Impact Aid Discretionary Grant Application

F orm Approved:

– OMB number: 1810-xxxx

– 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

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 8007(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