only by programs for which the area(s) affected are likely to be different than the place(s) of performance reported on the SF
- 424 Project/Performance Site Location(s) Form. Add attachment to enter additional areas, if needed.
3. **Date Received:** Leave this field blank. This date will be assigned by the Federal agency. 15. **Descriptive Title of Applicant’s Project:** (Require d) Enter a brief descriptive title of the project. If appropriate, attach a map showing project location (e.g., construction or real property projects). For pre
- applications, attach a summary description of the project. 4. **Applicant Identifier:** Enter the entity identifier assigned buy the Federal agency, if any, or the applicant’s control number if applicable. 5a. **Federal Entity Identifier** : Enter the number assigned to your organization by the federal agency, if any. 16. **Congressional Districts Of**: 16a . (Required) Enter the applicant’s congressional district. 16b. Enter all district(s) affected by the program or project. Enter in the format: 2 characters state abbreviation

– 3 characters district number, e.g., CA
- 005 for California 5th district, CA
- 012 for California 12 district, NC
- 103 for North Carolina’s 103 district. If all congressional districts in a state are affected, enter “all” for the district number, e.g., MD
- all for all congressional districts in Maryland. If nationwide, i.e. all district s within all states are affected, enter US
- all. If the program/project is outside the US, enter 00
- 000. This optional data element is intended for use only by programs for which the area(s) affected are likely to be different than place(s) of performance reported on the SF
- 424 Project/Performance Site Location(s) Form. Attach an additional list of program/project congressional districts, if needed. 5b. **Federal Award Identifier** : For new applications, enter NA. For a continuation or revision to an existi ng award, enter the previously assigned federal award identifier number. If a changed/corrected application, enter the federal identifier in accordance with agency instructions. 6. **Date Received by State:** Leave this field blank. This date will be assign ed by the state, if applicable. 7. **State Application Identifier:** Leave this field blank. This identifier will be assigned by the state, if applicable. 8. **Applicant Information** : Enter the following in accordance with agency instructions:
**a. Lega l Name**  : (Required) Enter the legal name of applicant that will undertake the assistance activity. This is the organization that has registered with the Central Contractor Registry (CCR). Information on registering with CCR may be obtained by visiting www.G rants.gov. 17. **Proposed Project Start and End Dates** : (Required) Enter the proposed start date and end date of the project. Completed by Grants.gov upon submission Completed by Grants.gov upon submission**b. Employer/Taxpayer Number (EIN/TIN):** (Required) Enter

the employer or taxpayer identification number (EIN or TIN) as assigned by the Internal Revenue Service. If your organization is not in the US, enter 44
- 4444444. 18. **Estimated Funding:** (Required) Enter the amount requested, or to be contributed during the first funding/budget period by each contributor. Value of in
- kind contribu tions should be included on appropriate lines, as applicable. If the action will result in a dollar change to an existing award, indicate only the amount of the change. For decreases, enclose the amounts in parentheses. **c. Organizational DUNS** : (Required) Enter the organization’s DUNS or DUNS+4 number received from Dun and Bradstreet. Information on obtaining a DUNS number may be obtained by visiting www.Grants.gov. 19. **Is Application Subject to Review by State Under Executive Order 12372 Process?**  (Requir ed**)** Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process. Select the appropriate box. If “a.” is selected, enter t he date the application was submitted to the State. **d. Address** : Enter address: Street 1 (Required); city (Required); County/Parish , State (Required if country is US), Province, Country (Required), 9
- digit zip/postal code (Required if country US). 20. **I s the Applicant Delinquent on any Federal Debt?**  (Required) Select the appropriate box. This question applies to the applicant organization, not the person who signs as the authorized representative. Categories of federal debt include; but, may not be limit ed to: delinquent audit disallowances, loans and taxes. If yes, include an explanation in an attachment. **e. Organizational Unit:** Enter the name of the primary organizational unit, department or division that will undertake the assistance activity. 21. **Authorized Representative** : To be signed and dated by the authorized representative of the applicant organization. Enter the first and last name (Required); prefix, middle name, suffix. Enter title, telephone number, email (Required); and fax number. A c opy of the governing body’s authorization for you to sign this application as the official representative must be on file in the applicant’s office. (Certain federal agencies may require that this authorization be submitted as part of the application.) **f . Name and contact information of person to be contacted on**  **matters involving this application:** Enter the first and last name (Required); prefix, middle name, suffix, title. Enter organizational affiliation if affiliated with an organization other than th at in 7.a. Telephone number and email (Required); fax number. 9. Type of Applicant: (Required) Select up to three applicant type(s) in accordance with agency instructions. A. State Government B. County Government C. City or Township Government D. Special District Government E. Regional Organization F. U.S. Territory or Possession G. Independent School District H. Public/State Controlled Institution of Higher Education I. Indian/Native American Tribal Government (Federally Recognized) J. Indian/Native American Tribal Government (Other than Federally Recognized) K. Indian/Native American Tribally Designated Organization L. Public/Indian Housing Authority M. Nonprofit N. Private Institution of Hi gher Education O. Individual P. For
- Profit Organization (Other than Small Business) Q. Small Business R. Hispanic
- serving Institution S. Historically Black Colleges and Universities (HBCUs) T. Tribally Controlled Colleges and Universi ties (TCCUs) U. Alaska Native and Native Hawaiian Serving Institutions V. Non
- US Entity W. Other (specify)

