Grant Package Forms

OMB Number: 4040-0004
Expiration Date: 03/31/2012

Application for Federal Assistance SF-424
* 1. Type of Submission:

* 2. Type of Application:

Preapplication

New

Application

Continuation

Changed/Corrected Application

Revision

* 3. Date Received:

* If Revision, select appropriate letter(s):

* Other (Specify):

4. Applicant Identifier:

Completed by Grants.gov upon submission.

5a. Federal Entity Identifier:

* 5b. Federal Award Identifier:

State Use Only:
6. Date Received by State:

7. State Application Identifier:

8. APPLICANT INFORMATION:
* a. Legal Name:
* b. Employer/Taxpayer Identification Number (EIN/TIN):

* c. Organizational DUNS:

d. Address:
* Street1:
Street2:
* City:
County/Parish:
* State:
Province:

USA: UNITED STATES

* Country:
* Zip / Postal Code:

e. Organizational Unit:
Department Name:

Division Name:

f. Name and contact information of person to be contacted on matters involving this application:
Prefix:

* First Name:

Middle Name:
* Last Name:
Suffix:
Title:
Organizational Affiliation:

* Telephone Number:
* Email:

Fax Number:

Application for Federal Assistance SF-424
9. Type of Applicant 1: Select Applicant Type:

Type of Applicant 2: Select Applicant Type:

Type of Applicant 3: Select Applicant Type:

* Other (specify):

* 10. Name of Federal Agency:

11. Catalog of Federal Domestic Assistance Number:

CFDA Title:

* 12. Funding Opportunity Number:

* Title:

13. Competition Identification Number:

Title:

14. Areas Affected by Project (Cities, Counties, States, etc.):

Add Attachment

* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.

Add Attachments

Delete Attachments

View Attachments

Delete Attachment

View Attachment

Application for Federal Assistance SF-424
16. Congressional Districts Of:
* a. Applicant

* b. Program/Project

Attach an additional list of Program/Project Congressional Districts if needed.

Add Attachment

Delete Attachment

View Attachment

17. Proposed Project:
* a. Start Date:

* b. End Date:

18. Estimated Funding ($):
* a. Federal
* b. Applicant
* c. State
* d. Local
* e. Other
* f. Program Income
* g. TOTAL

* 19. Is Application Subject to Review By State Under Executive Order 12372 Process?

a. This application was made available to the State under the Executive Order 12372 Process for review on

.

b. Program is subject to E.O. 12372 but has not been selected by the State for review.
c. Program is not covered by E.O. 12372.
* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.)

Yes

No

If "Yes", provide explanation and attach
Add Attachment

Delete Attachment

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21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements
herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to
comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may
subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)

** I AGREE
** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency
specific instructions.

Authorized Representative:
Prefix:

* First Name:

Middle Name:
* Last Name:
Suffix:
* Title:
* Telephone Number:

Fax Number:

* Email:
* Signature of Authorized Representative:

Completed by Grants.gov upon submission.

* Date Signed:

Completed by Grants.gov upon submission.

SUPPLEMENTAL INFORMATION
REQUIRED FOR
DEPARTMENT OF EDUCATION
1. Project Director:
Prefix:

*First Name:

Middle Name:

*Last Name:

Suffix:

Address:
* Street1:
Street2:
* City:
County:
* State

* Zip Code:

* Phone Number (give area code)

* Country:

Fax Number (give area code)

Email Address:

2. Applicant Experience:
Novice Applicant

Yes

No

Not applicable to this program

3. Human Subjects Research:
Are any research activities involving human subjects planned at any time during the
proposed project Period?
Yes

No

Are ALL the research activities proposed designated to be exempt from the regulations?
Yes

Provide Exemption(s) #:

No

Provide Assurance #, if available:

Please attach an explanation Narrative:
Add Attachment

Delete Attachment

View Attachment

OMB Control No. 1894-0007
Expiration Date: 05/31/2011

U.S. DEPARTMENT OF EDUCATION
BUDGET INFORMATION
NON-CONSTRUCTION PROGRAMS

OMB Control Number: 1894-0008
Expiration Date: 02/28/2011

Applicants requesting funding for only one year should complete the column under
"Project Year 1." Applicants requesting funding for multi-year grants should complete all
applicable columns. Please read all instructions before completing form.

