Application for Small, Rural School Achievement Program

CFDA 84.358A

U.S. Department of Education

Applicant Information Organizational Unit

1. Name of LEA/District: ________________________________________________________ 

 Mailing Address ____________________________________________________________ 

 __________________________________________________________________

 _______________________________________________ _______ ______________________ ____________ - ________

City State County ZIP Code + 4

2. Applicant’s D-U-N-S Number |___|___|___|___|___|___|___|___|___|

 

3. Applicant’s T-I-N |___|___| - |___|___|___|___|___|___|___| 6. Is the applicant delinquent on any Federal debt? ___Yes ___No

4. Applicant’s NCES LEA ID Number |___|___|___|___|___|___|___|___|___|

5. LEA Contact: _______________________________________

 Mailing Address:__________________________________________

 _____________________________ ______ _________ _______

 City State Zip code + 4

 Tel. #: ( ) _______-________ Fax #: ( ) _______-________

 E-Mail Address: __________________________________________

7. Is application subject to review by Executive Order 12372 process?

___ Yes (Date made available to the Executive Order 12372

process for review): ____/____/_________ 

___ No (If “No,” check appropriate box below.)

___ Program is not covered by E.O. 12372.

___ Program has not been selected by State for review.

8. The LEA, through the signature of its authorized representative, provides the assurances and certifications required in the following documents that are 

incorporated by reference into this application:

 The assurances in Standard Form 424B (Assurances – Non-Construction Programs).

 The certifications in ED-Form 80-0013 regarding lobbying, debarment/suspension/responsibility status, and drug-free workplace.

With respect to the Certification Regarding Lobbying, the LEA certifies that no 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 the making or renewal of Federal grants under this program; that the LEA shall complete and submit Standard 

Form-LLL, "Disclosure Form to Report Lobbying," when required (34 C.F.R. Part 82, Appendix B); and that the LEA shall require the full certification, as

set forth in 34 C.F.R. Part 82, Appendix A, in the award documents for all subawards at all tiers.

Authorized Representative Information

9. To the best of my knowledge and belief, all data in this application are true and correct. The document has been duly authorized by the governing body 

of the applicant and the applicant will comply with the attached assurances if the assistance is awarded.

a. Authorized Representative (Please type or print name clearly.)

________________________________________________________________________________

b. Title: _________________________________________________________________________

c. Tel. #: ( ) ________-____________ Fax #: ( ) ________-____________

E-Mail Address: _______________________________________________________________

e. Signature of Authorized Representative:

_____________________________________________________________ Date: ___/____/______

Form Approved 

OMB No. 1810-0646 

Exp. XX/XX/XXXX
Public Burden Statement:

According to the Paperwork Reduction Act of 1995, no persons

are required to respond to a collection of information unless 

such collection displays a valid OMB control number. Public 

reporting burden for this collection of information is estimated 

to average 40 hours per response, including time for reviewing 

instructions, searching existing data sources, gathering and 

maintaining the data needed, and completing and reviewing the 

collection of information. The obligation to respond to this collection is required to obtain or retain benefit (ESEA Section 

6212/6221). Send comments regarding the burden estimate or 

any other aspect of this collection of information, including 

suggestions for reducing this burden, to the U.S. Department of 

Education, 400 Maryland Ave., SW, Washington, DC 20210-

4537 or email ICDocketMgr@ed.gov and reference the OMB 

Control Number 1810-0646. Note: Please do not return the 

completed REAP application to this address.

If you have comments or concerns regarding the status of your 

individual submission of this form write directly to: 

Email: REAPSEA@ed.gov

Subject: SRSA Application Status