Higher Education Disaster Relief Pre-Application Form

OMB No.: 1840- ____

Form Expires __/__/2009

2009 HIGHER EDUCATION DISASTER RELIEF

PRE-APPLICATION INFORMATION

IHE seeking an award: __________________________________________________________

Location: State: ___________________ County: ___________________________________

Legal Address: _________________________________________________________________

______________________________________________________________________________

Contact person: Name ____________________________________________________

Title ____________________________________________________

Telephone ________________________________________________

Fax ______________________________________________________

E-mail ___________________________________________________

Briefly describe the extent of the impact on your institution of hurricanes, floods, or other natural disasters occurring in 2008. To what extent was the institution forced to close or relocate or to what extent did it have impaired operations as a result of damage directly caused by the 2008 natural disasters? ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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The amount of each Higher Education Disaster Relief award will be determined by a formula including the elements noted below and the number of Pell Grant recipients enrolled at the institution in FY 2008 (all references to fiscal years (FY) in this document refer to the applicant institution's fiscal years). This formula will be used to allocate an equitable proportion of available funds to each impacted institution. This application does not constitute a “claim” for a certain amount of funds.

Please fill in the following figures, rounding each to the nearest $1000:

1. Revenue lost by this institution in 2008 as a result of natural disasters:

$_______________

For the purposes of the Higher Education Disaster Relief awards, "lost revenue" includes decreased tuition and fees revenue in FY 2008 in comparison to the institution’s FY 2007 financial statements. The tuition and fees category includes all tuition and fees (net of refunds, bad debt estimates, and any discounts recognized) assessed for educational purposes. This is consistent with the definition used by the IPEDS Finance survey.

2. Expenses already incurred by the institution in remediation of the effects of 2008 natural disasters: $_______________

For the purposes of these awards, "expenses already incurred" is defined as expenses paid or accrued in 2008 as a direct consequence of hurricanes, floods, and other natural disasters. For example, you may include such expenses as cost of evacuation, temporary lodging, clean up, alternative facilities and operations, equipment repair and replacement, unusual personnel costs, etc.

3. Estimated construction costs to repair or replace campus buildings damaged by the natural disasters: $________________

For the purposes of these awards, "estimated construction costs" is defined as costs incurred, or reasonably expected to be incurred in the future, to repair or replace facilities damaged by hurricanes, floods, or other natural disasters, as calculated for a third party such as the Federal Emergency Management Administration, the state, or insurance claims. Do not include any expenses included in #2 above.

4. Please estimate how much of the expenses described in lines 1-3 above will be or has been reimbursed by insurance or other Federal agency, foundation or charitable outlays for disaster relief? $ _________________

For the purposes of these awards, "will be or has been reimbursed" is defined as payments received or expected to be received under a property, business continuity, or other applicable insurance policy or self-insurance arrangement, grants or other payments from Federal agencies, foundations, or charities intended to offset expenses or losses due to hurricane damages.

Note: Each applicant is required to retain the original documents supporting the information supplied here for the purpose of any future audits. Do not send those documents as part of your application for an award.

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 1840-_____. The time required to complete this information collection is estimated to average ____ hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4537. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Higher Education Disaster Relief Program, Room 6166, 1990 K St., N.W., Washington, D.C. 20006-8544.