Name of Institution/Organization

SECTION A - BUDGET SUMMARY
U.S. DEPARTMENT OF EDUCATION FUNDS
Budget Categories

Project Year 1
(a)

Project Year 2
(b)

Project Year 3
(c)

Project Year 4
(d)

Project Year 5
(e)

Total
(f)

1. Personnel
2. Fringe Benefits
3. Travel
4. Equipment
5. Supplies
6. Contractual
7. Construction
8. Other
9. Total Direct Costs (lines 1-8)
10. Indirect Costs*
11. Training Stipends
12. Total Costs (lines 9-11)
*Indirect Cost Information (To Be Completed by Your Business Office):
If you are requesting reimbursement for indirect costs on line 10, please answer the following questions:
(1)

Do you have an Indirect Cost Rate Agreement approved by the Federal government? ____Yes ____ No

(2)

If yes, please provide the following information:
Period Covered by the Indirect Cost Rate Agreement: From: ___/___/______ To: ___/___/______ (mm/dd/yyyy)
Approving Federal agency: ____ ED

(3)

____ Other (please specify): __________________________ The Indirect Cost Rate is _________%

For Restricted Rate Programs (check one) -- Are you using a restricted indirect cost rate that:
___ Is included in your approved Indirect Cost Rate Agreement? or ___ Complies with 34 CFR 76.564(c)(2)? The Restricted Indirect Cost Rate is _________%

ED 524

Name of Institution/Organization

Applicants requesting funding for only one year should complete the column under
"Project Year 1." Applicants requesting funding for multi-year grants should complete all
applicable columns. Please read all instructions before completing form.
SECTION B - BUDGET SUMMARY
NON-FEDERAL FUNDS

Budget Categories

Project Year 1
(a)

Project Year 2
(b)

Project Year 3
(c)

Project Year 4
(d)

1. Personnel
2. Fringe Benefits
3. Travel
4. Equipment
5. Supplies
6. Contractual
7. Construction
8. Other
9. Total Direct Costs
(Lines 1-8)
10. Indirect Costs
11. Training Stipends
12. Total Costs
(Lines 9-11)

SECTION C – BUDGET NARRATIVE (see instructions)
ED 524

Project Year 5
(e)

Total
(f)

Instructions for ED 524
General Instructions
This form is used to apply to individual U.S. Department of Education
(ED) discretionary grant programs. Unless directed otherwise, provide
the same budget information for each year of the multi-year funding
request. Pay attention to applicable program specific instructions, if
attached. You may access the Education Department General
Administrative Regulations, 34 CFR 74 – 86 and 97-99, on ED’s
website at:
http://www.ed.gov/policy/fund/reg/edgarReg/edgar.html
You must consult with your Business Office prior to submitting
this form.
Section A - Budget Summary
U.S. Department of Education Funds
All applicants must complete Section A and provide a break-down by
the applicable budget categories shown in lines 1-11.
Lines 1-11, columns (a)-(e): For each project year for which funding
is requested, show the total amount requested for each applicable
budget category.
Lines 1-11, column (f): Show the multi-year total for each budget
category. If funding is requested for only one project year, leave this
column blank.

Cost Rate Agreement or whether you are using a restricted indirect
cost rate that complies with 34 CFR 76.564(c)(2). Note: State or
Local government agencies may not use the provision for a restricted
indirect cost rate specified in 34 CFR 76.564(c)(2). Check only one
response. Leave blank, if this item is not applicable.
Section B - Budget Summary
Non-Federal Funds

