Filing Deadline:U.S. Department of EducationImpact Aid ProgramWashington, D.C. 20202-6244APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAMSECTION 8007(b)EMERGENCY GRANTCatalog of Federal Domestic Assistance #84-041CSend 1 copy to the State Educational Agency (SEA).Form Approved:– OMB number : 1810-0657– Expiration date:Is the Applicant Delinquent on Any Federal Debt?YesNoApplicant’sDUNS NumberApplicant’s TaxpayerIdentification NumberApplicant’sImpact Aid NumberApplicant Name :Street/P.O. Box :City :County :State & Zip :Contact Person Name :Title :Phone :Fax :E-Mail :Name of the School Facility for WhichFunding Is Requested: Amount Requested:Enrollment in this School Facility on the Survey Date Reported on Your Local Educational Agency’s (LEA’s) FiscalYear (FY) 2009 Section 8003 ApplicationIf Applicable, Date Application Was Submitted toState Agency for Executive Order 12372 Review:I certify that I have read the statements contained in this application and that these statements and all of the data includedin this application are, to the best of myknowledge and belief, true, complete and correct. I certify thatI am authorized to make therepresentations and commitments in this application, for and on behalf of theapplicant, and otherwise to act as the applicant’s authorized representative in submitting this application for funding under section 8007(b) of the Impact Aid Program (TitleVIII of the Elementary and Secondary Education Act). I declare that the applicant will mail a complete copy of this application to the SEA at the same time that it mails thisapplication to the U.S. Department of Education.Name and Title of Authorized Representative(Please type or print.)Signature DatePage: 1Fiscal Year2012APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM– SECTION 8007(b) – ADDITIONAL INFORMATIONAPPLICANT’S INTEREST IN THE SCHOOL FACILITYOwnLease ________________________Other(Expiration date)If Other, Specify ______________________________________________________________________________________________________________________TYPE OF SPECIAL DISTRICTCharter SchoolAlaskan Rural Education Attendance Area (REAA)Coterminous DistrictAGE OF THE SCHOOL FACILITYYear of Original Construction ________________Year(s) and Description(s) of Major Renovation(s) ________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________Square Footage of Existing School Facility ________________ACREAGE IN LOCAL EDUCATIONAL AGENCY (LEA)Total Acres Within Boundaries of LEA __________________ Total Acres of Nontaxable Federal Property Within Boundaries of LEA __________________BONDED INDEBTEDNESS AS OF THE END OF THE AGENCY’S FISCAL YEAR 2010-2011Maximum Bonding Capacity $______________________________________ Amount of Bonded Debt $_________________________________________ASSESSED VALUE OF TAXABLE PROPERTY IN LEAName of Taxing Jurisdiction (e.g., School District Name, TownshipTotal Assessed Value of RealProperty (Land and Improvements)That WasName, City Name, County Name, etc.) Taxed for School Purposes for school year2010-2011 on Behalf of the LEA________________________________________________________________ $_______________________________________________________________________________________________________________________________ $_______________________________________________________________________________________________________________________________ $_______________________________________________________________Form Approved: OMB number1810-0657, Expiration date: Page 2APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION8007(b) – PROJECT NARRATIVE FOR EMERGENCY GRANT APPLICATIONProposed Project Start Date Proposed Project Completion DateDescribe: (1) the emergency condition; (2) how the emergency condition adversely affects the health, safety and well-being ofoccupants of the schoolfacility; (3) the amount of square footageto be added to the school facility, if any; (4) the age of the facility systems associated with this project (e.g.,roofing, plumbing, HVAC, windows, electrical, etc.); (5) actionsthe applicant has taken to respond to the emergency conditionand why the applicant hasbeen unable to resolve the condition; (6) how the proposed project will address the emergency condition; and (7) the proposed project and budget.Form Approved: OMB number1810-0657, Expiration date: Page 3

# U.S. Department of Education

Impact Aid Program

Washington, D.C. 20202-6244

APPLICATION FOR IMPACT AID DISCRETIONARY CONSTRUCTION PROGRAM SECTION 8007(b)

Catalog of Federal Domestic Assistance #84-041C



# INDEPENDENT CERTIFICATION FOR EMERGENCY GRANT APPLICATION

This form must be completed and signed by a local building inspector, a licensed architect, or a licensed engineer, and include d as part

of an emergency application for the discretionary construction progr am. The person providing this certification may not be a m ember of

the staff of the applicant local educational agency (LEA).



# Name :

Title :

Organization :

Street/P.O. Box :

City, State & Zip :

Phone :

For the school facility identified in this application, please:

1. provide your professional and independent assessment of whether the condition is an emergency;

2. describe how the condition adversely affects the health, sa fety and well-being of occupants of the school facility;

3. describe the urgency of the need to address the condition; and

4. provide any additional comments you believe are relevant.

If you require more space for your narrative, cont inue on one blank page, using the title on this form.

I certify that these statements are, to the best of my knowledge and belief, true, complete and correct.



