1810-0657_Impact_Aid_Discretionary_Application_Work_Completion_Certification_Form

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

U.S. Department of Education
Impact Aid Program
Washington, D.C. 20202-6244
Certification of Work Completion
Grantee:
Project:
Address:

Work Project Description (as completed):

This work project has been reviewed and found, to the Facilities Manager or Architect’s best knowledge,
information and belief, to be designed and completed in conformance with applicable Federal, State, and
local laws, orders, regulations, standards, codes and ordinances.

Date

School District Facilities Manager or Architect

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

U.S. Department of Education
Impact Aid Program
Washington, D.C. 20202-6244
Request For Final Payment, Assurances, and Certification
Grantee:
Project:
Address:
o

This project has been completed in a manner satisfactory to the GRANTEE.

o
The GRANTEE also acknowledges that the accounts of the project have not been audited by the U.S.
Department of Education but ASSURES the Secretary of Education that it or its successors will refund to the
Department of Education such amounts, subject to an audit appeal by the GRANTEE, as may be determined
pursuant to a subsequent audit to be due the Federal Government.
o
The GRANTEE FURTHER ASSURES THE SECRETARY that any underpayment of wages, refunds or
rebates to the GRANTEE, or other revenue or monetary adjustments in its favor, will be reported to the Secretary of
Education, and the amount of such underpayment of wages and penalties resulting there from, and the Federal share
of any such refunds, rebates, revenue, or adjustments not considered in determining the amount of this payment for
the project will be refunded to the Department of Education.
$
$
$
$

Total 7007(b) Funds expended
Total local funds expended
Total Cost of the Project (Attach supporting documents)
Final draw down request

Certification
1. Interest earned to date and credited to this project.
$
2. Interest expected to be earned and/or credited to this project. $
3. Other.
$
I certify that to the best of my knowledge and belief the data above are correct and that all outlays were made in
accordance with the grant conditions or other agreement and that the final grant payment is due.

Date

Authorized LEA Representative