Indirect Cost Information: If you are requesting reimbursement for
indirect costs on line 10, this information is to be completed by your
Business Office. (1): Indicate whether or not your organization has an
Indirect Cost Rate Agreement that was approved by the Federal
government.
If you checked “no,” ED generally will authorize grantees to use a
temporary rate of 10 percent of budgeted salaries and wages subject to
the following limitations:
(a) The grantee must submit an indirect cost proposal to its
cognizant agency within 90 days after ED issues a grant award
notification; and
(b) If after the 90-day period, the grantee has not submitted
an indirect cost proposal to its cognizant agency, the grantee may not
charge its grant for indirect costs until it has negotiated an indirect
cost rate agreement with its cognizant agency.
(2): If you checked “yes” in (1), indicate in (2) the
beginning and ending dates covered by the Indirect Cost Rate
Agreement. In addition, indicate whether ED, another Federal agency
(Other) or State agency issued the approved agreement. If you check
“Other,” specify the name of the Federal or other agency that issued
the approved agreement.
(3): If you are applying for a grant under a Restricted Rate
Program (34 CFR 75.563 or 76.563), indicate whether you are using a
restricted indirect cost rate that is included on your approved Indirect

3.

If applicable to this program, provide the rate and base on which
fringe benefits are calculated.

4.

If you are requesting reimbursement for indirect costs on line
10, this information is to be completed by your Business Office.
Specify the estimated amount of the base to which the indirect
cost rate is applied and the total indirect expense. Depending on
the grant program to which you are applying and/or your
approved Indirect Cost Rate Agreement, some direct cost budget
categories in your grant application budget may not be included
in the base and multiplied by your indirect cost rate. For
example, you must multiply the indirect cost rates of “Training
grants" (34 CFR 75.562) and grants under programs with
“Supplement not Supplant” requirements ("Restricted Rate"
programs) by a “modified total direct cost” (MTDC) base (34
CFR 75.563 or 76.563). Please indicate which costs are
included and which costs are excluded from the base to which
the indirect cost rate is applied.

If you are required to provide or volunteer to provide cost-sharing or
matching funds or other non-Federal resources to the project, these
should be shown for each applicable budget category on lines 1-11 of
Section B.
Lines 1-11, columns (a)-(e): For each project year, for which
matching funds or other contributions are provided, show the total
contribution for each applicable budget category.
Lines 1-11, column (f): Show the multi-year total for each budget
category. If non-Federal contributions are provided for only one year,
leave this column blank.

When calculating indirect costs (line 10) for "Training grants" or
grants under "Restricted Rate" programs, you must refer to the
information and examples on ED’s website at:
http://www.ed.gov/fund/grant/apply/appforms/appforms.html.

Line 12, columns (a)-(e): Show the total matching or other
contribution for each project year.
Line 12, column (f): Show the total amount to be contributed for all
years of the multi-year project. If non-Federal contributions are
provided for only one year, leave this space blank.

Line 12, columns (a)-(e): Show the total budget request for each
project year for which funding is requested.
Line 12, column (f): Show the total amount requested for all project
years. If funding is requested for only one year, leave this space
blank.

cost principle circulars are available on OMB’s website at:
http://www.whitehouse.gov/omb/circulars/index.html]

You may also contact (202) 377-3838 for additional information
regarding calculating indirect cost rates or general indirect cost
rate information.

Section C - Budget Narrative [Attach separate sheet(s)]
Pay attention to applicable program specific instructions,
if attached.
5.
1.

2.

Provide an itemized budget breakdown, and justification by
project year, for each budget category listed in Sections A and
B. For grant projects that will be divided into two or more
separately budgeted major activities or sub-projects, show for
each budget category of a project year the breakdown of the
specific expenses attributable to each sub-project or activity.

For non-Federal funds or resources listed in Section B that are
used to meet a cost-sharing or matching requirement or provided
as a voluntary cost-sharing or matching commitment, you must
include:

a. The specific costs or contributions by budget category;
b. The source of the costs or contributions; and
c. In the case of third-party in-kind contributions, a description
of how the value was determined for the donated or contributed
goods or services.