[ **U.S Department of Education note**  : As of spring, 2010, the FON discussed in Block 12 of the instructions can be found via the foll owing URL: http://www.grants.gov/applicants/find_grant_opportunities.jsp

. ]

# 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: 07/31/2014

# Instructions for U.S. Department of Education **Supplemental Information for the SF -**  **424 1. Pr**  **oject Director.** Name, address, telephone and fax numbers, and e

- mail address of the person to be contacted on matters i nvolving this application. Items marked with an asterisk (*) are mandatory. **2**
. **Novice Applicant.** Check “Yes” if you meet the definit ion for novice applicants specified in the regulations in 34 CFR 75.225 and included on the attached page entitled “Definitions for U.S. Department of Educat i on Supplemental Information for the SF

- 424”). By checking “Yes” the applicant certifies th at it m eets these novice applicant requirements. Check “No” if you do not meet the definition for novice applicants **.** This novice applicant information will be used by ED to: 1) determine the amount and type of technical assistance that a novice might need , if funded, and 2) determine novice applicant eligibility in discretionary grant competitions that give special consideration to novice applications. Certain ED discretionary grant programs give special consideration to novice applications, either by establis hing a special competition for novice applicants or by giving competitive preference to novice applicants under the procedures in 34 CFR 75.105(c)(2). If special consideration is being given to novice applications under a particular discretionary grant c om petition, the application notice for the competition published in the Federal Register will specify this information **3. Hum an Subjects Research.**  (See I. A. “Definitions” in attached page ent i tled “Definitions for U.S. Department of Education Supplemental Information for the SF

- 424.”) **3a. If Not Hum an Subjects Research.**  Check “ **No** ” if research activities invol v ing human subjects are not planned at any time during the proposed project period. The r e maining parts of Item 3 are then not applicable. **3a. If Hum**  **an Subjects Research.** Check “ **Yes** ” if research activities involving human subjects are planned at any time dur ing the proposed project period, either at the applicant organization or at any other performance site or collaborating institution. Chec k “ **Yes** ” even if the research is exempt from the regul a tions for the protection of human subjects. (See I. B. “Exemptions” in attached page entitled “Definitions for U.S. Department of Education Supplemental Information for SF

- 424.”) **3b. If Hum an Subject**  **s Research is Exempt from the Human Subjects Regulations.** Check “ **Yes** ” if all the research activ i ties proposed are designated to be exempt from the regul ations. Check the exemption number(s) corresponding to one or more of the six exemption categories lis ted in I. B. “Exemptions.” In addition, follow the instructions in II. A. “Exempt Research Narr ative” in the attached page entitled “Definitions for U.S. Department of Education Supplemental Information for the SF

- 424.” **3b. If Hum an Subjects Research i**  **s Not Exempt from H u**  **man Subjects Regulations.** Check “ **No** ” if some or all of the planned research activities are covered (not exempt). In addition, follow the instructions in II. B. “Nonexempt Research Narr ative” in the attached page entitled “Definitions for U.S. Department of Education Supplemental Information for the SF

- 424.” **3b. Hum**  **an Subjects Assurance Number.** If the applicant has an approved Federal Wide Assurance (FWA) on file with the Office for Human Research Protections (OHRP), U.S. Department of Health and Human Serv ices, that covers the specific activity, insert the number in the space provided. **(A list of current FWAs is available at: http://ohrp.cit.nih.gov/search/asearch.a**  **sp#A SUR**  **)** If the applicant does not have an approved assurance on file with OHRP, enter “None.” In this case, the applicant, by signature on the SF

- 424, is d e claring that it will comply with 34 CFR 97 and proceed to obtain the human subjects assurance up on request by the de s ignated ED official. If the application is recommended/selected for funding, the de s ignated ED official will request that the applicant obtain the assurance within 30 days after the specific formal request. **3c.** If applicable, please attach your “Exempt Research” or “Nonexempt Research” narrative to your submission of the U.S Department of Education Supplemental Information for the SF

- 424 form as instructed in item II, “ Instructions for Exempt and Nonexempt Human Subjects Re search Narratives ” in the attached page entitled “Definitions for U.S. Department of Education Supplemental Information for the SF

- 424.” **Note about Institutional Review Board Approval.** ED does not require certification of Institutional Review Board approval with the application. However, if an application that involves non

- exem pt human subjects research is recommended/selected for funding, the designated ED official will request that the applicant obtain and send the certification to ED within 30 days after the f ormal r e quest 

### . **No covered human subjects research can be conducted until the study has ED clearance for protection of human**  **subjects in research** 

### . **Paperwork Burden Statement .**  According to the Paperwork Reduction Act of 1995, no persons are required to res pond to a co llection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information co llection is 1894

- 0007. The time required to complete this inform a tion collection is estimated to average b etween 15 and 45 minutes per response, including the time to review instructions, search existing data resources, gather the data needed and co m plete and review the information collection. If you have any comments concerning the accuracy of the estimate(s ) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202

- 0170. If you have comments or concerns regarding the status of your indivi d ual submission of this form write directly to : (insert program off ice), U.S. Department of Education, 400 Maryland Avenue, S.W., Washington, D.C. 20202.

