Impact Aid Discretionary Construction Grant Program

Filing Deadline:

U.S. Department of Education
Impact Aid Program
Washington, D.C. 20202-6244

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

APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM
SECTION 7007(b)

Fiscal Year

EMERGENCY GRANT
Catalog of Federal Domestic Assistance #84-041C
Send 1 copy to the State Educational Agency (SEA).
Is the Applicant Delinquent on Any Federal Debt?
 Yes  No
Applicant Name :
Street/P.O. Box :
City :
County :
State & Zip :

Applicant’s
DUNS Number

Applicant’s Taxpayer
Identification Number

Applicant’s
Impact Aid Number

Contact Person Name :
Title :
Phone :
Fax :
E-Mail :

Name of the School Facility for Which Funding Is Requested:

Amount Requested:

Enrollment in this School Facility on the Survey Date Reported on Your Local Educational Agency’s (LEA’s) Fiscal
Year (FY) 2017 Section 7003 Application

If Applicable, Date Application Was Submitted to State Agency for Executive Order 12372 Review:
I certify that I have read the statements contained in this application and that these statements and all of the data included in this application are, to the best of my
knowledge and belief, true, complete and correct. I certify that I am authorized to make the representations and commitments in this application, for and on behalf of the
applicant, and otherwise to act as the applicant’s authorized representative in submitting this application for funding under section 7007(b) of the Impact Aid Program (Title
VIII of the Elementary and Secondary Education Act). I declare that the applicant will mail a complete copy of this application to the SEA at the same time that it mails this
application to the U.S. Department of Education.

Name and Title of Authorized Representative (Please type or print.)

Signature

Date

Page: 1

APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 7007(b) – ADDITIONAL INFORMATION

 Own

APPLICANT’S INTEREST IN THE SCHOOL FACILITY

 Lease

 Other
(Expiration date)

If Other, Specify
TYPE OF SPECIAL DISTRICT
 Charter School  Alaskan Rural Education Attendance Area (REAA)  Coterminous District
AGE OF THE SCHOOL FACILITY

Year of Original Construction

Year(s) and Description(s) of Major Renovation(s)

Square Footage of Existing School Facility
ACREAGE IN LOCAL EDUCATIONAL AGENCY (LEA)
Total Acres Within Boundaries of LEA

Total Acres of Nontaxable Federal Property Within Boundaries of LEA

BONDED INDEBTEDNESS AS OF THE END OF THE AGENCY’S FISCAL YEAR 2015-2016
Maximum Bonding Capacity $

Amount of Bonded Debt $

ASSESSED VALUE OF TAXABLE PROPERTY IN LEA
Name of Taxing Jurisdiction (e.g., School District Name, Township
Name, City Name, County Name, etc.)

Total Assessed Value of Real Property (Land and Improvements) That Was
Taxed for School Purposes for school year 2015-2016 on Behalf of the LEA
$
$
$

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

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APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 7007(b) – PROJECT NARRATIVE FOR EMERGENCY GRANT APPLICATION
Proposed Project Start Date

Proposed Project Completion Date

Describe: (1) the emergency condition; (2) how the emergency condition adversely affects the health, safety and well-being of occupants of the school
facility; (3) the amount of square footage to be added to the school facility, if any; (4) the age of the facility systems associated with this project (e.g.,
roofing, plumbing, HVAC, windows, electrical, etc.); (5) actions the applicant has taken to respond to the emergency condition and why the applicant has
been unable to resolve the condition; (6) how the proposed project will address the emergency condition; and (7) the proposed project and budget.

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

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U.S. Department of Education
Impact Aid Program
Washington, D.C. 20202-6244
APPLICATION FOR IMPACT AID DISCRETIONARY CONSTRUCTION PROGRAM SECTION 7007(b)
Catalog of Federal Domestic Assistance #84-041C

INDEPENDENT CERTIFICATION FOR EMERGENCY GRANT APPLICATION
This form must be completed and signed by a local building inspector, a licensed architect, or a licensed engineer, and included as part
of an emergency application for the discretionary construction program. The person providing this certification may not be a member of
the staff of the applicant local educational agency (LEA).

Name :
Title :
Organization :
Street/P.O. Box :
City, State & Zip :
Phone :
For the school facility identified in this application, please:
1. provide your professional and independent assessment of whether the condition is an emergency;
2. describe how the condition adversely affects the health, safety and well-being of occupants of the school facility;
3. describe the urgency of the need to address the condition; and
4. provide any additional comments you believe are relevant.
If you require more space for your narrative, continue on one blank page, using the title on this form.

I certify that these statements are, to the best of my knowledge and belief, true, complete and correct.

SIGNATURE

DATE

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

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APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 7007(b) – JUSTIFICATION FOR REBUILDING
If proposing new construction, provide justification for rebuilding instead of repairing or renovating the existing school facility. Specify the total square
footage of the proposed new facility.