[Please review ED’s general cost sharing and matching
regulations, which include specific limitations, in 34 CFR 74.23,
applicable to non-governmental entities, and 80.24, applicable to
governments, and the applicable Office of Management and
Budget (OMB) cost principles for your entity type regarding
donations, capital assets, depreciation and use allowances. OMB

Provide other explanations or comments you deem necessary.
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 1894-0008. The
time required to complete this information collection is estimated to
vary from 13 to 22 hours per response, with an average of 17.5 hours
per response, including the time to review instructions, search existing
data sources, 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
(insert program office), U.S. Department of Education, 400 Maryland
Avenue, S.W., Washington, D.C. 20202.

OMB Approval No. 0348-0040

ASSURANCES - NON-CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average 15 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. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.
SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
NOTE: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the
awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such
is the case, you will be notified.
As the duly authorized representative of the applicant, I certify that the applicant:
1.

Has the legal authority to apply for Federal assistance
and the institutional, managerial and financial capability
(including funds sufficient to pay the non-Federal share
of project cost) to ensure proper planning, management
and completion of the project described in this
application.

2.

Will give the awarding agency, the Comptroller General
of the United States and, if appropriate, the State,
through any authorized representative, access to and
the right to examine all records, books, papers, or
documents related to the award; and will establish a
proper accounting system in accordance with generally
accepted accounting standards or agency directives.

3.

Will establish safeguards to prohibit employees from
using their positions for a purpose that constitutes or
presents the appearance of personal or organizational
conflict of interest, or personal gain.

4.

Will initiate and complete the work within the applicable
time frame after receipt of approval of the awarding
agency.

5.

Will comply with the Intergovernmental Personnel Act of
1970 (42 U.S.C. §§4728-4763) relating to prescribed
standards for merit systems for programs funded under
one of the 19 statutes or regulations specified in
Appendix A of OPM's Standards for a Merit System of
Personnel Administration (5 C.F.R. 900, Subpart F).

6.

Will comply with all Federal statutes relating to
nondiscrimination. These include but are not limited to:
(a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352)
which prohibits discrimination on the basis of race, color
or national origin; (b) Title IX of the Education
Amendments of 1972, as amended (20 U.S.C. §§16811683, and 1685-1686), which prohibits discrimination on
the basis of sex; (c) Section 504 of the Rehabilitation

Act of 1973, as amended (29 U.S.C. §794), which
prohibits discrimination on the basis of handicaps; (d)
the Age Discrimination Act of 1975, as amended (42
U.S.C. §§6101-6107), which prohibits discrimination
on the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.L. 92-255), as amended,
relating to nondiscrimination on the basis of drug
abuse; (f) the Comprehensive Alcohol Abuse and
Alcoholism Prevention, Treatment and Rehabilitation
Act of 1970 (P.L. 91-616), as amended, relating to
nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) §§523 and 527 of the Public Health
Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee3), as amended, relating to confidentiality of alcohol
and drug abuse patient records; (h) Title VIII of the
Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as
amended, relating to nondiscrimination in the sale,
rental or financing of housing; (i) any other
nondiscrimination provisions in the specific statute(s)
under which application for Federal assistance is being
made; and, (j) the requirements of any other
nondiscrimination statute(s) which may apply to the
application.
7.

Will comply, or has already complied, with the
requirements of Titles II and III of the Uniform
Relocation Assistance and Real Property Acquisition
Policies Act of 1970 (P.L. 91-646) which provide for
fair and equitable treatment of persons displaced or
whose property is acquired as a result of Federal or
federally-assisted programs. These requirements apply
to all interests in real property acquired for project
purposes regardless of Federal participation in
purchases.

8.

Will comply, as applicable, with provisions of the
Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328)
which limit the political activities of employees whose
principal employment activities are funded in whole or
in part with Federal funds.

Previous Edition Usable

Standard Form 424B (Rev. 7-97)

Authorized for Local Reproduction

Prescribed by OMB Circular A-102

9.

10.

11.

