Prison Education Program Application

OMB Control Number 1845-0171
Expiration 06/30/2026

Prison Education Program Supporting Documentation

Attachment 3 – Prison Education Program Assurances Certification
This form is to be completed by institutions of higher education or postsecondary vocational
institutions (institutions) applying to the Department of Education (Department) for approval of a
Prison Education Program (PEP) in collaboration with the appropriate State department of
corrections or other entity responsible for overseeing correctional facilities or the Federal Bureau
of Prisons, if applicable (Oversight entity). A separate form must be submitted as supporting
documentation for each PEP added via the Electronic Application to Participate in the Federal
Student Financial Aid Programs (E-App).

Institution name:
Institution OPEID:
Title of proposed PEP:

Oversight Entity name:
Oversight Entity contact person:
Name of Correctional Facility where proposed PEP will be offered:

Department of Education PEP Assurances Certification – Page 1 of 5

OMB Control Number 1845-0171
Expiration 06/30/2026
Institutional Assurances:

☐ By checking this box, I, the institution contact person submitting this form,
acknowledge and understand that that the Department can limit or terminate approval of
the institution to provide a PEP as described in 34 CFR § 668.240.

☐ By checking this box, I, the institution contact person submitting this form,
acknowledge and assure that the institution will provide the methodology by which the
oversight entity made each best interest determination for the PEP, as described in 34
CFR § 668.241(f).

☐ By checking this box, I, the institution contact person submitting this form,
acknowledge and assure that the institution will submit all required reports to the
Department as described in 34 CFR § 668.239.

Oversight Entity Assurances:

☐ By checking this box, I, the oversight entity contact person, verify that the
institution has approval to operate this proposed program in the correctional facility
identified above as required by 34 CFR § 668.236(a)(2).

☐ By checking this box, I, the oversight entity contact person, acknowledge and assure
that the oversight entity will provide the required best interest of students’ determination
of this proposed program:
(1) Through a feedback process that considers input from relevant stakeholders
and in light of the totality of the circumstances as described in 34 CFR §
668.241(b);
(2) Considering the required information described in 34 CFR § 668.241(a)(1);
(3) At the time intervals specified in 34 CFR § 668.241(d) and (e); and
(4) By submitting it to the Department no later than 30 days following the
determination.

☐ By checking this box, I, the oversight entity contact person, acknowledge and assure
that the oversight entity will allow programs to re-apply within a reasonable timeframe if
we determine the program is not operating in the best interest of students as required by
34 CFR § 668.241(c).

Department of Education PEP Assurances Certification – Page 2 of 5

OMB Control Number 1845-0171
Expiration 06/30/2026

☐ By checking this box, I, the oversight entity contact person, acknowledge and
assure that the oversight entity will maintain an agreement to provide transfer and
release data with the institution during the existence of the PEP.

Department of Education PEP Assurances Certification – Page 3 of 5

OMB Control Number 1845-0171
Expiration 06/30/2026
Institutional Certification:
To the best of my knowledge and belief, I certify that all information and
representations in this PEP and all supporting documentation is true and correct,
and the institution on behalf of which I make this attestation will remain in
compliance with the PEP program requirements.
I further acknowledge that failure to submit true and correct information, failure to
follow all PEP requirements, or failure to remain in compliance with the terms and
conditions of the PEP program 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.
Name:
Signature:
Date:
Oversight Entity Certification:
To the best of my knowledge and belief, I certify that my assurances made above
and any additional representations made by me on behalf of the oversight entity in
any supporting documentation is true and correct, and the oversight entity on
behalf of which I make this attestation will remain in compliance with the PEP
program requirements.
I further acknowledge that failure to submit true and correct information, failure to
follow all PEP requirements, or failure to remain in compliance with the terms and
conditions of the PEP program 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.
Name:
Signature:
Date:

Department of Education PEP Assurances Certification– Page 4 of 5

OMB Control Number 1845-0171
Expiration 06/30/2026

Paperwork Burden Statement
According to the Paperwork Reduction Act of 1995, 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 1845-0171. Public reporting burden for this collection of
information is estimated to average 10 hours 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 benefit (Free Application For Federal Student Aid Simplification Act (Title VII, Division FF of
P.L. 116-260)). If you have any comments concerning the accuracy of the time estimate, suggestions
for improving this individual collection, please send an email to: [email protected].
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 applicant, that are both customarily and actually treated as private by the
applicant, 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 applicant or grantee considers proprietary in a cover attachment to this form.
Please note that your designations of exempt material are not binding on the Department.

Department of Education PEP Assurances Certification – Page 5 of 5