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

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APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 7007(b) – COST ESTIMATE TABLE
Please provide a breakdown of the cost estimates related to this project.
Budget Category
(a)

Non-Federal Share

Direct Project Costs

Requested Federal Share

Total

Supplies
Equipment
Advertisements
Travel/Expenses

(b)

Planning /Design/Engineering/ Environmental Impact Study
Facilities Plan
Environmental Documentation
Plans and Specifications
Bid Documents
Engineering Services

(c)

Construction /Implementation
Independent Construction Manager
Labor
Materials
Equipment
Other (Specify)

(d)

Miscellaneous
Permits
Compliance Monitoring/Oversight/Contingency
Taxes
Other (Specify)

(e)

Project Summary (Sum lines (a) through (d) for each column)

(f)

Available Resources

State
Local

(g)

Total Request (Line (e) minus line (f) for each column)

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

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APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 7007(b) – CHILDREN WHO ATTENDED THIS SCHOOL FACILITY AND WHO
WERE INCLUDED ON TABLE 1 OF THE APPLICANT’S SECTION 7003 APPLICATION
Report children included on Table 1 of section 7003 FY 2017 (school year 2015-2016) application who attended school facility for which funding is requested.
FEDERAL PROPERTY ON WHICH CHILDREN WITH DISABILITIES RESIDE
PROPERTY
CODE
NUMBER
(1)

CHILDREN WITH DISABILITIES

NUMBER OF
CHILDREN
ON SURVEY
DATE
(3)

OFFICIAL NAME,
ADDRESS, CITY, STATE
(2)

CATEGORY
(5)

NUMBER OF
CHILDREN
ON SURVEY
DATE
(6)

WITH A PARENT ON ACTIVE DUTY IN THE
UNIFORMED SERVICES OF THE UNITED
STATES
WITH A PARENT WHO IS BOTH AN
ACCREDITED FOREIGN GOVERNMENT
OFFICIAL AND A FOREIGN MILITARY OFFICER
RESIDING ON ELIGIBLE INDIAN LANDS

TABLE 1-2 TOTAL 

TABLE 1-1 TOTAL 
Form Approved: OMB number 1810-0657, Expiration date:

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APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 7007(b) – CHILDREN WHO ATTENDED THIS SCHOOL FACILITY AND WHO
WERE INCLUDED ON TABLE 2 OF THE APPLICANT’S SECTION 7003 APPLICATION
Report children included on Table 2 of section 7003 FY 2017 (school year 2015-2016) application who attended school facility for which funding is requested.

CHILDREN WITH DISABILITIES
(2)

NUMBER OF CHILDREN ON SURVEY DATE
(3)

WITH A PARENT ON ACTIVE DUTY IN THE UNIFORMED SERVICES
OF THE UNITED STATES

WITH A PARENT WHO IS BOTH AN ACCREDITED FOREIGN GOVERNMENT
OFFICIAL AND A FOREIGN MILITARY OFFICER
Form Approved: OMB number 1810-0657, Expiration date:

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APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 7007(b) – CHILDREN WHO ATTENDED THIS SCHOOL FACILITY AND WHO
WERE INCLUDED ON TABLE 3 OF THE APPLICANT’S SECTION 7003 APPLICATION
Report children included on Table 3 of section 7003 FY 2017 (school year 2015-2016) application who attended school facility for which funding is requested.
FEDERAL PROPERTY ON WHICH CHILDREN RESIDE
PROPERTY CODE
NUMBER
(1)

OFFICIAL NAME, ADDRESS, CITY, STATE

NUMBER OF
CHILDREN
ON SURVEY
DATE

(4)

(5)

FEDERAL PROPERTY ON WHICH PARENTS ARE EMPLOYED
PROPERTY CODE
NUMBER
(3)

OFFICIAL NAME, ADDRESS, CITY, STATE
(2)

TOTAL 

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

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APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 7007(b) – CHILDREN WHO ATTENDED THIS SCHOOL FACILITY AND WHO
WERE INCLUDED ON TABLES 4 AND 5 OF THE APPLICANT’S SECTION 7003 APPLICATION
Report children included on Table 4 of section 7003 FY 2017 (school year
2015-2016) application who attended school facility for which funding is
requested.
NUMBER OF
CHILDREN
ON SURVEY
DATE
(3)

FEDERAL PROPERTY ON WHICH CHILDREN RESIDE
PROPERTY CODE
NUMBER
(1)

Report children included on Table 5 of section 7003 FY 2017 (school year
2015-2016) application who attended school facility for which funding is
requested.