Will comply, as applicable, with the provisions of the DavisBacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act
(40 U.S.C. §276c and 18 U.S.C. §874), and the Contract
Work Hours and Safety Standards Act (40 U.S.C. §§327333), regarding labor standards for federally-assisted
construction subagreements.
Will comply, if applicable, with flood insurance purchase
requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234) which requires
recipients in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of
insurable construction and acquisition is $10,000 or more.
Will comply with environmental standards which may be
prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National
Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating
facilities pursuant to EO 11738; (c) protection of wetlands
pursuant to EO 11990; (d) evaluation of flood hazards in
floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved State management
program developed under the Coastal Zone Management
Act of 1972 (16 U.S.C. §§1451 et seq.); (f) conformity of
Federal actions to State (Clean Air) Implementation Plans
under Section 176(c) of the Clean Air Act of 1955, as
amended (42 U.S.C. §§7401 et seq.); (g) protection of
underground sources of drinking water under the Safe
Drinking Water Act of 1974, as amended (P.L. 93-523);
and, (h) protection of endangered species under the
Endangered Species Act of 1973, as amended (P.L. 93205).

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

APPLICANT ORGANIZATION

12.

Will comply with the Wild and Scenic Rivers Act of
1968 (16 U.S.C. §§1271 et seq.) related to protecting
components or potential components of the national
wild and scenic rivers system.

13.

Will assist the awarding agency in assuring compliance
with Section 106 of the National Historic Preservation
Act of 1966, as amended (16 U.S.C. §470), EO 11593
(identification and protection of historic properties), and
the Archaeological and Historic Preservation Act of
1974 (16 U.S.C. §§469a-1 et seq.).

14.

Will comply with P.L. 93-348 regarding the protection of
human subjects involved in research, development, and
related activities supported by this award of assistance.

15.

Will comply with the Laboratory Animal Welfare Act of
1966 (P.L. 89-544, as amended, 7 U.S.C. §§2131 et
seq.) pertaining to the care, handling, and treatment of
warm blooded animals held for research, teaching, or
other activities supported by this award of assistance.

16.

Will comply with the Lead-Based Paint Poisoning
Prevention Act (42 U.S.C. §§4801 et seq.) which
prohibits the use of lead-based paint in construction or
rehabilitation of residence structures.

17.

Will cause to be performed the required financial and
compliance audits in accordance with the Single Audit
Act Amendments of 1996 and OMB Circular No. A-133,
"Audits of States, Local Governments, and Non-Profit
Organizations."

18.

Will comply with all applicable requirements of all other
Federal laws, executive orders, regulations, and policies
governing this program.

TITLE

DATE SUBMITTED

Standard Form 424B (Rev. 7-97) Back

DISCLOSURE OF LOBBYING ACTIVITIES

Approved by OMB

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
0348-0046
(See reverse for public burden disclosure.)
1. Type of Federal Action:
2. Status of Federal Action:
3. Report Type:
a. contract
a. bid/offer/application
a. initial filing
b. grant
b. initial award
b. material change
c. cooperative agreement
c. post-award
For Material Change Only:
d. loan
year _________ quarter _________
e. loan guarantee
date of last report ______________
f. loan insurance
4. Name and Address of Reporting Entity:
5. If Reporting Entity in No. 4 is a Subawardee, Enter Name
Subawardee
and Address of Prime:
Prime
Tier ______, if known :

Congressional District, if known :
6. Federal Department/Agency:

Congressional District, if known :
7. Federal Program Name/Description:

CFDA Number, if applicable : _____________
8. Federal Action Number, if known :

9. Award Amount, if known :
$

10. a. Name and Address of Lobbying Registrant
( if individual, last name, first name, MI ):

b. Individuals Performing Services (including address if
different from No. 10a )
( last name, first name, MI ):

requested through this form is authorized by title 31 U.S.C. section
11. Information
1352. This disclosure of lobbying activities is a material representation of fact

Signature:

upon which reliance was placed by the tier above when this transaction was made
or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This
information will be reported to the Congress semi-annually and will be available for
public inspection. Any person who fails to file the required disclosure shall be
subject to a civil penalty of not less that $10,000 and not more than $100,000 for
each such failure.

