Standard Forms

A

OMB Number: 4040-0004

Expiration Date: 03/31/2012

pplication for Federal Assistance SF-424

Application for Federal Assistance SF-424
* 1. Type of Submission: Preapplication Application Changed/Corrected Application		* 2. Type of Application: New Continuation Revision			* If Revision, select appropriate letter(s):
					*Other (Specify):      
* Completed by Grants.gov upon submission 3. Date Received: 4. Applicant Identifier:      
5a. Federal Entity Identifier:      				*5b. Federal Award 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:
* Street 1:      
Street 2:      
* 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:
P refix:       *First Name:      
Middle Name:      
* Last Name:      
Suffix:      
Title:      
Organizational Affiliation:      
*Telephone Number:       Fax Number:      
*Email:      
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.
Application for Federal Assistance SF-424
1 6. Congressional Districts Of: *a. Applicant:       *b. Program/Project:      
Attach an additional list of Program/Project Congressional Districts if needed.
1 7. 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.
2 1. *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:
P refix:       *First Name:       M iddle Name:       *Last Name:       Suffix:      
* Title:      
* Telephone Number:      						Fax Number:      
* Email:      
* Completed by Grants.gov upon submission Signature of Authorized Representative:							* Completed by Grants.gov upon submission Date Signed:

Instructions for Application for Federal Assistance (SF-424)

This is a standard form required for use as a cover sheet for submission of pre-applications and applications and related information under discretionary programs. Some of the items are required and some are optional at the discretion of the applicant or the federal agency (agency). Required fields on the form are identified with an asterisk (*) and are also specified as “Required” in the instructions below. In addition to these instructions, applicants must consult agency instructions to determine other specific requirements.

