OMB Number: 4040 - 0004 Expiration Date: 8/31/2016 **Application for**  **Federal Assistance**  **SF -** **424** Preapplication Application * 2. Ty pe of Application: * If Revision, select appropriate letter(s): New Continuation * Other (Specify): Changed/Corrected Application Revision

* 3. Date Received: 4. Applicant Identifier:
5a. Federal Entity Identifier: 5b. Federal Aw ard 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:** 
* Street1: Street2:
* City: County/Parish:
* State: Province:
* Country: * Zip / Postal Code: **e. Organizational**  **Unit:** Department Name: Division Name:
**f. Name**  **and contact**  **information of**  **person to**  **be contacted**  **on matters**  **involving this**  **application:** Prefix: * First Name: Middle Name:
* Last Name: Suffix: Title: Organizational Affiliation:

* Telephone Number: Fax Number:
* Email: * 1. Type of Submission:

USA: UNITED STATES**Application for**  **Federal Assistance**  **SF -** **424**

***** **9. Type**  **of Applicant**  **1: Select**  **Applicant Type:**  Type of Applicant 2: Select Applicant Type: Type of Applicant 3: Select Applicant Type:

* Other (specify):

***** **10. Name**  **of Federal**  **Agency:**
**11. Catalog**  **of Federal**  **Domestic Assistance**  **Number:** CFDA Title:

***** **12. Funding**  **Opportunity Number:** 

* Title:

**13. Competition**  **Identification Number:**  Title:

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

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

Attach supporting documents as specified in agency instructions. Add Attachment Delete Attachment View Attachment

Add Attachments Delete Attachments View Attachments**Application for**  **Federal Assistance**  **SF -** **424**

**16. Congressional**  **Districts Of:**  * a. Applicant Attach an additional list of Program/Project Congressional Districts if needed. * b. Program/Project

**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**  **Any Federal**  **Debt? (If**  **"Yes," provide**  **explanation in**  **attachment.)** Yes No If "Yes", provide explanation and attach Add Attachment Delete Attachment View Attachment **21.** ***By signing**  **this application,**  **I certify**  **(1) to**  **the statements**  **contained in**  **the list**  **of certifications** ** **and (2)**  **that the**  **statements herein**  **are true,**  **complete and**  **accurate to**  **the best**  **of my**  **knowledge. I**  **also provide**  **the required**  **assurances  ** and** **agree to**  **comply with**  **any resulting**  **terms if**  **I accept**  **an award.**  **I am**  **aware that**  **any false,**  **fictitious, or**  **fraudulent statements**  **or claims**  **may subject**  **me to**  **criminal, civil,**  **or administrative**  **penalties. (U.S.**  **Code, Title**  **218, Section**  **1001)  I AGREE
**  The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions. **Authorized Representative:**  Prefix: * First Name: Middle Name:
* Last Name: Suffix:

* Title:

* Telephone Number:

* Email: Fax Number:

* Signature of Authorized Representative: * Date Signed: Add Attachment Delete Attachment View Attachment

## U.S. Department **of Education**  **Supplemental Information for the SF**  **- 424**  **1. Project**  **Director:** Prefix: * First Name: Middle Name: * Last Name: Suffix: 

## Address: * Street1: Street2: * City: County :


### * State: * Zip Code: Country: * Phone Number (give area code): Fax Number (give area code):

* Email Address: 

## 2. **Novice Applicant**  **:** Are you are a novice applicant as defined in the regulations in 34 CFR 75.225 (and included in the definitions page in the attached instructions)? Yes No 

## 3. **Human Subjects**  **Research:** a. Are any research activities involving human subjects planned at any time during the proposed Project Period? Yes No b. Are ALL the research activities proposed designated to be exempt from the regulations? Yes Provide Exemption(s) # (s): 1 2 3 4 5 6 No Provide Assurance #(s), if available:
c. If applicable, please attach your “Exempt Research” or “Nonexempt Research” narrative to this form as indicated in the definitions page in the attached instructions. OMB Number: 1894 - 0007 Expiration Date: 8/31/2017

### U **. S**  **. 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 Contr o l N u m b er : 1894 - 000 8 E x p i rat io n Dat e : 0 6/ 30

/ 201 7 Nam e o f I n s t i tu t ion/ Org an 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 th e c o l

u m n und e r " Pr oj ec t Y ear 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 al l app licab le c o l

u m n s . P lea s e read all i

n s tr 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**

**D G** **E T**  **S U**  **MM A**  **R Y**  **U .**  **S .**  **D E**  **P AR**  **T M** **E N**  **T O** **F E** 

**D U**  **C A** **T I**  **O N**  **F**

**U N**  **DS** Budg e t Cat e go rie s Pr oj ec t Y ear 1 (a) Pr

oj ec t Y ear 2 ( b ) Pr

oj ec t Y ear 3 (c ) Pr

oj ec t Y ear 4 (d ) Pr

oj ec t Y ear 5 (e ) T o t al (f) 1 . P ers onn e l 2 . F r i ng e B e n e f

i t s 3 . Trav e l 4 . E qu i p m e n t 5 . Supp lie s 6 . Con trac t u al 7 . Con s t r u c t io n 8 . Oth e r 9 . To t al Di