## Definitions for **U.S. Department of Education Supplemental Information for the SF**  **- 424**  **Definitions: Novice Applicant (See 34 CFR 75.225)**  For discretionary grant pr ograms, novice applicant means any applicant for a grant from ED that

—

 Has never received a grant or subgrant under the pr o gram from which it seeks funding;

 Has never been a member of a group application, submi tted in accordance with 34 CFR 75.127

- 75.129 , that r e ceived a grant under the program from which it seeks fun d ing; and

 Has not had an active discretionary grant from the Fe d eral government in the five years before the deadline date for applications under the program. For the purposes of this requi rement, a grant is a c tive until the end of the grant’s project or funding period, including any exte n sions of those periods that extend the grantee’s authority to obl i gate funds. In the case of a group application submitted in accordance with 34 CFR 75.12 7
- 75.129, a group includes only parties that meet the requir e me nts listed above.

**PROTECTION OF HUMAN SUBJECTS IN R E**  **SEARCH I. Definitions and Exe**  **mptions A. Definitions.**  A research activity involves human subjects if the activity is research, as defin ed in the Department’s regulations, and the r e search activity will involve use of human subjects, as defined in the regul ations.

—**Research** The ED Regulations for the Protection of Human Su b jects, Title 34, Code of Federal Regulations, Part 97, define res earch as “a systematic investigation, including research development, tes t ing and evaluation, designed to develop or contribute to generali z able knowledge. Activities which meet this definition constitute research whether or not they are conducted or su p po rted under a program that is considered research for other purposes. For example, some demonstration and service pr o grams may include research activities. **— Human Subject**  The regulations define human subject as “a living individual about whom an investi gator (whether professional or student) conducting research obtains (1) data through intervention or interaction with the individual, or (2) identifiable private information.” (1) If an activity involves obtaining information about a living person by mani pulating that person or that person’s env i ronment, as might occur when a new instructional technique is tested, or by comm u nicating or interacting with the individual, as occurs with surveys and interviews, the definition of human su b

ject is met. (2) If an activity involves obtaining private inform a tion about a living person in such a way that the information can be **directly or indirectly** linked to that individual, the defin i tion of human subject is met [Private information includes info rmation about behav ior that occurs in a context in which an individual can re a sonably expect that no observation or recording is taking place, and information which has been provided for sp e cific purposes by an individual and which the individual can re a sonably expect will n ot be made public (for example, a school health re c ord).] **B. Exemptions.** Research activities in which the **only** involvement of human su b jects will be in one or more of the following six categories of **e x** **em ptions**  are not covered by the regulations: (1) Re search conducted in established or commonly accepted edu cational settings, involving normal educational practices, such as (a) research on regular and special education instru c tional strategies, or (b) research on the effectiveness of or the compar i son amo ng instructional techniques, curricula, or classroom management meth ods. **If an educational practice is being introduced to the site and is not widely used**  **for similar populations** 

**, it is not covered by this exemption**

. (2) Research involving the use of edu cational tests (cognitive, d i agnostic, aptitude, achievement), survey procedures, interview procedures or observation of public behavior, unless: (a) information obtained is recorded in such a manner that human su b jects can be identified, directly or throu gh identifiers linked to the subjects; and (b) any disclosure of the human subjects’ responses outside the r e search could reasonably place the subjects at risk of criminal or civil liability or be damaging to the su b jects’ financial standing, employability , or reputation. **If the subjects are chi** 

**l dren, exemption 2 applies only to research**  **involving educ a**  **tional tests and observations of public behavior when the investig** **a tor(s) do not participate in the activities**  **being observed. Exemption 2 does not apply**  **if children are su r** **veyed or interviewed or if the research involves observation of public**  **behavior and the investigator(s) participate in the activ i** **ties being observed.**  [C hildren are d e fined as persons who have not attained the legal age for consent to treatments or procedures

### involved in the r e search, under the applicable law or jurisdiction in which the research will be co n ducted.] (3) Research involving the use of educational tests (cognitive, d i agnostic, aptitude, achievement), survey procedures, int erview proc e dures or observation of public behavior that is not exempt under section (2) above, if the human subjects are elected or ap pointed public officials or candidates for public office; or federal statute(s) require(s) without exception that the con fidentiality of the personally identifiable information will be maintained throughout the r e search and thereafter. (4) Research involving the collection or study of existing data, documents, records, pathological specimens, or diagnostic specimens, if the se sources are publicly available or if the information is recorded by the investigator in a manner that su b jects cannot be identified, directly or through identifiers linked to the subjects **. [This exemption applies only to**  **retrospective studies using da ta collected before the initiation**  **of the research.]** (5) Research and demonstration projects which are conducted by or subject to the approval of department or agency heads, and which are designed to study, evaluate, or otherwise examine: (a) public ben efit or service programs; (b) procedures for obtai n ing benefits or services under those programs; (c) possible changes in or altern atives to those programs or procedures; or (d) possible changes in methods or levels of payment for ben e fits or services unde r those programs. **[The standards of this exemption are rarely met because it was designed to apply**  **only to specific research conducted by HHS at the time the regulations were established. We will strictly construe this**  **exemption because it was not intended to apply to ED**  **research**