# SIGNATURE DATE

Form Approved: OMB number 

# 1810-0657 , Expiration date: page 4APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM– SECTION 8007(b) – JUSTIFICATION FOR REBUILDINGIf proposing new construction, provide justification for rebuilding instead ofrepairing or renovating the existing school facility. Specify the total squarefootage of the proposed new facility.Form Approved: OMB number1810-0657, Expiration date: Page 5APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – COST ESTIMATE TABLEPlease provide a break down of the cost estimates related to this project.Budget Category Non-Federal Share Requested Federal Share Total(a) Direct Project CostsSuppliesEquipmentAdvertisementsTravel/Expenses(b) Planning /Design/Engineering/Environmental Impact StudyFacilities PlanEnvironmental DocumentationPlans and SpecificationsBid DocumentsEngineering Services(c) Construction /ImplementationIndependent Construction ManagerLaborMaterialsEquipmentOther (Specify)(d) MiscellaneousPermitsCompliance Monitoring/Oversight/ContingencyTaxesOther (Specify)(e) Project Summary (Sum lines (a) through (d) for each column)(f) Available ResourcesStateLocal(g) Total Request (Line (e) minus line (f) for each column)Form Approved: OMB number1810-0657, Expiration date: Page 6APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – CHILDREN WHO ATTENDED THIS SCHOOL FACILITY AND WHOWERE INCLUDED ON TABLE 1 OF THEAPPLICANT’S SECTION 8003 APPLICATIONReport children included on Table 1 of section 8003 FY 2009 (school year2010-2011) application who attended school facility for which funding is requested.FEDERAL PROPERTY ON WHICH CHILDREN WITH DISABILITIES RESIDECHILDREN WITH DISABILITIESPROPERTYCODENUMBER(1)OFFICIAL NAME,ADDRESS, CITY, STATE(2)NUMBER OFCHILDRENON SURVEYDATE(3)CATEGORY(5)NUMBER OFCHILDRENON SURVEYDATE(6)WITH A PARENT ON ACTIVE DUTY IN THEUNIFORMED SERVICES OF THE UNITEDSTATESWITH A PARENT WHO IS BOTH ANACCREDITED FOREIGN GOVERNMENTOFFICIAL AND A FOREIGN MILITARY OFFICERRESIDING ON ELIGIBLE INDIAN LANDSTABLE 1-2 TOTALÄTABLE 1-1 TOTALÄForm Approved: OMB number1810-0657, Expiration date: Page 7APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – CHILDREN WHO ATTENDED THIS SCHOOL FACILITY AND WHOWERE INCLUDED ON TABLE 2 OF THEAPPLICANT’S SECTION 8003 APPLICATIONReport children included on Table 2 of section 8003 FY 2009 (school year2010-2011) application who attended school facility for which funding is requested.CHILDREN WITH DISABILITIES(2)NUMBER OF CHILDREN ON SURVEY DATE(3)WITH A PARENT ON ACTIVE DUTYIN THE UNIFORMED SERVICESOF THE UNITED STATESWITH A PARENT WHO IS BOTH AN ACCREDITED FOREIGN GOVERNMENTOFFICIAL AND A FOREIGN MILITARY OFFICERForm Approved: OMB number1810-0657, Expiration date: Page 8APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – CHILDREN WHO ATTENDED THIS SCHOOL FACILITY AND WHOWERE INCLUDED ON TABLE 3 OF THEAPPLICANT’S SECTION 8003 APPLICATIONReport children included on Table 3 of section 8003 FY 2009 (school year2010-2011) application who attended school facility for which funding is requested.FEDERAL PROPERTY ON WHICH CHILDREN RESIDE FEDERAL PROPERTY ON WHICHPARENTS ARE EMPLOYEDNUMBER OFCHILDRENON SURVEYDATE(5)PROPERTY CODENUMBER(1)OFFICIAL NAME, ADDRESS, CITY, STATE(2)PROPERTY CODENUMBER(3)OFFICIAL NAME, ADDRESS, CITY, STATE(4)TOTALÄForm Approved: OMB number 1810-0657, Expiration date: Page 9APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – CHILDREN WHO ATTENDED THIS SCHOOL FACILITY AND WHOWERE INCLUDED ON TABLES 4 AND 5 OF THE APPLICANT’S SECTION 8003 APPLICATIONReport children included on Table 4 ofsection 8003 FY 2009 (school year2010-2011) application who attendedschool facility for which funding isrequested.Report children included on Table 5 ofsection 8003 FY 2009 (school year2010-2011) application who attendedschool facility for which funding isrequested.FEDERAL PROPERTY ON WHICH CHILDREN RESIDENUMBER OFCHILDRENON SURVEYDATE(3)FEDERAL PROPERTY ON WHICH PARENTS ARE EMPLOYEDNUMBER OFCHILDRENON SURVEYDATE(6)PROPERTY CODENUMBER(1)OFFICIAL NAME,ADDRESS, CITY, STATE(2)PROPERTY CODENUMBER(4)OFFICIAL NAME,ADDRESS, CITY, STATE(5)TABLE 4 TOTALÄTABLE 5 TOTALÄForm Approved: OMB number 1810-0657, Expiration date: Page 10APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – PROGRAM ASSURANCES AND CERTIFICATIONSThe applicant local educational agency (LEA) declares that it has filed the three certifications in ED Form 80-0013 regarding lobbying,debarment/suspension/responsibility status, and drug-free workplacewith the U.S. Department of Education (Department) as partof itssection 8003 or section 8002 Impact Aid application. As of the dateof the signature below, the LEA reaffirms and incorporatesby referencethose assurances and certificationswith respect to this grant award. The LEA certifies that no circumstances affecting the validity of theseassurances have changed since their previous filing.With respect to the Certification Regarding Lobbying, the LEA recertifies that no Federal appropriated funds have been paid orwill be paid toany person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer oremployee ofCongress, or an employee of a Member of Congress in connection with the making or renewal of Federal grants under this program;that theLEA 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 atall tiers.The LEA further agrees to comply with the following Education Department General Administrative Regulations (EDGAR):34 CFR Part 75 -- Direct Grant Programs, except 75.600 through 75.61734 CFR Part 77 -- Definitions that Apply to Department Regulations34 CFR Part 80 -- Uniform Administrative Requirements for Grantsand Cooperative Agreements to State and Local Governments, includingthe procurement provisions34 CFR Part 81 -- General Education Provisions Act--Enforcement34 CFR Part 82 -- New Restrictions on Lobbying34 CFR Part 84 -- Governmentwide Requirements for Drug –Free Workplace (Grants).34 CFR Part 85 -- Governmentwide Debarment and Suspension (Nonprocurement).Signature Of Authorized RepresentativeDateForm Approved: OMB number1810-0657, Expiration date: Page 11APPLICATION FOR DISCRETIONARY CONSTRUCTIONPROGRAM – SECTION 8007(b) – ADDITIONAL DEPARTMENT OF EDUCATION CONSTRUCTION ASSURANCESThe applicant local educational agency (LEA)further certifies that it will ensure that:20. It has or will have title or other interest in the project site(s), including right of access, and that the site(s) will continue to be used for educationalpurposes after the completion of the project(s).21. Sufficient funds are available to meet any share of the costs of the repair, renovation, or construction projects that arenot covered by this grant.22. Except for school facilities modificationsnecessary to render publicschool facilities accessiblein order to comply withthe Americans with DisabilitiesAct (ADA) of 1990 or section 504 of the Rehabilitation Act of 1973, this grant will beused only to supplement the amount of funds that in the absence ofthe Federal funds would be made available from non-Federal sources for schoolrepair and renovation.23. Except for modifications necessary to meet ADA or section 504 of the Rehabilitation Act standards and asbestos abatement orremoval, the grant willnot be used for repair, renovation, or construction of facilitiesor any part of a facility that will be used for religious worship, instruction, orproselytization.24. Competent architectural engineering supervision and inspection will be maintained atthe project’s site to ensure that thework conforms to thedrawings and specificationsfor the approved project.25. Grant projects will be: (a)functional; (b) economical; and (c) not elaboratein design or extravagant in the use of materials, compared with the facilitiesof a similar type constructed in the State or other applicable geographical area.26. Standards under the Occupational Safety and Health Act of 1970 (P.L. 91-576), or State and local codes, if they are more stringent, will be observed inthe design and completion of the projects.27. Grant projects will comply with any applicable requirements under the ADA and section 504 of the Rehabilitation Act of 1973regarding accessibility forthe disabled.28. As applicable and to the extent feasible, the design and completion of grantproject(s) should maximize efficient use of energy. Standard 90.1-1989 and90.2-1993 of the American Society of Heating, Refrigerating, and Air-ConditioningEngineers, Inc. (ASHRAE) will be applied in the design andcompletion of the grant projects.29. It will follow the "Earthquake Hazards Reduction Act of 1977" (P.L. 95-125) and Executive Order12699, "Seismic Safety of Federal and FederallyAssisted or Regulated New Building Construction," as applicable.30. If applicable, it will comply with the following Indian Preferences and Opportunities requirements. Section 7(b) of the Indian Self-Determination andEducation Assistance Act of 1975 (P.L. 93-638) requires that, tothe greatest extent feasible, the recipient of any grant or contract awarded for thebenefit of Indians give to: (1) Indians, preferences and opportunities for training and employment in connection with the administration of the grant orcontract; and (2) Indian organizations and Indian-owned economic enterprises, asdefined in section 3 of the Indian Financing Act of 1974 (P.L. 93-262),preference in the award of contracts and subcontracts atany level of the administration of the grant project.31. If it carries out repair, renovation,or construction through a contract, any suchcontract process ensures the maximum number of qualified bidders,including small, minority, and women-owned businesses, through full and open competition.32. The facilities will be operated and maintained in accordancewith applicable Federal, State, and local requirements.33. When the project is completed, sufficient operational fundswill be available for effectiveoperation and maintenance of the facilities.34.Funds received under this program will not be used to supplant otheravailable non-Federal construction money.35.The grantee shall conduct and submit a Feasibility of Construction report to the Department prior to commencing new construction demonstrating thatthe area upon which the construction will take place is suitable for constructionand will be able to sustain the new facilityor addition.Signature Of Authorized RepresentativeDateForm Approved: OMB number1810-0657, Expiration date: Page 12