InternetSafety_public libraries

INTERNET SAFETY CERTIFICATION FOR APPLICANT PUBLIC LIBRARIES,

PUBLIC ELEMENTARY AND SECONDARY SCHOOL LIBRARIES, and CONSORTIA WITH PUBLIC AND/OR PUBLIC SCHOOL LIBRARIES

As the duly authorized representative of the applicant library, I hereby certify that the library is (check only one of the following boxes)

A. 􀂉 CIPA Compliant (The applicant library has complied with the requirements of 20 U.S.C. § 9134(f).)

OR

B. 􀂉 The CIPA requirements do not apply because no funds made available under the LSTA Grants to States program are being used to purchase

computers to access the Internet or to pay for direct costs associated with accessing the Internet.

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Signature of Authorized Representative

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Printed Name of Authorized Representative

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Title of Authorized Representative

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Date

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Name of Applicant Library/Program

OMB No. 3137-0071; Expiration Date: XX/XX/XXXX