.**]** (6) Taste and food quality evaluation and consumer acceptance studies, (a) if wholesome foods without additives are consumed or (b) if a food is consumed that contains a food ingredient at or b e low the level and for a use found to be safe, or agricultural chem i cal or environmental contaminant at or below the level found to be safe, by the Food and Drug Administration or ap proved by the Environmental Protection Agency or the Food Safety and Inspection Service of the U.S. Departme nt of Agricu l ture. **II. Instructions for Exe mpt and Nonexempt Human**  **Subjects R e**  **search Narratives** If the applicant marked “Yes” for Item 3.b. of the U.S. Department of Education Supplemental Information for the SF 424, the ap plicant must attach a human su bjects “exempt research” or “nonexempt research” narrative to the U.S. Department of Education Supplemental Information for the SF

424 form. If you have multiple projects and need to provide mo re than one narrative, be sure to label each set of responses a s to the project they address. **A. Exempt Research Narrative.** If you marked “Yes” for item 3.b. and designated exemption numbers( s), attach the “exempt research” narrative to the U.S. Department of Education Supplemental Information for the SF

424. The narr ative must contain sufficient information about the involvement of human subjects in the proposed research to allow a determi nation by ED that the designated exemption(s) are appropriate. The narrative must be succinct. **B. Nonexempt Research Narrati ve.**  If you marked “No” for item 3.b. you must attach the “none x em

pt research” narrative to the U.S. Department of Education Supplemental Information for the SF

- 424. The narrative must address the follo wing seven points. Although no specific page limitati on ap plies to this section of the application, be succinct. (1) **Hum an Subjects Involvement and Characteristics**  : Pr o vide a detailed description of the proposed involvement of human su b jects. Describe the characteristics of the subject population, includin g their anticipated num ber, age range, and health status. Identify the criteria for inclusion or exclusion of any subpopulation. Explain the ratio n ale for the involvement of special classes of subjects, such as children, children with di s abilities, adult s with disabilities, persons with mental disabilities, pregnant women, prisoners, institutiona l ized individuals, or others who are likely to be vulne r able (2) **Sources of Materials** : Identify the sources of research material obtained from individually ident ifiable living human su b jects in the form of specimens, records, or data. Indicate whether the material or data will be obtained specifically for research pur

poses or whether use will be made of existing specimens, re c ords, or data. (3) **Recruitm ent and I**  **nformed Consent** : Describe plans for the recruitment of subjects and the consent procedures to be followed. I n clude the circumstances under which consent will be sought and obtained, who will seek it, the nature of the information to be pr o vided to prospe ctive subjects, and the method of documenting consent. State if the Institutional Revie w Board (IRB) has autho r ized a modification or waiver of the elements of consent or the requirement for document ation of consent. (4) **Potential Risks** : Describe potenti al risks (physical, psych o logical, social, legal, or other) and assess their likelihood and seriou s ness. Where appropriate, describe alternative treatments and procedures that might be advant a geous to the subjects. (5) **Protection Against Risk** : Describe the procedures for protec t ing against or minimizing potential risks, including risks to conf i dentiality, and assess their likely effectiveness. Where appropr i ate, discuss provisions for ensuring necessary medical or profe s sional intervention in the event o f adverse effects to the subjects. Also, where appropriate, d e scribe the provisions for mo nitoring the data collected to ensure the safety of the su b jects.

### (6) **Im portance of the Knowledge to be Gained**  : Discuss the i m portance of the knowledge gained or to be gained as a result of the proposed research. Discuss why the risks to subjects are re a sonable in relation to the anticipated benefits to subjects and in relation to the importance of the knowledge that may re a sonably be expected to result. (7) **Collab orating Site(s)**  : If research involving human su b jects will take place at collaborating site(s) or other perfo rmance site(s), name the sites and briefly describe their involv e ment or role in the research. **Copies of the Department of Education’s Regulations for the**  **Protection of Human Subjects, 34 CFR Part 97 and other pertinent materials on the protection of human subjects in**  **r e** **search are available from the Office of the Chief Financial**  **Officer, U.S. Department of Education, Washington, D.C. 20202**  **- 4331, tel** 

**e phone: (202)**  **245 -**  **8090**

**, and on the U.S. Department of Education’s Protection of Human Su**  **b jects in**  **Research Web Site: http://www.ed.gov/about/offices/list/ocfo/humansub.html**  NOTE: The **State Applicant Identifier** on the SF

- 424 is for State Use only. Plea se complete it on the SF

- 424 in the upper right corner of the form (if applicable).