OFFICIAL NAME,
ADDRESS, CITY, STATE
(2)

FEDERAL PROPERTY ON WHICH PARENTS ARE EMPLOYED
PROPERTY CODE
NUMBER
(4)

TABLE 4 TOTAL 
Form Approved: OMB number 1810-0657, Expiration date:

OFFICIAL NAME,
ADDRESS, CITY, STATE
(5)

NUMBER
OF
CHILDREN
ON SURVEY
DATE
(6)

TABLE 5 TOTAL 
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APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 7007(b) – PROGRAM ASSURANCES AND CERTIFICATIONS
The applicant local educational agency (LEA) declares that it has filed the three certifications in ED Form 80-0013 regarding lobbying,
debarment/suspension/responsibility status, and drug-free workplace with the U.S. Department of Education (Department) as part of its
section 7003 or section 7002 Impact Aid application. As of the date of the signature below, the LEA reaffirms and incorporates by reference
those assurances and certifications with respect to this grant award. The LEA certifies that no circumstances affecting the validity of these
assurances have changed since their previous filing.
With respect to the Certification Regarding Lobbying, the LEA recertifies that no 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 the making or renewal of Federal grants under this program; that the
LEA shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," when required (34 C.F.R. Part 82, Appendix B);
and that the LEA shall require the full certification, as set forth in 34 C.F.R. Part 82, Appendix A, in the award documents for all subawards at
all tiers.
The LEA further agrees to comply with the following Education Department General Administrative Regulations (EDGAR):
34 CFR Part 75 -- Direct Grant Programs, except 75.600 through 75.617
34 CFR Part 77 -- Definitions that Apply to Department Regulations
34 CFR Part 80 -- Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments, including
the procurement provisions
34 CFR Part 81 -- General Education Provisions Act--Enforcement
34 CFR Part 82 -- New Restrictions on Lobbying
34 CFR Part 84 -- Governmentwide Requirements for Drug –Free Workplace (Grants).
34 CFR Part 85 -- Governmentwide Debarment and Suspension (Nonprocurement).

Signature Of Authorized Representative

Date

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

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APPLICATION FOR DISCRETIONARY CONSTRUCTION PROGRAM – SECTION 7007(b) – ADDITIONAL DEPARTMENT OF EDUCATION CONSTRUCTION ASSURANCES

The applicant local educational agency (LEA) further certifies that it will ensure that:
20. It has or will have title or other interest in the project site(s), including right of access, and that the site(s) will continue to be used for educational
purposes after the completion of the project(s).
21. Sufficient funds are available to meet any share of the costs of the repair, renovation, or construction projects that are not covered by this grant.
22. Except for school facilities modifications necessary to render public school facilities accessible in order to comply with the Americans with Disabilities
Act (ADA) of 1990 or section 504 of the Rehabilitation Act of 1973, this grant will be used only to supplement the amount of funds that in the absence of
the Federal funds would be made available from non-Federal sources for school repair and renovation.
23. Except for modifications necessary to meet ADA or section 504 of the Rehabilitation Act standards and asbestos abatement or removal, the grant will
not be used for repair, renovation, or construction of facilities or any part of a facility that will be used for religious worship, instruction, or
proselytization.
24. Competent architectural engineering supervision and inspection will be maintained at the project’s site to ensure that the work conforms to the
drawings and specifications for the approved project.
25. Grant projects will be: (a) functional; (b) economical; and (c) not elaborate in design or extravagant in the use of materials, compared with the facilities
of a similar type constructed in the State or other applicable geographical area.
26. Standards under the Occupational Safety and Health Act of 1970 (P.L. 91-576), or State and local codes, if they are more stringent, will be observed in
the design and completion of the projects.
27. Grant projects will comply with any applicable requirements under the ADA and section 504 of the Rehabilitation Act of 1973 regarding accessibility for
the disabled.
28. As applicable and to the extent feasible, the design and completion of grant project(s) should maximize efficient use of energy. Standard 90.1-1989 and
90.2-1993 of the American Society of Heating, Refrigerating, and Air-Conditioning Engineers, Inc. (ASHRAE) will be applied in the design and completion
of the grant projects.
29. It will follow the "Earthquake Hazards Reduction Act of 1977" (P.L. 95-125) and Executive Order 12699, "Seismic Safety of Federal and Federally
Assisted or Regulated New Building Construction," as applicable.
30. If applicable, it will comply with the following Indian Preferences and Opportunities requirements. Section 7(b) of the Indian Self-Determination and
Education Assistance Act of 1975 (P.L. 93-638) requires that, to the greatest extent feasible, the recipient of any grant or contract awarded for the
benefit of Indians give to: (1) Indians, preferences and opportunities for training and employment in connection with the administration of the grant or
contract; and (2) Indian organizations and Indian-owned economic enterprises, as defined in section 3 of the Indian Financing Act of 1974 (P.L. 93-262),
preference in the award of contracts and subcontracts at any level of the administration of the grant project.
31. If it carries out repair, renovation, or construction through a contract, any such contract process ensures the maximum number of qualified bidders,
including small, minority, and women-owned businesses, through full and open competition.
32. The facilities will be operated and maintained in accordance with applicable Federal, State, and local requirements.
33. When the project is completed, sufficient operational funds will be available for effective operation and maintenance of the facilities.
34. Funds received under this program will not be used to supplant other available non-Federal construction money.
35. The grantee shall conduct and submit a Feasibility of Construction report to the Department prior to commencing new construction demonstrating that
the area upon which the construction will take place is suitable for construction and will be able to sustain the new facility or addition.
Signature Of Authorized Representative

Date

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

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