Standard Forms

^OMB Number: 4040-0004

Expiration Date: 8/31/2016

Application for Federal Assistance SF-424

* 1. Type of Submission:

Preapplication Application

* 2. Type of Application: * If Revision, select appropriate letter(s):

New

_Continuation * Other (Specify):

Changed/Corrected Application Revision

• ^{3. Date Received:} 4. Applicant Identifier:

5a. Federal Entity Identifier: 5b. Federal 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:

4. Address:

• 

  USA: UNITED STATES

  
  

  Street1: Street2:

• City: County/Parish:

• State: Province:

• Country:

• Zip / Postal Code:

4. Organizational Unit:

Department Name: Division Name:

4. Name and contact information of person to be contacted on matters involving this application:

Prefix: * First Name:

Middle Name:

• Last Name:

Suffix: Title:

Organizational Affiliation:

• Telephone Number: Fax Number:

• Email:

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:

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

Add Attachment

Delete Attachment

View Attachment

* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.

Add Attachments

Delete Attachments

View Attachments

Application for Federal Assistance SF-424

16. Congressional Districts Of:

• a. Applicant

Attach an additional list of Program/Project Congressional Districts if needed.

• b. Program/Project

Add Attachment

Delete Attachment

View Attachment

16. Proposed Project:

• a. Start Date: * b. End Date:

16. 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?

1. This application was made available to the State under the Executive Order 12372 Process for review on ^.

2. Program is subject to E.O. 12372 but has not been selected by the State for review.

3. Program is not covered by E.O. 12372.

* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.)

Yes No

If "Yes", provide explanation and attach

Add Attachment

Delete Attachment

View Attachment

21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)

** I AGREE

** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency

specific instructions.

Authorized Representative:

Prefix: * First Name:

Middle Name:

• Last Name:

Suffix:

• Title:

• Telephone Number:

• Email:

Fax Number:

• Signature of Authorized Representative: * Date Signed:

U.S. Department of Education Supplemental Information for the SF-424

1. Project Director:

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

Address:

• Street1: Street2:

• City: County:

• State: * Zip Code: Country:

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

• Email Address:

2. Novice Applicant:

Are you are a novice applicant as defined in the regulations in 34 CFR 75.225 (and included in the definitions page in the attached instructions)?

Yes No

3. Human Subjects Research:

1. Are any research activities involving human subjects planned at any time during the proposed Project Period?

Yes No

2. 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:

3. If applicable, please attach your “Exempt Research” or “Nonexempt Research” narrative to this form as indicated in the definitions page in the attached instructions.

OMB Number: 1894-0007

Expiration Date: 8/31/2017

U.S. DEPARTMENT OF EDUCATION B UDGET INFORMATION NON-CONSTRUCTION PROGRAMS						OMB Control Number: 1894-0008 Expiration Date: 06/30/2017
Name of Ins titution/Organization			Applicants reques ting funding for only one year s h ould complete the column under "Project Year 1." Applicants reques ting funding for multi-year grants s hould complete all applicable columns . Pleas e read all ins tructions before completing form.
SECTION A - BUDGET SUMMARY U.S. DEPARTMENT OF EDUCATIO N 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. Pers onnel
2. Fringe Benefits
3. Travel
4. Equipment
5. Supplies
6. Contractual
7. Cons truction
8. Other
9. Total Direct Cos ts (lines 1-8)
10. Indirect Cos ts *
11. Training Stipends
12. Total Cos ts (lines 9-11)
*Indirect Cos t Information (To Be Completed by Your Business Office): If you are reques ting reimburs ement for indirect cos ts on line 10, pleas e ans wer the following ques tions : (1) Do you have an Indirect Cos t Rate Agreement approved by the Federal government? ____Yes ____ No (2) If yes , pleas e provide the following information: Period Covered by the Indirect Cos t Rate Agreement: From: ___/___/___ _ To: ___/___/___ _ (mm/dd/yyyy) Approving Federal agency: ____ ED ____ Other (pleas e s pecify): _________ _ _ _ _ _ The Indirect Cos t Rate is ___ ______% (3) For Res tricted Rate Programs (check one) -- Are you us ing a res tricted indirect cos t rate that: ___ Is included in your approved Indirect Cos t Rate Agreement? or ___ Complies with 34 CFR 76.564(c)(2)? The Res tricted In direct Cos t Rate is _________%

ED 524

Name of Ins titution/Organization			Applicants reques ting funding for only one year s hould complete the column under "Project Year 1." Applicants reques ting funding for multi-year grants s hould complete all applicable columns . Pleas e read all ins tructions 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. Pers onnel
2. Fringe Benefits
3. Travel
4. Equipment
5. Supplies
6. Contractual
7. Cons truction
8. Other
9. Total Direct Cos ts (Lines 1-8)
10. Indirect Cos ts
11. Training Stipends
12. Total Cos ts (Lines 9-11)
SECTION C – B UDGET NARRATIVE (see instructions)

ED 524

ASSURANCES - NON-CONSTRUCTION PROGRAMS

OMB Approval No. 0348-0040

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:

   1. 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 provisions of the Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds.

Previous Edition Usable Standard Form 424B (Rev. 7-97)

Authorized for Local Reproduction Prescribed by OMB Circular A-102

9.

10.

11.

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.

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.

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 (Clean Air) Implementation Plans under Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. §§7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking 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).

12.

13.

14.

15.

16.

17.

18.

Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system.

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.).

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.

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.

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.

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."

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

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL	TITLE
APPLICANT ORGANIZATION		DATE SUBMITTED

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

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 an 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 than 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, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, ''Disclosure of Lobbying Activities,'' in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,00 0 and not more than $100,000 for each such failure.

Statement for Loan Guarantees and Loan Insurance

The undersigned states, to the best of his or her knowledge and belief, that:

If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or 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 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 subjec t to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

_____________

_______________________

DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046

_________

_________

______________

(See reverse for public burden disclosure.)

Type of Federal Action: contract grant cooperative agreement loan loan guarantee loan insurance	Status of Federal Action: bid/offer/application initial award post-award		Report Type: initial filing material change For Material Change Only: year quarter date of last report
4. Name and Address of Reporting Entity: Prime Subawardee Tier , if known : Congressional District, if known : 4c		5. If Reporting Entity in No. 4 is a Subawardee, Enter Name and Address of Prime: Congressional District, if known :
6. Federal Department/Agency:		7. Federal Program Name/Description: CFDA Number, if applicable :
8. Federal Action Number, if known :		9. Award Amount, if known : $
10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if
( if individual, last name, first name, MI ):		different from No. 10a ) (last name, first name, MI ):
11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.		Signature: Print Name: Title: Telephone No.: Date:
Federal Use Only:				Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)

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