### U.S. DEPARTMENT OF EDUCATION **BUDGET INFORMATION NON**  **- CONSTRUCTION PROGRAMS**  

## OMB Control Number: 1894

- 0008 Expiration Date: 04/30/2014 Name of Institution/Organization Applicants requesting funding for onl y one year should complete the column under "Project Year 1." Applicants requesting funding for multi

ye ar 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)

## *In **direct 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 b y the Federal government? _ ___Yes ____ No (2) If yes, please provide the following information: Period Covered b y the Indirect Cost Rate Agreement: From: ___/___/______ To: ___/___/______ (mm/dd/yyyy) Approving Federal agency : ____ ED ____ Other (please spe cify): __________________________ The Indirect Cost Rate is _________% (3) For Restricted Rate Programs (check one)

-- Are you using a restricted indirect cost rate that: ___ I s included in your approved Indirect Cost Rate Agreement? or ___ Compl ies with 34 CFR 76.564(c)(2)? The Restricted Indirect Cost Rate is _________% ED 524

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

- ye ar 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 Y ear 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 (L in es 1

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

- 11) **SECTION C**

**– BUDGET NARRATIVE**  (see instructions) 

## ED 524

# Instructions for ED 524

General I nstructions 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 submitting 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. Li nes 1

- 11 , columns (a)

- (e): For each project year for which funding is requested, show the total amount requested for each applicable budget category. Li nes 1

- 11, column (f): Show the multi

- year total for each budget category. I f funding is requested for only o ne project year, leave this column blank. Li ne 12, columns (a)

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

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

ndicate whether or not your organization has an I ndirect 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) I f 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): I f you checked “yes” in (1), indicate in (2) the beginning and ending dates covered by the I ndirect Cost Rate Agreement. In addition, indicate whether ED, another Federal agency (Other) or State agency issued the approved agreement. If you check “Oth er,” specify the name of the Federal or other agency that issued the approved agreement.

(3): I f you are applying for a grant und er a Restricted Rate Program (34 CFR 75.563 or 76.563), indicate whether you are using a restricted indirect cost rate that is included on your approved I ndirect Cost Rate Agreement or whether you are using a restricted indirect cost rate that complies with 34 CFR 76.564(c)(2). Note: State or Local government agencies may not use the provision for a restricted indirect cost rat e 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. Li nes 1

- 11, c olumns (a)

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

- 11, column (f): Show the multi

- year total for each budget category. I f non

- Fed eral contributions are provided for only one year, leave this column blank. Li ne 12, columns (a)

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

- year project. I f 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 itemize d 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 p roject 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 o r matching commitment, you must include:
a. The specific costs or contributions by budget category; b. The source of the costs or contributions; andc. I n the case of third

- party in

- kind contributions, a description of how the value was determined f or 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, appli cable to non

governmental entities, and 80.24, applicable to governments, and th e 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/circ ulars/index.html ]
3. If applicable to this program, provide the rate and base on which fringe benefits are calculated.
4. If you are requesting reimbursement for indirect costs on line 10, this information is to be completed by your Business Office. S pecify the estimated amount of the base to which the indirect cost rate is applied and the total indirect expense. Depending on the gra nt program to which you are applying and/or your approved I ndirect Cost Rate Agreement, some direct cost budget categories in yo ur 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 calcul ating indirect costs (line 10) for "Training grants" or grants under "Restricted Rate" programs, you must refer to the inform ation and examples on ED’s website at: http://www.ed.gov/fund/grant/apply/appforms/appforms.html

. Yo u may also contact (202) 3 77
- 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 19 95, 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 co llection 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 informatio n 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.Additional Indirect Cost Information and Example for Training Gra nts



## If you are appl yi ng for a discretionary grant that the U.S. Department of Education considers to be a “Training grant,” yo ur indirect cost reimbursement is limited. See the Education Department General Administration Regulations (EDGAR), 34 CFR 75.5 62, Indirect cost rates for educational training projects at: http://www.ed.gov/policy/fund/reg/edgarReg/edlite

- part75e.html Indirect cost reimbursement on ED training grants is limited to the grantee’s actual indirect costs as determined by the grantee’s negotiated indirect cost rate agreement or 8% of a modified total direct cost base, **whichever is less**

. Indirect costs in excess of the 8% limit may not be charged directly, u sed to satisfy matching or cost

- sharing requirements, or charged to another Federal award. For the purposes of calculating indirect costs for training grants, EDGAR, §75.562(c), defines a modified total direct cost base as: **“total direct costs less stipe nds, tuition and related fees, and capital expenditures of $5,000 or m**  **ore.”** Note: This limitation on indirect cost reimbursement for training grants does not apply to agencies of State or local governments, including federally recognized Indian tribal go vernments. However, the 8% limit applies to cost

- ty pe contracts under grants, if these contracts are for training as defined in EDGAR, §75.562(a). Below is a simplified example for calculating indirect costs for a training grant using the budget categori es from the ED 524 form, Budget Information