Federal Use Only:

Print Name:
Title:
Telephone No.: _______________________ Date:
Authorized for Local Reproduction
Standard Form LLL (Rev. 7-97)

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal
action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make
payment to any lobbying entity for influencing or attempting to influence an officer or employeeof any agency, a Member of Congress, an officer or employee of
Congress, or an employeeof a Member of Congress in connection with a covered Federal action. Complete all items that apply for both the initial filing and material
change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.

1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information previously reported, enter
the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal
action.
4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriateclassification
of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee,e.g., the first subawardee
of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.
5. If the organization filing the report in item 4 checks "Subawardee," then enter the full name, address, city, State and zip code of the prime Federal
recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizationallevel below agency name, if known. For
example, Department of Transportation, United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance
(CFDA) number for grants, cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number;
Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number
assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan
commitment for the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting
entity identified in item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and
Middle Initial (MI).
11. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control
Number. The valid OMB control number for this information collection is OMB No. 0348-0046. Public reporting burden for this collection of information is
estimated to average 10 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. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington,
DC 20503.

Certification of Eligibility for Federal Assistance in Certain Programs
I understand that 34 CFR 75.60, 75.61, and 75.62 require that I make specific certifications of eligibility to the U.S. Department of
Education (ED) as a condition of applying for Federal funds in certain programs and that these requirements are in addition to any other
eligibility requirements that ED imposes under program regulations. Under 34 CFR 75.60 – 75.62:
I.

I certify that:
A.

I do not owe a debt, or I am current in repaying a debt, or I am not in default (as that term is used at 34 CFR Part 668) on a
debt:
1.

To the Federal Government under a nonprocurement transaction (e.g., a previous loan, scholarship, grant, or
cooperative agreement); or

2.

For a fellowship, scholarship, stipend, discretionary grant, or loan in any program of ED that is subject to
34 CFR 75.60, 75.61, and 75.62, including:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Federal Pell Grant Program (20 U.S.C. 1070a, et seq.);
Federal Supplemental Educational Opportunity Grant (SEOG) Program (20 U.S.C. 1070(b), et seq.):
State Student Incentive Grant Program (SSIG) 20 U.S.C. 1070c, et seq.);
Federal Perkins Loan Program (20 U.S.C. 1087aa, et seq.);
Income Contingent Direct Loan Demonstration Project (20 U.S.C. 1087a, note);
Federal Stafford Loan Program, Federal Supplemental Loans for Students [SLS], Federal PLUS, or Federal
Consolidation Loan Program (20 U.S.C. 1071, et seq.);
William D. Ford Federal Direct Loan Program (20 U.S.C. 1087a, et. seq.);
Cuban Student Loan Program (20 U.S.C. 2601, et seq.);
Robert C. Byrd Honors Scholarship Program (20 U.S.C. 1070d-31, et seq.);
Jacob K. Javits Fellows Program (20 U.S.C. 1134h-1134l);
Patricia Roberts Harris Fellowship Program (20 U.S.C. 1134d-1134g);
Christa McAuliffe Fellowship Program (20 U.S.C. 1105-1105i);
Bilingual Education Fellowship Program (20 U.S.C. 3221-3262);
Rehabilitation Long-Term Training Program (29 U.S.C. 774(b));
Paul Douglas Teacher Scholarship Program (20 U.S.C. 1104, et seq.);
Law Enforcement Education Program (42 U.S.C. 3775);
Indian Fellowship Program (29 U.S.C. 774(b));
Teacher Quality Enhancement Grants Program (20 U.S.C. 1021, et seq.);

OR
B.
II.

I have made arrangements satisfactory to ED to repay a debt as described in A.1. or A.2. (above) on which I had not been
current in repaying or on which I was in default (as that term is used in 34 CFR Part 668).

I certify also that I have not been declared by a judge, as a condition of sentencing under section 5301 of the Anti-Drug Abuse
Act of 1988 (21 U.S.C. 862), ineligible to receive Federal assistance for the period of this requested funding.

