Required Proprietary Institution Certification Form

OMB Control Number: 1840-NEW

Expiration Date: X/X/XXXX

Required Proprietary Institution Certification Form

Higher Education Emergency Relief Fund (HEERF) III

American Rescue Plan Act of 2021 (ARP)

Note: To receive funding under the ARP (a)(4) program, all proprietary institutions must complete and submit this form to assist with management and oversight.

Directions: Proprietary institution presidents or chief executive officers (CEOs) must complete the first certification and acknowledgement, and all owners that have at least a 25% interest in the institution must complete the second certification and acknowledgement. If no owners have at least a 25% interest in the institution, the institution president or CEO must certify to that effect.

Proprietary institutions that received an (a)(4) award under the Coronavirus Response and Relief Supplemental Appropriations Act, 2021 (CRRSAA) must email this completed form to [email protected]. Proprietary institutions that are applying for an ARP (a)(4) award for the first time must submit this document along with other required documents through the Grants.gov application process.

If the institution believes there is proprietary business information contained within this submission, it must indicate the specific information the institution considers proprietary in a cover attachment to this form.

Section 1: The institution’s president or CEO must provide the following certification and acknowledgement:

To the best of my knowledge and belief, I certify that (1) all information in this certification is true and correct, (2) all HEERF grant funds made available pursuant to the ARP (a)(4) ALN 84.425Q Supplemental Agreement (if receiving an (a)(4) supplemental grant award) or Certification and Agreement (if receiving a new (a)(4) grant award) will be distributed to students in accordance with the American Rescue Plan Act of 2021 (P.L. 117-2), the applicable laws, regulations, and terms and conditions described in my institution’s Supplemental Agreement or Certification and Agreement, and (3) my institution, on behalf of which the supplemental or new grant award was made, will remain in compliance with the terms and conditions of this grant described in the Supplemental Agreement or Certification and Agreement.

I acknowledge that failure to submit true and correct information, failure to distribute HEERF grant funds in accordance with the provisions described in the paragraph above, or failure to remain in compliance with the terms and conditions of this grant may result in liability under the False Claims Act, 31 U.S.C. § 3729, et seq.; OMB Guidelines to Agencies on Governmentwide Debarment and Suspension (Nonprocurement) in 2 C.F.R. part 180, as adopted and amended as regulations of the Department in 2 C.F.R. part 3485; and 18 U.S.C. § 1001, as appropriate, and/or other enforcement actions.

I acknowledge that any person who knowingly provides false or misleading information in this certification may be subject to a $250,000 fine per individual, a $500,000 fine per organization, and/or imprisonment up to five years under the provisions of 18 U.S.C. § 1001.

Name: _________________________________________

President or CEO Signature: _________________________________________

Phone: _________________________________________

Email: _________________________________________

Date: _________________________________________

DUNS Number: _________________________________________

OPE ID: _________________________________________

Section 2: Each owner that has at least a 25% interest in the institution, either directly or through their ownership interest in any entity (or entities) in the ownership chain, must provide the following certification and acknowledgement:

To the best of my knowledge and belief, I certify that (1) all information in this certification is true and correct, (2) all HEERF grant funds made available pursuant to the ARP (a)(4) ALN 84.425Q Supplemental Agreement (if receiving an (a)(4) supplemental grant award) or Certification and Agreement (if receiving a new (a)(4) grant award) will be distributed to students in accordance with the American Rescue Plan Act of 2021 (P.L. 117-2), the applicable laws, regulations, and terms and conditions described in my institution’s Supplemental Agreement or Certification and Agreement, and (3) my institution, on behalf of which the supplemental or new grant award was made, will remain in compliance with the terms and conditions of this grant described in the Supplemental Agreement or Certification and Agreement.

I acknowledge that failure to submit true and correct information, failure to distribute HEERF grant funds in accordance with the provisions described in the paragraph above, or failure to remain in compliance with the terms and conditions of this grant may result in liability under the False Claims Act, 31 U.S.C. § 3729, et seq.; OMB Guidelines to Agencies on Governmentwide Debarment and Suspension (Nonprocurement) in 2 C.F.R. part 180, as adopted and amended as regulations of the Department in 2 C.F.R. part 3485; and 18 U.S.C. § 1001, as appropriate, and/or other enforcement actions.

I acknowledge that any person who knowingly provides false or misleading information in this certification may be subject to a $250,000 fine per individual, a $500,000 fine per organization, and/or imprisonment up to five years under the provisions of 18 U.S.C. § 1001.

First Owner:

Indicate percentage owned: ______________

Print name of entity or individual: _________________________________________

If entity, name and title of entity’s authorized representative: _________________________________________

Signature of owner (individual or authorized representative): _________________________________________

Entity or individual’s address: _________________________________________

Entity Tax ID (if not an individual): _________________________________________

Phone: _________________________________________

Email: _________________________________________

Date: _________________________________________

Second Owner:

Indicate percentage owned: ______________

Print name of entity or individual: _________________________________________

If entity, name and title of entity’s authorized representative: _________________________________________

Signature of owner (individual or authorized representative): _________________________________________

Entity or individual’s address: _________________________________________

Entity Tax ID (if not an individual): _________________________________________

Phone: _________________________________________

Email: _________________________________________

Date: _________________________________________

Third Owner:

Indicate percentage owned: ______________

Print name of entity or individual: _________________________________________

If entity, name and title of entity’s authorized representative: _________________________________________

Signature of owner (individual or authorized representative): _________________________________________

Entity or individual’s address: _________________________________________

Entity Tax ID (if not an individual): _________________________________________

Phone: _________________________________________

Email: _________________________________________

Date: _________________________________________

Fourth Owner:

Indicate percentage owned: ______________

Print name of entity or individual: _________________________________________

If entity, name and title of entity’s authorized representative: _________________________________________

Signature of owner (individual or authorized representative): _________________________________________

Entity or individual’s address: _________________________________________

Entity Tax ID (if not an individual): _________________________________________

Phone: _________________________________________

Email: _________________________________________

Date: _________________________________________

If no owners have at least a 25% interest in the institution, the President or CEO must certify by checking the box and signing below:

☐

I hereby certify that there are no owners of this institution that have at least a 25% interest in the institution.

Name: _________________________________________

President or CEO Signature: _________________________________________

Phone: _________________________________________

Email: _________________________________________

Date: _________________________________________

Submission of Proprietary Information

FOIA exempts from mandatory disclosure any “trade secrets or commercial or financial information obtained from a person and privileged or confidential.” 5 U.S.C. 552(b)(4) (Exemption 4). In accordance with Exemption 4, the Department will maintain as confidential any documents submitted by you, or prepared by the institution, that are both customarily and actually treated as private by the institution, or closely held and not publicly disseminated. If you feel that some or all of this submission falls within the scope of Exemption 4 and is entitled to confidential treatment, you must indicate the specific information the institution considers proprietary in a cover attachment to this form. Please note that your designations of exempt material are not binding on the Department.

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-NEW. Public reporting burden for this collection of information is estimated to average 30 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 a benefit (ARP (Pub. L. 117-2)). 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.

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