– Non
- construction Programs. The ED 524 and Instructions can be found at: http://www.ed.gov/fund/grant/apply/appforms/appforms.html F or the purposes of this example, 8% of a modified total direct cost base is used to calculate indirect costs. 1. Personnel 174,000 2. Fringe Benefits 50,000 3. Travel 10,000 4. Equipment 8,200 5. Supplies 920 6. Contractual 4,900 7. Construction

- 8. Other (Tuition) 5,400 9. Total Direct Costs 253,420 Calculate Modified Total Direct Cost Base Total Direct Costs 253,420 Less: Equipment 8,200 Tuition 5,400 13,600 Modified Total Direct Cost Base: 239,820 Multiply $239,820 by 8%: 19,186 10. Indirect Costs 19,186 11. Training Stipends 6,300 12. Total Costs 278,906Ad ditional Indirect Cost Information and Example for Grants under Restricted Rate Programs 

### If you are applying for a grant from the U.S. Department of Education (ED) under a Restricted Rate Program that is subject to a statutory “supplement not supplant” r estriction, you are required to use a restricted indirect cost rate. See the Education Department General Administrative Regulations (EDGAR), 34 CFR 75.563 [discretionary grants] at http://www.ed.gov/policy/fund/reg/edgarReg/edlite

- part75e.html or 34 CFR 76.563 [formula grants] at http://www.ed.gov/policy/fund/reg/edgarReg/edlite

- part76f.html , as applicable, and 34 CFR 76.564 through 76.569 at http://www.ed.gov/policy/fund/reg/edgarReg/edlite

- part76f.html

. Restricted rates for State Educational Agencies (SEA) are includ ed on the SEA’s negotiated indirect cost rate agreement. Restricted rates for Local Educational Agencies are provided by the SEA, using a method approved by ED. The restricted rate requirements also apply to any subgrants from the prime recipient. All applicants must use the restricted rate included on their negotiated indirect cost rate agreement. Applicants for discretionary grants that are not a State or Local government and do not have a negotiated restricted rate, may use the 8% rate described at § 76.564(c )(2). If an applicant’s calculated restricted rate is less than 8%, the lower rate must be used for the application’s budget. The 8% rate in §76.564(c)(2) must also be multiplied by the modified total direct cost base described in §76.569. For grants under Restricted Rate Programs, §76.569 requires that grantees multiply their restricted indirect cost rate by: “T otal direct costs of the grant minus capital outlays, subgrants, and other distorting or unallow able items as specified in the grant ee's indirect cost rate agreement.”
Commonly, such a procedure is referred to as multiplying by a modified total direct cost base. Below is a simplified example for calculating indirect costs for a Restricted Rate program using budget categories from the ED 524 form, Budget Information

– Non
- Construction Programs. The ED 524 and Instructions can be found at: http://www.ed.gov/fund/grant/apply/appforms/appforms.html For the p urposes of this example, a 6% restricted rate from a negotiated indirect cost rate agreement is used to calculate indirect costs.

1. Personnel 150,000 2. Fringe Benefits 50,000 3. Travel 10,000 4. Equipment 5,400 5. Supplie s 600 6. Contractual 3,700 7. Construction

- 8. Other (tuition) 72,000 9. Total Direct Costs 291,700 Calculate Modified Total Direct Cost Base Total Direct Costs 291,700 Less: Equipment 5,40 0 Tuition 72,000 77,400 Modified Total Direct Cost Base: 214,300 Multiply $214,300 by 6% restricted rate: 12,858

### 10. Indirect Costs (using 6% restricted rate) 12,858

11. Training Stipends

- 12. Total Costs 304,558 OMB Control No. 1894

- 0005 (Exp. 03/31/2014) 

## NOTICE TO ALL APPLICANTS**Previous Edition Usable Standard Form 424B (Rev. 7**  **- 97)**  **Authorized for Local Reproduction Prescribed by OMB Circular A**  **- 102**  

### The purpose of this enclosure is to inform you about a new

p rovision in the Department of Education's General Education Provisions Ac t (GEPA) that applies to applicants for new grant aw ards under Department programs. Th is 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 aw ards 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. I n 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. T he 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 4 27 requires each applicant for funds (other than an individual person) to include in its application a description of the steps the applicant proposes to take to ensure equitable access to, and participation in, its Federally

- assisted program for students, teachers, and other program beneficiaries with special needs. T his provision allows applicants discretion in developing the required description. T he statute highlights six ty pes of barriers that can im pede equitable access or participation: gender, rac e, national origin, color, disability, or age. B ased 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. T h e 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 yo u plan to address those barriers that are applicable to yo ur circumstances. I n addition, the i nformation may be provided in a single narrative, or, if appropriate, may be discussed in connection with related topics in the application. Section 427 is not intended to duplicate the requirements of civil rights statutes, but rather to ensure that, in designing their projects, applicants for Federal funds address equity concerns that may affect the ability of certain potential beneficiaries to fully participate in the project and to achieve to high standards. C onsistent with program requirements and it s 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 Require ment of This Provision?**  The following examples may help illustrate how an app licant may comply with Section 427. (1) An applicant that proposes to carry o ut 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 p roposed project to suc h 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 i t intends to conduct "outreach" efforts to girls , to encourage their enrollment. We recognize that many applicants may already be im plementing effective steps to ensure equity of access and participation in their grant programs, and we appreciate your cooperation in responding to the requirements of th is provision.**Previous Edition Usable Standard Form 424B (Rev. 7**  **- 97)**  **Authorized for Local Reproduction Prescribed by OMB Circular A**  **- 102**  