Item	Entry:		Item:	Entry:
1.	Type of Submission: (Required) Select one type of submission in accordance with agency instructions. • Pre-application • Application • Changed/Corrected Application – Check if this submission is to change or correct a previously submitted application. Unless requested by the agency, applicants may not use this form to submit changes after the closing date.		10.	Name Of Federal Agency: (Required) Enter the name of the federal agency from which assistance is being requested with this application.
			11.	Catalog Of Federal Domestic Assistance Number/Title: Enter the Catalog of Federal Domestic Assistance number and title of the program under which assistance is requested, as found in the program announcement, if applicable.
2.	Type of Application: (Required) Select one type of application in accordance with agency instructions. • New – An application that is being submitted to an agency for the first time. • Continuation - An extension for an additional funding/budget period for a project with a projected completion date. This can include renewals. • Revision - Any change in the federal government’s financial obligation or contingent liability from an existing obligation. If a revision, enter the appropriate letter(s). More than one may be selected. If "Other" is selected, please specify in text box provided. A. Increase Award D. Decrease Duration B. Decrease Award E. Other (specify) C. Increase Duration		12.	Funding Opportunity Number/Title: (Required) Enter the Funding Opportunity Number (FON) and title of the opportunity under which assistance is requested, as found in the program announcement.
			13.	Competition Identification Number/Title: Enter the competition identification number and title of the competition under which assistance is requested, if applicable.
			14.	Areas Affected By Project: This data element is intended for use only by programs for which the area(s) affected are likely to be different than the place(s) of performance reported on the SF-424 Project/Performance Site Location(s) Form. Add attachment to enter additional areas, if needed.
3.	Date Received: Leave this field blank. This date will be assigned by the Federal agency.		15.	Descriptive Title of Applicant’s Project: (Required) Enter a brief descriptive title of the project. If appropriate, attach a map showing project location (e.g., construction or real property projects). For pre-applications, attach a summary description of the project.
4.	Applicant Identifier: Enter the entity identifier assigned buy the Federal agency, if any, or the applicant’s control number if applicable.
5a.	Federal Entity Identifier: Enter the number assigned to your organization by the federal agency, if any.		16.	Congressional Districts Of: 16a. (Required) Enter the applicant’s congressional district. 16b. Enter all district(s) affected by the program or project. Enter in the format: 2 characters state abbreviation – 3 characters district number, e.g., CA-005 for California 5th district, CA-012 for California 12 district, NC-103 for North Carolina’s 103 district. If all congressional districts in a state are affected, enter “all” for the district number, e.g., MD-all for all congressional districts in Maryland. If nationwide, i.e. all districts within all states are affected, enter US-all. If the program/project is outside the US, enter 00-000. This optional data element is intended for use only by programs for which the area(s) affected are likely to be different than place(s) of performance reported on the SF-424 Project/Performance Site Location(s) Form. Attach an additional list of program/project congressional districts, if needed.
5b.	Federal Award Identifier: For new applications, enter NA. For a continuation or revision to an existing award, enter the previously assigned federal award identifier number. If a changed/corrected application, enter the federal identifier in accordance with agency instructions.
6.	Date Received by State: Leave this field blank. This date will be assigned by the state, if applicable.
7.	State Application Identifier: Leave this field blank. This identifier will be assigned by the state, if applicable.
8.	Applicant Information: Enter the following in accordance with agency instructions:
	a. Legal Name: (Required) Enter the legal name of applicant that will undertake the assistance activity. This is the organization that has registered with the Central Contractor Registry (CCR). Information on registering with CCR may be obtained by visiting www.Grants.gov.		17.	Proposed Project Start and End Dates: (Required) Enter the proposed start date and end date of the project.
	b. Employer/Taxpayer Number (EIN/TIN): (Required) Enter the employer or taxpayer identification number (EIN or TIN) as assigned by the Internal Revenue Service. If your organization is not in the US, enter 44-4444444.		18.	Estimated Funding: (Required) Enter the amount requested, or to be contributed during the first funding/budget period by each contributor. Value of in-kind contributions should be included on appropriate lines, as applicable. If the action will result in a dollar change to an existing award, indicate only the amount of the change. For decreases, enclose the amounts in parentheses.
	c. Organizational DUNS: (Required) Enter the organization’s DUNS or DUNS+4 number received from Dun and Bradstreet. Information on obtaining a DUNS number may be obtained by visiting www.Grants.gov.		19.	Is Application Subject to Review by State Under Executive Order 12372 Process? (Required) Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process. Select the appropriate box. If “a.” is selected, enter the date the application was submitted to the State.
	d. Address: Enter address: Street 1 (Required); city (Required); County/Parish, State (Required if country is US), Province, Country (Required), 9-digit zip/postal code (Required if country US).		20.	Is the Applicant Delinquent on any Federal Debt? (Required) Select the appropriate box. This question applies to the applicant organization, not the person who signs as the authorized representative. Categories of federal debt include; but, may not be limited to: delinquent audit disallowances, loans and taxes. If yes, include an explanation in an attachment.
	e. Organizational Unit: Enter the name of the primary organizational unit, department or division that will undertake the assistance activity.		21.	Authorized Representative: To be signed and dated by the authorized representative of the applicant organization. Enter the first and last name (Required); prefix, middle name, suffix. Enter title, telephone number, email (Required); and fax number. A copy of the governing body’s authorization for you to sign this application as the official representative must be on file in the applicant’s office. (Certain federal agencies may require that this authorization be submitted as part of the application.)
	f. Name and contact information of person to be contacted on matters involving this application: Enter the first and last name (Required); prefix, middle name, suffix, title. Enter organizational affiliation if affiliated with an organization other than that in 7.a. Telephone number and email (Required); fax number.
9.	Type of Applicant: (Required) Select up to three applicant type(s) in accordance with agency instructions.
	A.     State Government B.     County Government C.     City or Township Government D.     Special District Government E.     Regional Organization F.     U.S. Territory or Possession G.    Independent School District H.     Public/State Controlled Institution of Higher Education I.      Indian/Native American Tribal Government (Federally Recognized) J.     Indian/Native American Tribal Government (Other than Federally Recognized) K.     Indian/Native American Tribally Designated Organization L.     Public/Indian Housing Authority	M.    Nonprofit N.     Private Institution of Higher Education O.    Individual P.     For-Profit Organization (Other than Small Business) Q.    Small Business R.     Hispanic-serving Institution S.     Historically Black Colleges and Universities (HBCUs) T.     Tribally Controlled Colleges and Universities (TCCUs) U.     Alaska Native and Native Hawaiian Serving Institutions V.     Non-US Entity W.    Other (specify)

[U.S Department of Education note: As of spring, 2010, the FON discussed in Block 12 of the instructions can be found via the following URL: http://www.grants.gov/applicants/find_grant_opportunities.jsp.]

ed Supplemental form sf 424

1. Project Director:

Prefix: *First Name: Middle Name: *Last Name: Suffix:

Address:

*

Street1:

S

treet2:

*

City:

C

ounty:

*

State * Zip Code: * Country:

*

Phone Number (give area code) Fax Number (give area code)

Email Address:

2. Applicant Experience:

Novice Applicant Yes No Not applicable to this program

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: 07/31/2014

Instructions for ED Supplemental SF-424

1. Project Director. Name, address, telephone and fax numbers, and e-mail address of the person to be contacted on matters involving this application. Items marked with an asterisk (*) are mandatory.

2. Novice Applicant. Check “Yes” if you meet the definition for novice applicants specified in the regulations in 34 CFR 75.225 and included on the attached page entitled “Definitions for U.S. Department of Education Supplemental Information for the SF-424”). By checking “Yes” the applicant certifies that it meets these novice applicant requirements. Check “No” if you do not meet the definition for novice applicants.

This novice applicant information will be used by ED to: 1) determine the amount and type of technical assistance that a novice might need, if funded, and 2) determine novice applicant eligibility in discretionary grant competitions that give special consideration to novice applications. Certain ED discretionary grant programs give special consideration to novice applications, either by establishing a special competition for novice applicants or by giving competitive preference to novice applicants under the procedures in 34 CFR 75.105(c)(2). If special consideration is being given to novice applications under a particular discretionary grant competition, the application notice for the competition published in the Federal Register will specify this information

3. Human Subjects Research. (See I. A. “Definitions” in attached page entitled “Definitions for U.S. Department of Education Supplemental Information for the SF-424.”)

3a. If Not Human Subjects Research. Check “No” if research activities involving human subjects are not planned at any time during the proposed project period. The remaining parts of Item 3 are then not applicable.

3a. If Human Subjects Research. Check “Yes” if research activities involving human subjects are planned at any time during the proposed project period, either at the applicant organization or at any other performance site or collaborating institution. Check “Yes” even if the research is exempt from the regulations for the protection of human subjects. (See I. B. “Exemptions” in attached page entitled “Definitions for U.S. Department of Education Supplemental Information for SF-424.”)

3b. If Human Subjects Research is Exempt from the Human Subjects Regulations. Check “Yes” if all the research activities proposed are designated to be exempt from the regulations. Check the exemption number(s) corresponding to one or more of the six exemption categories listed in I. B. “Exemptions.” In addition, follow the instructions in II. A. “Exempt Research Narrative” in the attached page entitled “Definitions for U.S. Department of Education Supplemental Information for the SF-424.”

3b. If Human Subjects Research is Not Exempt from Human Subjects Regulations. Check “No” if some or all of the planned research activities are covered (not exempt). In addition, follow the instructions in II. B. “Nonexempt Research Narrative” in the attached page entitled “Definitions for U.S. Department of Education Supplemental Information for the SF-424.”

3b. Human Subjects Assurance Number. If the applicant has an approved Federal Wide Assurance (FWA) on file with the Office for Human Research Protections (OHRP), U.S. Department of Health and Human Services, that covers the specific activity, insert the number in the space provided. (A list of current FWAs is available at:  http://ohrp.cit.nih.gov/search/asearch.asp#ASUR) If the applicant does not have an approved assurance on file with OHRP, enter “None.” In this case, the applicant, by signature on the SF-424, is declaring that it will comply with 34 CFR 97 and proceed to obtain the human subjects assurance upon request by the designated ED official. If the application is recommended/selected for funding, the designated ED official will request that the applicant obtain the assurance within 30 days after the specific formal request.

3c. If applicable, please attach your “Exempt Research” or “Nonexempt Research” narrative to your submission of the U.S Department of Education Supplemental Information for the SF-424 form as instructed in item II, “Instructions for Exempt and Nonexempt Human Subjects Research Narratives” in the attached page entitled “Definitions for U.S. Department of Education Supplemental Information for the SF-424.”

Note about Institutional Review Board Approval. ED does not require certification of Institutional Review Board approval with the application. However, if an application that involves non-exempt human subjects research is recommended/selected for funding, the designated ED official will request that the applicant obtain and send the certification to ED within 30 days after the formal request.

No covered human subjects research can be conducted until the study has ED clearance for protection of human subjects in research.

Paperwork 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. The valid OMB control number for this information collection is 1894-0007. The time required to complete this information collection is estimated to average between 15 and 45 minutes per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-0170. If you have comments or concerns regarding the status of your individual submission of this form write directly to: (insert program office), U.S. Department of Education, 400 Maryland Avenue, S.W., Washington, D.C. 20202.

Budget Information for Non-Construction Programs (SF-524)

U.S. DEPARTMENT OF EDUCATION BUDGET INFORMATION NON-CONSTRUCTION PROGRAMS

OMB Control Number: 1894-0008 Expiration Date: 04/30/2014

Name of Institution/Organization

Applicants requesting funding for only one year should complete the column under "Project Year 1." Applicants requesting funding for multi-year grants should complete all applicable columns. Please read all instructions before completing form.

SECTION A - BUDGET SUMMARY U.S. DEPARTMENT OF EDUCATION FUNDS

Budget Categories

Project Year 1 (a)

Project Year 2 (b)

Project Year 3 (c)

Project Year 4 (d)

Project Year 5 (e)

Total (f)

1. Personnel

2. Fringe Benefits

3. Travel

4. Equipment

5. Supplies

6. Contractual

7. Construction

8. Other

9. Total Direct Costs (lines 1-8)

10. Indirect Costs*

11. Training Stipends

12. Total Costs (lines 9-11)

*Indirect Cost Information (To Be Completed by Your Business Office): If you are requesting reimbursement for indirect costs on line 10, please answer the following questions: Do you have an Indirect Cost Rate Agreement approved by the Federal government? ____Yes ____ No If yes, please provide the following information: Period Covered by the Indirect Cost Rate Agreement: From: ___/___/______ To: ___/___/______ (mm/dd/yyyy) Approving Federal agency: ____ ED ____ Other (please specify): __________________________ The Indirect Cost Rate is _________% For Restricted Rate Programs (check one) -- Are you using a restricted indirect cost rate that: ___ Is included in your approved Indirect Cost Rate Agreement? or ___ Complies with 34 CFR 76.564(c)(2)? The Restricted Indirect Cost Rate is _________%

Name of Institution/Organization

Applicants requesting funding for only one year should complete the column under "Project Year 1." Applicants requesting funding for multi-year grants should complete all applicable columns. Please read all instructions before completing form.

SECTION B - BUDGET SUMMARY NON-FEDERAL FUNDS

Budget Categories

Project Year 1 (a)

Project Year 2 (b)

Project Year 3 (c)

Project Year 4 (d)

Project Year 5 (e)

Total (f)

1. Personnel

2. Fringe Benefits

3. Travel

4. Equipment

5. Supplies

6. Contractual

7. Construction

8. Other

9. Total Direct Costs (Lines 1-8)

10. Indirect Costs

11. Training Stipends

12. Total Costs (Lines 9-11)

SECTION C – BUDGET NARRATIVE (see instructions)

Instructions for ED 524

General Instructions This form is used to apply to individual U.S. Department of Education (ED) discretionary grant programs. Unless directed otherwise, provide the same budget information for each year of the multi-year funding request. Pay attention to applicable program specific instructions, if attached. You may access the Education Department General Administrative Regulations, 34 CFR 74 – 86 and 97-99, on ED’s website at: http://www.ed.gov/policy/fund/reg/edgarReg/edgar.html You must consult with your Business Office prior to submitting this form. Section A - Budget Summary U.S. Department of Education Funds All applicants must complete Section A and provide a break-down by the applicable budget categories shown in lines 1-11. Lines 1-11, columns (a)-(e): For each project year for which funding is requested, show the total amount requested for each applicable budget category. Lines 1-11, column (f): Show the multi-year total for each budget category. If funding is requested for only one project year, leave this column blank. Line 12, columns (a)-(e): Show the total budget request for each project year for which funding is requested. Line 12, column (f): Show the total amount requested for all project years. If funding is requested for only one year, leave this space blank. Indirect Cost Information: If you are requesting reimbursement for indirect costs on line 10, this information is to be completed by your Business Office. (1): Indicate whether or not your organization has an Indirect Cost Rate Agreement that was approved by the Federal government. If you checked “no,” ED generally will authorize grantees to use a temporary rate of 10 percent of budgeted salaries and wages subject to the following limitations: (a) The grantee must submit an indirect cost proposal to its cognizant agency within 90 days after ED issues a grant award notification; and (b) If after the 90-day period, the grantee has not submitted an indirect cost proposal to its cognizant agency, the grantee may not charge its grant for indirect costs until it has negotiated an indirect cost rate agreement with its cognizant agency. (2): If you checked “yes” in (1), indicate in (2) the beginning and ending dates covered by the Indirect Cost Rate Agreement. In addition, indicate whether ED, another Federal agency (Other) or State agency issued the approved agreement. If you check “Other,” specify the name of the Federal or other agency that issued the approved agreement. (3): If you are applying for a grant under a Restricted Rate Program (34 CFR 75.563 or 76.563), indicate whether you are using a restricted indirect cost rate that is included on your approved Indirect

Cost Rate Agreement or whether you are using a restricted indirect cost rate that complies with 34 CFR 76.564(c)(2). Note: State or Local government agencies may not use the provision for a restricted indirect cost rate specified in 34 CFR 76.564(c)(2). Check only one response. Leave blank, if this item is not applicable. Section B - Budget Summary Non-Federal Funds If you are required to provide or volunteer to provide cost-sharing or matching funds or other non-Federal resources to the project, these should be shown for each applicable budget category on lines 1‑11 of Section B. Lines 1-11, columns (a)-(e): For each project year, for which matching funds or other contributions are provided, show the total contribution for each applicable budget category. Lines 1-11, column (f): Show the multi-year total for each budget category. If non-Federal contributions are provided for only one year, leave this column blank. Line 12, columns (a)-(e): Show the total matching or other contribution for each project year. Line 12, column (f): Show the total amount to be contributed for all years of the multi-year project. If non-Federal contributions are provided for only one year, leave this space blank. Section C - Budget Narrative [Attach separate sheet(s)] Pay attention to applicable program specific instructions, if attached. Provide an itemized budget breakdown, and justification by project year, for each budget category listed in Sections A and B. For grant projects that will be divided into two or more separately budgeted major activities or sub-projects, show for each budget category of a project year the breakdown of the specific expenses attributable to each sub-project or activity. For non-Federal funds or resources listed in Section B that are used to meet a cost-sharing or matching requirement or provided as a voluntary cost-sharing or matching commitment, you must include: a. The specific costs or contributions by budget category; b. The source of the costs or contributions; and c. In the case of third-party in-kind contributions, a description of how the value was determined for the donated or contributed goods or services. [Please review ED’s general cost sharing and matching regulations, which include specific limitations, in 34 CFR 74.23, applicable to non-governmental entities, and 80.24, applicable to governments, and the applicable Office of Management and Budget (OMB) cost principles for your entity type regarding donations, capital assets, depreciation and use allowances. OMB

cost principle circulars are available on OMB’s website at: http://www.whitehouse.gov/omb/circulars/index.html] If applicable to this program, provide the rate and base on which fringe benefits are calculated. If you are requesting reimbursement for indirect costs on line 10, this information is to be completed by your Business Office. Specify the estimated amount of the base to which the indirect cost rate is applied and the total indirect expense. Depending on the grant program to which you are applying and/or your approved Indirect Cost Rate Agreement, some direct cost budget categories in your grant application budget may not be included in the base and multiplied by your indirect cost rate. For example, you must multiply the indirect cost rates of “Training grants" (34 CFR 75.562) and grants under programs with “Supplement not Supplant” requirements ("Restricted Rate" programs) by a “modified total direct cost” (MTDC) base (34 CFR 75.563 or 76.563). Please indicate which costs are included and which costs are excluded from the base to which the indirect cost rate is applied. When calculating indirect costs (line 10) for "Training grants" or grants under "Restricted Rate" programs, you must refer to the information and examples on ED’s website at: http://www.ed.gov/fund/grant/apply/appforms/appforms.html. You may also contact (202) 377-3838 for additional information regarding calculating indirect cost rates or general indirect cost rate information. Provide other explanations or comments you deem necessary. Paperwork 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. The valid OMB control number for this information collection is 1894-0008. The time required to complete this information collection is estimated to vary from 13 to 22 hours per response, with an average of 17.5 hours per response, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4537. If you have comments or concerns regarding the status of your individual submission of this form, write directly to (insert program office), U.S. Department of Education, 400 Maryland Avenue, S.W., Washington, D.C. 20202.