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 St i p e nd s 12 . To t al Co s t s (li

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

**n f**  **o r**  **m a** **t i**  **o n**  **( T**  **o B**  **e C**  **o m**  **p l** **e t** **e d**  **b y**  **Y o**  **u r**  **B u** **s i** **n e** **s s**  **O**

**ff i**  **c e**  **):** If yo u are re qu e s t i

n g re i m burs e m en 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 wer th e f o llo w i n g qu e s t ion s : ( 1 ) Do yo u h av e an I

nd i rec t Co s t R

at e A g ree m

en t app r ov e d b y th e Fe d eral gov er n m en t ?

____Y

e s

____ No (2 ) If y e s , p lea s e p r

ov id e th e f

o llo w i n g i n f o r m at ion : P er io d Cov ere d b y th e I

nd i rec t Co s t R

at e A g ree m

en t : Fr o m :

___/

___/

___ _ To :

___/

___/

___ _ ( mm / dd/ yyyy ) A pp r ov i n g Fe d eral a g en c y :

____ E D

____ Oth er (

p lea s e s p ec if

y ) :

_________ _ _ _ _ _ Th e I nd i rec t Co s t R

at e is

___ ______% (3 ) Fo r R

e s tr ic te d R at e Pr og ram s (c h ec k on e ) - - A re yo u u s i n g a re s tr ic t e d i nd i rec t c o s t rat e th at :

___ Is 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

at e A g ree m

e n t ? o r

___ Co m

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

at e is

_________ % E D 524Nam

e o f I n s t i tu t ion/ Org an 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 hou ld c o m

p le t e th e c o l

u m n und e r " Pr oj ec t Y ear 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 al l app licab le c o l

u m n s . P lea s e read all in s tr 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** 

**U ND**  **S** Budg e t Cat e go rie s Pr oj ec t Y ear 1 (a) Pr

oj ec t Y ear 2 ( b ) Pr

oj ec t Y ear 3 (c ) Pr

oj ec t Y ear 4 (d ) Pr

oj ec t Y ear 5 (e ) T o t al (f) 1 . P ers onn e l 2 . F r i ng e B e n e f

i t s 3 . Trav e l 4 . E qu i p m e n t 5 . Supp lie s 6 . Con trac t u al 7 . Con s t r u c t io n 8 . Oth e r 9 . To t al Di

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 St i p e nd s 12 . To t al Co s t s (L i n e s 9 - 11) 

### S**E C**  **T I**  **O N**  **C**
**– B**  **UD G**  **ET NARRA**  **T I** **V**

**E** ( s e e i ns t r uc ti ons ) E D 524

. , W a s h i n g to n , D . C . 20 202 .OMB Control No. 1894 - 0005 (Exp. 03/31/2017) 

## NOTICE **TO ALL**  **APPLICANTS** The purpose of this enclosure is to inform you about a new provision in the Department of Education's General Education Provisions Act (GEPA) that applies to applicants for new grant awards under Department programs. This provision is Section 427 of GEPA, enacted as part of the Improving America's Schools Act of 1994 (Public Law (P.L.) 103 - 382). **To Whom**  **Does This**  **Provision Apply?**  Section 427 of GEPA affects applicants for new grant awards under this program. **ALL APPLICANTS**  **FOR NEW**  **AWARDS MUST**  **INCLUDE INFORMATION**  **IN THEIR**  **APPLICATIONS TO**  **ADDRESS THIS**  **NEW PROVISION**  **IN ORDER**  **TO RECEIVE**  **FUNDING UNDER**  **THIS PROGRAM.**  (If this program is a State - formula grant program, a State needs to provide this description only for projects or activities that it carries out with funds reserved for State - level uses. In addition, local school districts or other eligible applicants that apply to the State for funding need to provide this description in their applications to the State for funding. The State would be responsible for ensuring that the school district or other local entity has submitted a sufficient section 427 statement as described below.) **What Does**  **This Provision**  **Require?** Section 427 requires each applicant for funds (other than an individual person) to include in its application a description of the steps the applicant proposes to take to ensure equitable access to, and participation in, its Federally- assisted program for students, teachers, and other program beneficiaries with special needs. This provision allows applicants discretion in developing the required description. The statute highlights six types of barriers that can im pede equitable access or participation: gender, race, national origin, color, disability, or age. Based on local circumstances, you should determine whether these or other barriers may prevent your students, teachers, etc. from such access or participation in, the Federally- funded project or activity. The description in your application of steps to be taken to overcome these barriers need not be lengthy; you may provide a clear and succinct description of how you plan to address those barriers that are applicable to your circumstances. In addition, the information may be provided in a single narrative, or, if appropriate, may be discussed in connection with related topics in the application. Section 427 is not intended to duplicate the requirements of civil rights statutes, but rather to ensure that, in designing their projects, applicants for Federal funds address equity concerns that may affect the ability of certain potential beneficiaries to fully participate in the project and to achieve to high standards. Consistent with program requirements and its approved application, an applicant may use the Federal funds awarded to it to eliminate barriers it identifies. **What are**  **Exam ples**  **of How**  **an Applicant**  **Mi ght**  **Satisfy the**  **Requirement of**  **This Provision?**  The following examples may help illustrate how an applicant may com

ply with Section 427. 

### (1) An applicant that proposes to carry out an adult literacy project serving, among others, adults with limited English proficiency, might describe in its application how it intends to distribute a brochure about the proposed project to such potential participants in their native language. 

### (2) An applicant that proposes to develop instructional materials for classroom use might describe how it will make the materials available on audio tape or in braille for students who are blind. 

### (3) An applicant that proposes to carry out a mo del science program for secondary students and is concerned that girls may be less likely than boys to enroll in the course, might indicate how it intends to conduct "outreach" efforts to girls, to encourage their enrollment. 

### (4) An applicant that proposes a project to increase school safety might describe the special efforts it will take to address concern of lesbian, gay, bisexual, and transgender students, and efforts to reach out to and involve the families of LGBT students We recognize that many applicants may already be implementing effective steps to ensure equity of access and participation in their grant programs, and we appreciate your cooperation in responding to the requirements of this provision. **Estimated Burden**  **Statem ent**  **for GEPA**  **Requirem ents**  **According to**  **the Paperwork**  **Reduction Act**  **of 1995,**  **no persons**  **are required**  **to respond**  **to a**  **collection of**  **information unless**  **such collection**  **displays a**  **valid OMB**  **control number.**  **Public reporting**  **burden for**  **this collection**  **of information**  **is estimated**  **to average**  **1.5 hours**  **per response,**  **including time**  **for reviewing**  **instructions, searching**  **existing data**  **sources, gathering**  **and maintaining**  **the data**  **needed, and**  **completing and**  **reviewing the**  **collection of**  **information. The**  **obligation to**  **respond to**  **this collection**  **is required**  **to obtain**  **or retain**  **benefit (Public**  **Law 103**  **- 382.**  **Send comments**  **regarding the**  **burden estimate**  **or any**  **other aspect**  **of this**  **collection of**  **information, including**  **suggestions for**  **reducing this**  **burden, to**  **the U.S.**  **Department of**  **Education, 400**  **Maryland Ave.,**  **SW, Washington,**  **DC 20210**  **- 4537**  **or email**  **ICDocketMgr@ed.gov and**  **reference the**  **OMB Control**  **Number 1894**  **- 0005.** 

### ASSURA **NCES -**  **NON -**  **CONSTRUCTION PROGRA MS**  OMB Approval No. 0348 - 0040

**NOTE:** Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified. As the duly authorized representative of the applicant, I certify that the applicant: 1. Has the legal authority to apply for Federal assistance and the institutional, managerial and financial capability (including funds sufficient to pay the non - Federal share of project cost) to ensure proper planning, management and completion of the project described in this application. 2. 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; a nd 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 prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92 - 255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91 - 616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) §§523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. §§290 dd - 3 and 290 ee 3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title V III 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 I II 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** 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.** 9.

10.

11. Wi ll 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 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 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 Z one Management Act of 1972 (16 U.S.C. §§1451 et seq.); (f) conformity of Federal actions to State (Clean Air) Implementation Plans under Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. §§7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Wa ter Act of 1974, a s amended (P.L. 93 - 523); and, (h) protection o f 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** 

### 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 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 Mem ber of Congress, an officer or employee of Congress, or an employee of a Mem ber of Congress in connection with the awarding of any Federal contract, the ma king of any Federal grant, the ma king of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, am endment, 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 em ployee of any agency, a Mem ber of Congress, an officer or em ployee of Congress, or an em ployee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form - LLL, ''Disclosure of Lobbying Activities,'' in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,00 0 and not more than $100,000 for each such failure. Statement for Loan Guarantees and Loan Insurance The undersigned states, to the best of his or her knowledge and belief, that: If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or em ployee of any agency, a Mem ber of Congress, an officer or em ployee of Congress, or an employee of a Mem ber of Congress in connection with this commitment providing for th e United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form - LLL, ''Disclosure of Lobbying Activities,'' in accordance with its instructions. Submission of this statement is a prerequisite for ma king 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 subject 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 Nam e: Middle Nam e:
* Last Nam e: Suffix:
* Title:

* SIGNATURE: * DATE:

### _________ _________

______________

_____________

_______________________ 

## 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. Ty**  **pe 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 Type:**  a. initial filing b. ma terial 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 : 4c **5. If Reporting Entity in No. 4 is a Subawardee, Enter Name and A** **ddress of Prime:**

**Congressional District** , if known : **6. Federal Department/A gency:**  **7. Federal Program Name/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.** Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. 

### Signature: Print Name: Title: Telephone No.: Date: **Federal Use Only:** Authorized for Local Reproduction Standard Form LLL (Rev. 7 - 97) 

## PRINT