### 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**  **su ch**  **collection displays**  **a valid**  **OMB control**  **number. P**  **ublic rep**  **orting burden**  **for this**  **collection of**  **information is**  **estimated to**  **average 1.5**  **hours per**  **response, including**  **tim e**  **for reviewing**  **instructions, searching**  **existing data**  **sources, gathering**  **and mai**  **ntaining the**  **data needed,**  **and com**  **pleting and**  **review ing**  **the collect**  **ion of**  **information. T**  **he 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 red**  **ucing this**  **burden, to**  **the U.S.**  **Depart me**  **nt of**  **Education, 400**  **Maryland Ave.,**  **SW, Washington, DC 20210**  **- 4537 or**  **em ail**  **ICDocketMgr@ed.gov and reference the OMB Control Number 1894**  **- 0005.** 



# Electronic Notification Op **tion for Grant Awards**

If your application is successful, we notify your U.S. Representative and U.S. Senators and send you a Grant Award Notification (GAN); **OR** we may send you an e - mail containing a link to access G5, the Department’s Grant Management Sy stem. The email will be sent to both the project director and certifying representative in order for them to view and print the Adobe Acrobat version of the electronically

signed GAN. If neither the project director nor certifying representative is reg istered in G5, they will immediatel y be prompted to register once the link is accessed. **The electronic signature and issuance of the GAN makes it crucial that your application include correct email addresses for both**  **the project director and certifying re presentative.** **Previous Edition Usable Standard Form 424B (Rev. 7**  **- 97)**  **Authorized for Local Reproduction Prescribed by OMB Circular A**  **- 102**  

### CERTIFICA

**TI ON REG**  **AR DING 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 Fe deral 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 emplo yee 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 mo dification 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 und er 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. Submissi on of this certification is a prerequisite 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 $10,000 and n ot 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 att empting 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, th e 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, titl e 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.**Previous Edition Usable Standard Form 424B (Rev. 7**  **- 97)**  **Authorized for Local Reproduction Prescribed by OMB Circular A**  **- 102**  

## C **ertification of**  **E ligibility**  **for F**  **ederal A**  **ssistance in**  **C ertain**  **P rograms**  I understand that 34 CFR 75.60, 75.61, and 75.62 require that I make specific certifications of eligibility to the U.S. Departm ent of Education (ED) as a condition of applying for Federal funds in certain programs and that these requirements are in addition to any other eligibility requirements that ED imposes under program regulations. Under 34 CFR 75.60

– 75.62: I. I certify that: A. I do not owe a debt, or I am current in repaying a debt, or I am not in default (as that term is used at 34 C FR Part 668) on a debt: 1. To the Federal Government under a nonprocurement transaction (e.g., a previous loan, scholarship, grant, or cooperative agreement); or 2. For a fellowship, scholarship, stipend, discretionary grant, or loan in any program of ED that is subject to 34 CFR 75.60, 75.61, and 75.62, including:

 Federal Pell Grant Program (20 U.S.C. 1070a, et seq.);  Federal Supplemental Educational Opportunity Grant (SEOG) Program (20 U.S.C. 1070(b), et seq.):  State Student Incentive Grant Program (SSIG) 2 0 U.S.C. 1070c, et seq.);  Federal Perkins Loan Program (20 U.S.C. 1087aa, et seq.);  Income Contingent Direct Loan Demonstration Project (20 U.S.C. 1087a, note);  Federal Stafford Loan Program, Federal Supplemental Loans for Students [SLS], Federal PLUS, or Federal Consolidation Loan Program (20 U.S.C. 1071, et seq.);  William D. Ford Federal Direct Loan Program (20 U.S.C. 1087a, et. seq.);  Cuban Student Loan Program (20 U.S.C. 2601, et seq.);  Robert C. Byrd Honors Scholarship Program (20 U.S.C. 1070d

- 31, et s eq.);  Jacob K. Javits Fellows Program (20 U.S.C. 1134h

- 1134l);  Patricia Roberts Harris Fellowship Program (20 U.S.C. 1134d

- 1134g);  Christa McAuliffe Fellowship Program (20 U.S.C. 1105

- 1105i);  Bilingual Education Fellowship Program (20 U.S.C. 3221

- 3262);  Re habilitation Long

- Term Training Program (29 U.S.C. 774(b));  Paul Douglas Teacher Scholarship Program (20 U.S.C. 1104, et seq.);  Law Enforcement Education Program (42 U.S.C. 3775);  Indian Fellowship Program (29 U.S.C. 774(b));  Teacher Quality Enhancement Gr ants Program (20 U.S.C. 1021, et seq.); 

## OR
B. I have made arrangements satisfactory to ED to repay a debt as described in A.1. or A.2. (above) on which I had not been current in repaying or on which I was in default (as that term is used in 34 CFR Part 668)

. II. I certify also that I have not been declared by a judge, as a condition of sentencing under section 5301 of the Anti

- Drug Abuse Act

of 1988 (21 U.S.C. 862), ineligible to receive Federal assistance for the period of this requested funding. I understand that providing a false certification to any of the statements above makes me liable for repayment to ED for funds received on the basis of this certification, for civil penalties, and for criminal prosecution under 18 U.S.C. 1001.