I understand that providing a false certification to any of the statements above makes me liable for repayment to ED for funds received on
the basis of this certification, for civil penalties, and for criminal prosecution under 18 U.S.C. 1001.
____________________________________________
(Signature)

____________________________________
(Date)

____________________________________________
(Typed or Printed Name)
Name or number of ED program under which this certification is being made: _____________________________
ED 80-0016 (Revised 2/01)

SURVEY ON ENSURING EQUAL OPPORTUNITY FOR APPLICANTS
OMB NO. 1894-0010 EXP. 05/31/2012

Purpose: The Federal government is committed to ensuring that all qualified applicants, small or large, non-religious or faithbased, have an equal opportunity to compete for Federal funding. In order for us to better understand the population of applicants
for Federal funds, we are asking nonprofit private organizations (not including private universities) to fill out this survey.
Upon receipt, the survey will be separated from the application. Information provided on the survey will not be considered in any
way in making funding decisions and will not be included in the Federal grants database. While your help in this data collection
process is greatly appreciated, completion of this survey is voluntary.
Instructions for Submitting the Survey: If you are applying using a hard copy application, please place the completed survey in an
envelope labeled “Applicant Survey.” Seal the envelope and include it along with your application package. If you are applying
electronically, please submit this survey along with your application.

Applicant’s (Organization) Name: ______________________________________________________________
Applicant’s DUNS Number: ___________________________________________________________________
Federal Program: __________________________________________________CFDA Number: ___________

1. Has the applicant ever received a grant or
contract from the Federal government?
Yes

No

2. Is the applicant a faith-based organization?
Yes

No

6. How many full-time equivalent employees does
the applicant have? (Check only one box).
3 or Fewer

15-50

4-5

51-100

6-14

over 100

7. What is the size of the applicant’s annual budget?
(Check only one box.)

3. Is the applicant a secular organization?
Less Than $150,000
Yes

No
$150,000 - $299,999

4. Does the applicant have 501(c)(3) status?
Yes

No

5. Is the applicant a local affiliate of a national
organization?
Yes

No

$300,000 - $499,999
$500,000 - $999,999
$1,000,000 - $4,999,999
$5,000,000 or more

Survey Instructions on Ensuring Equal Opportunity for Applicants
Provide the applicant’s (organization)
name and DUNS number and the
grant name and CFDA number.
Paperwork Burden Statement
1. Self-explanatory.
2. Self-identify.
3. Self-identify.
4. 501(c)(3) status is a legal designation
provided on application to the Internal
Revenue
Service
by
eligible
organizations. Some grant programs
may require nonprofit applicants to
have 501(c)(3) status. Other grant
programs do not.
5. Self-explanatory.
6. For
example,
two
part-time
employees who each work half-time
equal one full-time equivalent
employee. If the applicant is a local
affiliate of a national organization, the
responses to survey questions 2 and 3
should reflect the staff and budget
size of the local affiliate.

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 1890-0014. The
time required to complete this information
collection is estimated to average five (5)
minutes 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: The Agency
Contact listed in this grant application
package.

7. Annual budget means the amount of
money your organization spends each
year on all of its activities.
OMB No. 1894-0010 Exp. 05/31/2012

CERTIFICATION REGARDING LOBBYING
Certification for Contracts, Grants, Loans, and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any
person for influencing or attempting to influence an officer or employee of an agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with
the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the
entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or
modification of any Federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal
contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard
Form-LLL, ''Disclosure of Lobbying Activities,'' in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award documents
for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and
cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification
is a material representation of fact upon which reliance was placed when this transaction was made or
entered into. Submission of this certification is a prerequisite for making or entering into this transaction
imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be
subject to a civil penalty of not less than $10,00 0 and not more than $100,000 for each such failure.
Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that:
If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer
or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of
a Member of Congress in connection with this commitment providing for the United States to insure or
guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, ''Disclosure of Lobbying
Activities,'' in accordance with its instructions. Submission of this statement is a prerequisite for making or
entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the
required statement shall be subjec t to a civil penalty of not less than $10,000 and not more than $100,000
for each such failure.

* APPLICANT'S ORGANIZATION

* PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
Prefix:

* First Name:

Middle Name:
Suffix:

* Last Name:
* Title:
* SIGNATURE:

* DATE: