Filing Deadline: U.S. Department of Education 

Impact Aid Program 

Washington, D.C. 20202-6244 

APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM 

SECTION 8007(b) 

EMERGENCY GRANT 

Catalog of Federal Domestic Assistance #84-041C 

Send 1 copy to the State Educational Agency (SEA).

F– – 

Is the Applicant Delinquent on Any Federal Debt? 

 Yes  No 

Applicant’s 

DUNS Number 

Applicant’s Taxpayer 

Identification Number 

 Applicant Name :  Street/P.O. Box :  City :  County :  State & Zip : 

 Contact Person Name : 

 Title :  Phone :  Fax :  E-Mail : 

Name of the School Facility for Which Funding Is Requested: Amount Requested: 

Enrollment in this School Facility on the Survey Date Reported on Your Local Educational Agency’s (LEA’s) Fiscal Year (FY) 2009 Section 8003 Application 

If Applicable, Date Application Was Submitted to State 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 included in this applknowledge and belief, true, complete and correct. I certify that I am authorized to make the representations and commitments in this applic

applicant, and otherwise to act as the applicant’s authorized representative in submitting this application for funding under section 8007(b) o

VIII of the Elementary and Secondary Education Act). I declare that the applicant will mail a complete copy of this application to the SEA at tapplication to the U.S. Department of Education. 

Name and Title of Authorized Representative (Please type or print.) Signature D
APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – ADDITIONAL INFORM

APPLICANT’S INTEREST IN THE SCHOOL FACILITY

 Own 

 Lease ________________________ 

 Other 

(Expiration date) 

If Other, Specify ________________________________________________________________________________________________TYPE OF SPECIAL DISTRICT  Charter School 

 Alaskan Rural Education Attendance Area (REAA) 

 Coterminous District 

AGE OF THE SCHOOL FACILITY Year 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 L

BONDED INDEBTEDNESS AS OF THE END OF THE AGENCY’S FISCAL YEAR 2010-2011

Maximum Bonding Capacity $______________________________________ Amount of Bonded Debt $____________________

ASSESSED VALUE OF TAXABLE PROPERTY IN LEA

Name of Taxing Jurisdiction (e.g., School District Name, Township Total Assessed Value of Real Property (Land and 

Name, City Name, County Name, etc.) Taxed for School Purposes for school year 2010-2

________________________________________________________________ $__________________________________________________________________________________________________________ $__________________________________________________________________________________________________________ $__________________________________________

 Form Approved: OMB number 1810-0657, Expiration date: 
APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – PROJECT NARRATIVE FOR EMERGEN

Proposed Project Start Date Proposed Project Completion Date Describe: (1) the emergency condition; (2) how the emergency condition adversely affects the health, safety and well-being of oc

facility; (3) the amount of square footage to be added to the school facility, if any; (4) the age of the facility systems associated wroofing, plumbing, HVAC, windows, electrical, etc.); (5) actions the applicant has taken to respond to the emergency condition an

been unable to resolve the condition; (6) how the proposed project will address the emergency condition; and (7) the proposed p

 Form Approved: OMB number 1810-0657, Expiration date: 
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 included as part 

of an emergency application for the discretionary construction program. The person providing this certification may not be a member 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, safety 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, continue 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 4
APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – JUSTIFICATION FOR RE

If proposing new construction, provide justification for rebuilding instead of repairing or renovating the existing school facility. S

footage of the proposed new facility. 

 Form Approved: OMB number 1810-0657, Expiration date: 
APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – COST ESTIMATE T

Please provide a break down of the cost estimates related to this project. 

Budget Category Non-Federal Share Requested Federal Shar

(a) Direct Project Costs 

Supplies Equipment Advertisements Travel/Expenses 

(b) Planning /Design/Engineering/ Environmental Impact Study 

Facilities Plan Environmental Documentation Plans and Specifications Bid Documents Engineering Services 

(c) Construction /Implementation 

Independent Construction Manager Labor Materials Equipment Other (Specify) 

(d) Miscellaneous 

Permits Compliance Monitoring/Oversight/Contingency Taxes Other (Specify) 

(e) Project Summary (Sum lines (a) through (d) for each column) (f) Available Resources 

State Local 

(g) Total Request (Line (e) minus line (f) for each column) 

 Form Approved: OMB number 1810-0657, Expiration date: 
APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – CHILDREN WHO ATTENDED THIS SCH

WERE INCLUDED ON TABLE 1 OF THE APPLICANT’S SECTION 8003 APPLICATION

Report children included on Table 1 of section 8003 FY 2009 (school year 2010-2011) application who attended school facility for 

FEDERAL PROPERTY ON WHICH CHILDREN WITH DISABILITIES RESIDE CHILDREN WITH DISABILIT

PROPERTY 

CODE 

NUMBER 

(1) 

OFFICIAL NAME, 

 ADDRESS, CITY, STATE 

(2) 

NUMBER OF 

CHILDREN 

ON SURVEY 

DATE 

(3) 

CATEGORY 

(5) 

WITH A PARENT ON ACTIVE DUTUNIFORMED SERVICES OF THE USTATES WITH A PARENT WHO IS BOTH AACCREDITED FOREIGN GOVERNOFFICIAL AND A FOREIGN MILITA

 RESIDING ON ELIGIBLE INDIAN L TABLE 

 TABLE 1-1 TOTAL

Ä

 Form Approved: OMB number 1810-0657, Expiration date: 
APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – CHILDREN WHO ATTENDED THIS SCH

WERE INCLUDED ON TABLE 2 OF THE APPLICANT’S SECTION 8003 APPLICATION

Report children included on Table 2 of section 8003 FY 2009 (school year 2010-2011) application who attended school facility for 

CHILDREN WITH DISABILITIES 

(2) 

NUMBER OF 

WITH A PARENT ON ACTIVE DUTY IN THE UNIFORMED SERVICES 

OF THE UNITED STATES 

WITH A PARENT WHO IS BOTH AN ACCREDITED FOREIGN GOVERNMENT 

OFFICIAL AND A FOREIGN MILITARY OFFICER 

 Form Approved: OMB number 1810-0657, Expiration date: 
APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – CHILDREN WHO ATTENDED THIS SCH

WERE INCLUDED ON TABLE 3 OF THE APPLICANT’S SECTION 8003 APPLICATION

Report children included on Table 3 of section 8003 FY 2009 (school year 2010-2011) application who attended school facility for 

FEDERAL PROPERTY ON WHICH CHILDREN RESIDE FEDERAL PROPERTY ON WHICH PARENTS ARE EMPL

PROPERTY CODE 

NUMBER 

(1) 

OFFICIAL NAME, ADDRESS, CITY, STATE 

(2) 

PROPERTY CODE 

NUMBER 

(3) 

OFFICIAL NAME, ADDRESS, CITY

(4) 

 Form Approved: OMB number 1810-0657, Expiration date: 
APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – CHILDREN WHO ATTENDED THIS SCH

WERE INCLUDED ON TABLES 4 AND 5 OF THE APPLICANT’S SECTION 8003 APPLICATION 

Report children included on Table 4 of section 8003 FY 2009 (school year 2010-2011) application who attended school facility for which funding is requested. 

Report children included on Table 5 of section 802010-2011) application who attended school facili

requested. 

FEDERAL PROPERTY ON WHICH CHILDREN RESIDE NUMBER OF 

CHILDREN 

ON SURVEY 

DATE 

(3) 

FEDERAL PROPERTY ON WHICH PARENTS ARE E

PROPERTY CODE 

NUMBER 

(1) 

OFFICIAL NAME, 

ADDRESS, CITY, STATE 

(2) 

PROPERTY CODE 

NUMBER 

(4) 

OFFICIAL NAM

ADDRESS, CITY, S

(5) 

TABLE 4 TOTAL

Ä TABLE 

 Form Approved: OMB number 1810-0657, Expiration date: 
APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – PROGRAM ASSURANCES AND 

The applicant local educational agency (LEA) declares that it has filed the three certifications in ED Form 80-0013 regdebarment/suspension/responsibility status, and drug-free workplace with the U.S. Department of Education (Departm

section 8003 or section 8002 Impact Aid application. As of the date of the signature below, the LEA reaffirms and inco

those assurances and certifications with respect to this grant award. The LEA certifies that no circumstances affecting assurances have changed since their previous filing. With respect to the Certification Regarding Lobbying, the LEA recertifies that no Federal appropriated funds have be

any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an Congress, or an employee of a Member of Congress in connection with the making or renewal of Federal grants under 

LEA shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," when required (34 C.Fand that the LEA shall require the full certification, as set forth in 34 C.F.R. Part 82, Appendix A, in the award documall tiers. The LEA further agrees to comply with the following Education Department General Administrative Regulations (ED34 CFR Part 75 -- Direct Grant Programs, except 75.600 through 75.617 34 CFR Part 77 -- Definitions that Apply to Department Regulations 34 CFR Part 80 -- Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local 

the procurement provisions 

34 CFR Part 81 -- General Education Provisions Act--Enforcement 34 CFR Part 82 -- New Restrictions on Lobbying 34 CFR Part 84 -- Governmentwide Requirements for Drug –Free Workplace (Grants). 

34 CFR Part 85 -- Governmentwide Debarment and Suspension (Nonprocurement). 

Signature Of Authorized Representative D

 Form Approved: OMB number 1810-0657, Expiration date: 
APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 8007(b) – ADDITIONAL DEPARTMENT OF EDUCATION CON

The 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 

purposes 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 are not c

22. Except for school facilities modifications necessary to render public school facilities accessible in order to comply with the 

Act (ADA) of 1990 or section 504 of the Rehabilitation Act of 1973, this grant will be used only to supplement the amount of f

the Federal funds would be made available from non-Federal sources for school repair and renovation. 

23. Except for modifications necessary to meet ADA or section 504 of the Rehabilitation Act standards and asbestos abatement 

not be used for repair, renovation, or construction of facilities or any part of a facility that will be used for religious worship, proselytization. 

24. Competent architectural engineering supervision and inspection will be maintained at the project’s site to ensure that the wo

drawings and specifications for the approved project. 

25. Grant projects will be: (a) functional; (b) economical; and (c) not elaborate in design or extravagant in the use of materials, c

of 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 strin

the 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 1973 

the disabled. 

28. As applicable and to the extent feasible, the design and completion of grant project(s) should maximize efficient use of ener

90.2-1993 of the American Society of Heating, Refrigerating, and Air-Conditioning Engineers, Inc. (ASHRAE) will be applied icompletion of the grant projects. 

29. It will follow the "Earthquake Hazards Reduction Act of 1977" (P.L. 95-125) and Executive Order 12699, "Seismic Safety of Fe

Assisted 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 

Education Assistance Act of 1975 (P.L. 93-638) requires that, to the greatest extent feasible, the recipient of any grant or conbenefit of Indians give to: (1) Indians, preferences and opportunities for training and employment in connection with the adm

contract; and (2) Indian organizations and Indian-owned economic enterprises, as defined in section 3 of the Indian Financin

preference in the award of contracts and subcontracts at any level of the administration of the grant project. 

31. If it carries out repair, renovation, or construction through a contract, any such contract process ensures the maximum num

including small, minority, and women-owned businesses, through full and open competition. 

32. The facilities will be operated and maintained in accordance with applicable Federal, State, and local requirements. 33. When the project is completed, sufficient operational funds will be available for effective operation and maintenance of the f

34. Funds received under this program will not be used to supplant other available non-Federal construction money. 

35. The grantee shall conduct and submit a Feasibility of Construction report to the Department prior to commencing new cons

the area upon which the construction will take place is suitable for construction and will be able to sustain the new facility o

Signature Of Authorized Representative D

 Form Approved: OMB number 1810-0657, Expiration date: