Written Application for the Independent Living Services for Older Individuals Who are Blind Formula Grant

Janet L. LaBreck, Commissioner

Rehabilitation Services Administration, OSERS

U.S. Department of Education

400 Maryland Ave, SW - PCP Room 5086

Washington, D.C. 20202

Dear Commissioner LaBreck:

In accordance with Section 752 of the Rehabilitation Act of 1973, as amended (Act), we are applying for an Independent Living Services for Older Individuals Who are Blind

(IL-OIB) grant for fiscal years 2014-2016 on behalf of the State of ______________ for such amounts as our agency may be entitled to receive.

We agree to administer the formula grant program in accordance with the Federal requirements in the enclosed signed assurances.

The name of the director, the designated state agency, and the address of the agency are:

State law allows payment directly to the designated state agency or requires payment to be made to:

The DUNS number of the payee agency is __________________________.

______________________________

(Signature of Director)

______________________________

(State)

______________________________

(Date)

Public 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. 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. The obligation to respond to this collection is required to obtain or retain benefit (Public Law 105-220-751 et seq. ). 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 20202-4536 or email [email protected] and reference the OMB Control Number 1820-0660. Note: Please do not return the completed Older Blind Application to this address.