# 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.** A pplicant’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 f ollowing 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 appropria ted 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 A pproved OMB No. **1810 -**  **0646** Exp. XX/XX/XXXX

### Public Burd **en Statem ent:**  According to the Paperw ork 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 instr uctions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this co llection 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, W ashington, 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:

Em ail: REAPSEA@ed.gov Subject: SRSA Application Status