____________________ ___ ____________________ _
____________________ ________________ (S ignature) (Date)**Previous Edition Usable Standard Form 424B (Rev. 7**  **- 97)**  **Authorized for Local Reproduction Prescribed by OMB Circular A**  **- 102**  **____________________________________________**

(Typed or P rinted N ame ) N ame or number of ED program under which this certification is being made :

_____________________________ ED 80

- 0016 (Revised 2/01)

**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 fo r reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. S end comments regarding the burden estimate or any other aspect of this collection of information, including su ggestion s 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 SPON SORING 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 ass urances. 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 ac counting 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 Ad ministration (5 C.F.R. 900, Subpart F). 6. Will co mply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1 964 (P .L. 88

- 352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of th e Education Amendments of 1972, as amended (20 U.S.C.  1681

- 1683, and 1685

- 1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C.  794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 197 5, as amended (42 U.S.C.  6101

- 6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92

- 255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcoh ol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91

- 616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g)  523 and 527 of the Public Health Service Act of 1912 (42 U.S.C.  290 dd

- 3and 290 ee 3), as amended, relating to confidentiality of

alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C.  3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being ma de; and (j) the requirements of any o ther nondiscrimination statute(s) which may apply to the application. 7. Will co mply, or has already complied, with the requirements of Titles II and III of the uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91

- 646) which provide for fair and equitable treatment of persons displaced or whose pro perty is acquired as a result of Federal or federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases. 8. Will comply, as applicable, with the pro visions of the Hatch Act (5 U.S.C.  1501

- 1508 and 7324

- 7328) which limit the political activities of em

ployees whose principal employment activities are funded in whole or in part with Federal funds. 9. Will comply, as applicable, with the provisions of the Davis

Bacon Act (40 U.S.C.  276a to 276a

- 7), the Copeland Act (40 U.S.C.  276c and 18 U.S.C.  874) and the Contract Work Hours and Safety Standards Act (40 U.S.C.  327

- 333), regarding labor standards for federally assisted construction subagreements. 10. Will comply, if

a pplicabl e, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93

- 234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total c ost of insurable construction and acquisition is $10,000 or more. 11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (P .L. 91

- 190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C.  1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Pla ns under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C.  7401 et seq.); (g) protection of underground sources of drinking water under the Saf e Drinking Water Act of 1974, as amended, (P .L. 93

- 523); and ( h) protection of endangered species under the Endangered S pecies 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 sy stem. 13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C.  470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C.  469a

- 1 et seq.). 14. Will comply with P.L. 93

- 348 regarding the protection of human subjects involved in rese arch, development, and related activities supported by this award of assistance. 15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89

- 544, as amended, 7 U.S.C.  2131 et seq.) pertaining to the care, handling, and treatment of warm bl ooded animals held for research, teaching, or other activities supported by this award of assistance. 16. Will comply with the Lead

- Based Paint Poisoning Prevention Act (42 U.S.C.  4801 et seq.) which prohibits the use of lead

- based paint in constructio n or rehabilitation of residence structures. 17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act Amendments of

1 996 and OMB Circular No. A

- 133, Audits of States, Local Go vernments, and Non
- P rofit Organizations.  18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program.SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE

AP PL ICANT ORGANIZATI ON DATE SUBMITTED

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

## Approved b y OMB 0348

- 0046 **Disclosure of Lobbying Activities** Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352

(See reverse for publi c 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 kn own: **$ 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 req uested through this form is authorized by**  **title 31 U.S.C. section 1352. This disclosure of lobbying activities is a**  **material representation of fact upon which reliance was placed by the tier above when this transaction**  **wa s made or entered into. This discl**  **osure is required pursuant to 31 U.S.C. 1352. This information will be reported**  **to the Congress sem i**  **- annually and will be available for public**  **inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less**  **than $10,000 and not**  **more than $100,000 for each such 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 b y the reporting entit y, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal ac tion, 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 pay ment to an y lobbying entit y for influencing or attempting to influence an officer or emplo yee 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 t o the implementing guidance published by the Office of Management and Budget for additional information. 1. Id entify

the t ype of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal ac tion. 2. Id entify

the status of the covered Federal action.
3. Id entify

the appropriate classification of this report. I f 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 kn own. 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 C ongressional 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/propo sal 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 fo r the prime entity identified in item 4 or 5.

## 10. (a) Enter the full name, address, city, State and zip code of the lobb yi ng registrant under the

Lobb yi ng 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 (M I). 11. The certifying official shall sign and date the form, print h is/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 unles s 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, se arching existing data sources, gathering and maintaining the d ata 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 Budg et, Paperwork Reduction Project (0348

- 0046), Washington, DC 20503