Higher Education Emergency Relief Fund (HEERF) Improper Payments Information Form

OMB Control Number: 1840-0851

Expiration date: 7/31/2021

Higher Education Emergency Relief Fund (HEERF) Refunds Resolution and Grant Interest Form

Directions: Grantees that have returned HEERF funds to their G5 grant account (1) in an amount over $1,000, and (2) outside of a specified window after a drawdown are required to complete this form and return it to [email protected] and their assigned U.S. Department of Education program officer (as indicated in Box 3 of the Grant Award Notification (GAN)). Funds must be returned anytime during the grant award performance period, which is usually 12 months, or later. Funds should be returned for any of the categories identified below and whenever a grantee earns over $500 for funds deposited in an interest-bearing account. The date interest should be calculated is based upon the date the funds were drawn down as applicable. Information about Federal Payment to grant awards is available in 2 CRF §200.305, which applies to the student and institutional HEERF categories. Failure to promptly complete and return this form may result in enforcement actions from the Department and/or your institution may be determined to be ineligible to receive future CARES Act, COVID-19 relief, or HEERF grant funding.

Institution Name:Click or tap here to enter text. Institution DUNS: Click or tap here to enter text. Institution OPEID: Click or tap here to enter text.

Authorized Representative of the Institution:

Name: Click or tap here to enter text.

Title: Click or tap here to enter text.

Email: Click or tap here to enter text.

Phone: Click or tap here to enter text.

Refund #1

Date of refund	Click or tap here to enter text.
Amount of refund	Click or tap here to enter text.
Reason(s) for Refund	☐Pandemic Emergency / Correcting an Administrative Error ☐Student Financial Aid Grant Refunds ☐Correcting an Unallowable Cost ☐Correcting a Cost Outside the Period of Performance ☐ Returning funds associated with an Excessive Drawdown determination ☐ Returning funds related to a grant termination (whether voluntary or involuntary)

Refund #2

Date of refund	Click or tap here to enter text.
Amount of refund	Click or tap here to enter text.
Reason(s) for Refund	☐Pandemic Emergency / Correcting an Administrative Error ☐Student Financial Aid Grant Refunds ☐Correcting an Unallowable Cost ☐Correcting a Cost Outside the Period of Performance ☐ Returning funds associated with an Excessive Drawdown determination ☐ Returning funds related to a grant termination (whether voluntary or involuntary)

Refund #3

Date of refund	Click or tap here to enter text.
Amount of refund	Click or tap here to enter text.
Reason(s) for Refund	☐Pandemic Emergency / Correcting an Administrative Error ☐Student Financial Aid Grant Refunds ☐Correcting an Unallowable Cost ☐Correcting a Cost Outside the Period of Performance ☐ Returning funds associated with an Excessive Drawdown determination ☐ Returning funds related to a grant termination (whether voluntary or involuntary)

Refund #4

Date of refund	Click or tap here to enter text.
Amount of refund	Click or tap here to enter text.
Reason(s) for Refund	☐Pandemic Emergency / Correcting an Administrative Error ☐Student Financial Aid Grant Refunds ☐Correcting an Unallowable Cost ☐Correcting a Cost Outside the Period of Performance ☐ Returning funds associated with an Excessive Drawdown determination ☐ Returning funds related to a grant termination (whether voluntary or involuntary)

Refund #5

Date of refund	Click or tap here to enter text.
Amount of refund	Click or tap here to enter text.
Reason(s) for Refund	☐Pandemic Emergency / Correcting an Administrative Error ☐Student Financial Aid Grant Refunds ☐Correcting an Unallowable Cost ☐Correcting a Cost Outside the Period of Performance ☐ Returning funds associated with an Excessive Drawdown determination ☐ Returning funds related to a grant termination (whether voluntary or involuntary)

Grantee Excess Interest Accounting and Returning

☐ By checking this box, I assure the U.S. Department of Education that our institution will account for and return any excess interest generated by our CARES Act HEERF Funds over $500 as required by 2 CFR § 200.305(b)(9).

As of the date of completion of this form, our institution has determined we have the following amount in excess interest generated by our HEERF grants: Click or tap here to enter text.

We will return this interest to the Federal Government (using the instructions provided below), as required by 2 CFR § 200.305(b)(11), by no later than the following date¹: Click or tap here to enter text.

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995 (PRA), 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 1840-0851. Public reporting burden for this collection of information is estimated to average 1 hour 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. Under the PRA, participants are required to respond to this collection to obtain or retain benefit. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this individual collection, or if you have comments or concerns regarding the status of your individual form, application, or survey, please contact: Karen Epps, U.S. Department of Education, 400 Maryland Avenue, SW, Washington, DC 20202.

1 Please note the following instructions: The preferred method to return interest is through Automated Clearing House (ACH) Direct Deposit or Fedwire.

a. When returning interest through ACH Direct Deposit or Fedwire, grantees must include the following in their return transaction:

·  PMS Account Number (PAN). NOTE: The PAN is the same series of alpha-numeric characters used for payment request purposes (e.g.: C1234G1).

·  PMS document number.

·  The reason for the return (e.g. interest, part interest part other, etc.).

·  An explanation stating that the refund is for interest payable to the Department of Health and Human Services, and the grant number(s) for which the interest was earned.

b. U.S. Department of Education grantees are generally located and operate domestically and return interest domestically. Below is PSC ACH account information for interest returned domestically. For international ACH interest returned, account information is available at: Returning Funds/Interest.

·  PSC ACH Routing Number is: 051036706

·  PSC DFI Accounting Number: 303000

·  Bank Name: Credit Gateway - ACH Receiver

·  Location: St. Paul, MN

c. Service charges may be incurred from a grantee’s financial institution when a Fedwire to return interest is initiated. For FedWire returns, Fedwire account information is as follows:

·  Fedwire Routing Number: 021030004

·  Agency Location Code (ALC): 75010501

·  Bank Name: Federal Reserve Bank

·  Treas NYC/Funds Transfer Division

·  Location: New York, NY