Disclosure of Lobbying Activities (SF-LLL)

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352

Type of Federal Action: a. contract ____ b. grant c. cooperative agreement d. loan e. loan guarantee f. loan insurance	Status of Federal Action: a. bid/offer/application _____ b. initial award c. post-award		Report Type: a. initial filing _____ b. material change For material change only: Year _______ quarter _______ Date of last report___________
Name and Address of Reporting Entity: ____ Prime _____ Subawardee Tier______, if Known: Congressional District, if known:		If Reporting Entity in No. 4 is Subawardee, Enter Name andAddress of Prime: Congressional District, if known:
Federal Department/Agency:		7. Federal Program Name/Description: CFDA Number, if applicable: __________________
Federal Action Number, if known:		9. Award Amount, if known: $
10. a. Name and Address of Lobbying Registrant (if individual, last name, first name, MI):		b. Individuals Performing Services (including address if 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 reported to the Congress semi-annually and 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)

Instructions for Disclosure of Lobbying Activities (SF-LLL)

This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.

1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.

2. Identify the status of the covered Federal action.

3. Identify the appropriate classification of this report. If this is a follow up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action.

4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.

5. If the organization filing the report in item 4 checks “Subawardee,” then enter the full name, address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known.

6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard.

7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.

8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., “RFP-DE-90-001.”

9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5.

10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action.

(b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (MI).

11. The certifying official shall sign and date the form, print his/her name, title, and telephone number.

According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB control Number. The valid OMB control number for this information collection is OMB No. 0348-0046. Public reporting burden for this collection of information is estimated to average 10 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 (0348-0046), Washington, DC 20503

General Education Provisions Act (GEPA) Section 427

OMB Control No. 1894-0005 (Exp. 03/31/2014)

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 impede 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 Examples of How an Applicant Might Satisfy the Requirement of This Provision?

The following examples may help illustrate how an applicant may comply 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 model 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.

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 Statement for GEPA Requirements

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 [email protected] and reference the OMB Control Number 1894-0005.

Survey on Ensuring Equal Opportunity for Applicants

OMB No. 1894-0010 Exp. 05/31/2012

Purpose: The Federal government is committed to ensuring that all qualified applicants, small or large, non-religious or faith-based, have an equal opportunity to compete for Federal funding. In order for us to better understand the population of applicants for Federal funds, we are asking nonprofit private organizations (not including private universities) to fill out this survey.

Upon receipt, the survey will be separated from the application. Information provided on the survey will not be considered in any way in making funding decisions and will not be included in the Federal grants database. While your help in this data collection process is greatly appreciated, completion of this survey is voluntary.

Instructions for Submitting the Survey: If you are applying using a hard copy application, please place the completed survey in an envelope labeled “Applicant Survey.” Seal the envelope and include it along with your application package. If you are applying electronically, please submit this survey along with your application.

Applicant’s (Organization) Name: ____________________________________________________________

Applicant’s DUNS Number: _________________________________________________________________

Federal Program: ________________________________________________CFDA Number: ___________

1. Has the applicant ever received a grant or contract from the Federal government?

Yes No

2. Is the applicant a faith-based organization?

Yes No

3. Is the applicant a secular organization?

Yes No

4. Does the applicant have 501(c)(3) status?

Yes No

5. Is the applicant a local affiliate of a national
organization?

Yes No

6. How many full-time equivalent employees does the applicant have? (Check only one box).

3 or Fewer 15-50

4 -5 51-100

6-14 over 100

7. What is the size of the applicant’s annual budget? (Check only one box.)

Less Than $150,000

$150,000 - $299,999

$300,000 - $499,999

$500,000 - $999,999

$1,000,000 - $4,999,999

$5,000,000 or more

Survey Instructions for Ensuring Equal Opportunity for Applicants

Provide the applicant’s (organization) name and DUNS number and the grant name and CFDA number.

1. Self-explanatory.

2. Self-identify.

3. Self-identify.

4. 501(c)(3) status is a legal designation provided on application to the Internal Revenue Service by eligible organizations. Some grant programs may require nonprofit applicants to have 501(c)(3) status. Other grant programs do not.

5. Self-explanatory.

6. For example, two part-time employees who each work half-time equal one full-time equivalent employee. If the applicant is a local affiliate of a national organization, the responses to survey questions 2 and 3 should reflect the staff and budget size of the local affiliate.

7. Annual budget means the amount of money your organization spends each year on all of its activities.

Paperwork 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. The valid OMB control number for this information collection is 1890-0014. The time required to complete this information collection is estimated to average five (5) minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: The Agency Contact listed in this grant application package.

SF 424B Form ASSURANCES NON-CONSTRUCTION PROGRAMS

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), Washington, DC 20503

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

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. Will 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; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives.

3. Will 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. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.

5. Will 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. Will 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 VIII 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. Will comply, or has already complied, with the requirements of Titles II and III 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. Will comply, as applicable, with the 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.

9. Will 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 Work Hours and Safety Standards Act (40 U.S.C.  327-333), regarding labor standards for federally assisted construction subagreements.

10. Will 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.

11. Will 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 Zone Management Act of 1972 (16 U.S.C. 1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176(c) of the Clear 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 Water Act of 1974, as amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93-205).

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL	TITLE
APPLICANT ORGANIZATION		DATE SUBMITTED

12 Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. 1721 et seq.) related to protecting components or potential components of the national wild and scenic rivers system.

13. Will 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.).

14. Will 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.

15. Will comply with the Laboratory Animal Welfare 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.

16. Will 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.

17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act Amendments of 1996 and OMB Circular No. A-133, Audits of States, Local Governments, and Non-Profit Organizations.

18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program

Standard Form 424B (Rev. 7-97) Back

Grants.gov CERTIFICATION REGARDING 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 any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal Loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan or cooperative agreement.

2. If any funds other 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 this Federal contract, grant, loam 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 $10,000 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:

Applicant’s Organization

Printed Name of Authorized Representative Printed Title of Authorized Representative

Signature Date

If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee or any agency, a member of Congress, an officer or employee of Congress or an employee of a Member of Congress in connection with this commitment providing for the 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 making 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.

EXECUTIVE ORDER 12372

Intergovernmental Review of Federal Programs

(This program falls under the rubric of Executive Order 12372 (Intergovernmental Review of Federal Programs) and the regulations in 34 CFR Part 79. One of the objectives of the Executive order is to strengthen federalism--or the distribution of responsibility between localities, States, and the Federal government--by fostering intergovernmental partnerships. This idea includes supporting processes that State or local governments have devised for coordinating and reviewing proposed Federal financial grant applications.

The process for doing this requires grant applicants to contact State Single Points of Contact for information on how this works. Multi-state applicants should follow procedures specific to each state.

Further information about the State Single Point of Contact process and a list of names by State can be found at:

http://www.whitehouse.gov/omb/grants_spoc

Absent specific State review programs, applicants may submit comments directly to the Department. All recommendations and comments must be mailed or hand-delivered by the date indicated in the actual application notice to the following address: The Secretary, EO 12372--CFDA# [commenter must insert number--including suffix letter, if any], U.S. Department of Education, room 7E200. 400 Maryland Avenue, SW., Washington, DC 20202.

Proof of mailing will be determined on the same basis as applications (see 34 CFR §75.102). Recommendations or comments may be hand-delivered until 4:30 p.m. (Eastern Time) on the closing date indicated in this notice.

Important note: The above address is not the same address as the one to which the applicant submits its completed applications. Do not send applications to the above address.

Applicant Checklist

Use This Checklist While Preparing Your Application Package.

All items listed on this checklist are required, except as noted.

• SF 424 Application Form for Federal Assistance

• ED Supplemental Form for SF 424

• ED 524 Form (Budget Summary Form)

• Narrative addressing GEPA Section 427

• Assurances and Certifications

• SF 424B Form - Assurances for Non-Construction Programs

• Lobbying Disclosure Form (SF LLL) (if applicable; refer to instructions)

• Grants.gov Certification Regarding Lobbying (formerly ED 80-0013)

• Survey on Ensuring Equal Opportunity for Applicants

• Abstract

• Project Narrative

• Budget Narrative

• Other Attachments

• Resumes/Curriculum Vitae

• Proof of non-profit status

• Documentation of status as a national non-profit organization

• Letters of Support, if applicable

• Additional information