Student Support Services Annual Performance Report

OMB Approval No: 1840-0525

Expiration Date: xx/xx/xxxx

Student Support Services Program

2009-2010 Annual Performance Report

Section I -- Project Identification, Certification and Warning

A. Identification

1. PR/Award Number: [will be pre-populated]___________________________________________

2. Name of Grantee Institution: [will be pre-populated]____________________________________

3. Address: ______________________________________________________________________

4. Name of Project Director: [will be pre-populated]______________________________________

5. Telephone Number: _____________________________________________________________

6. Fax and E-mail: ________________________________________________________________

6. Report Period: [will be pre-populated]

6. Project Characteristics

1. Has a Summer Bridge Program

_____Yes _____No

2. Uses Federal Grant Funds to Provide Grant Aid

_____Yes _____No

3. Receives institutional or other non-federal funds

_____Yes _____No

If yes, indicate the dollar amount for reporting period: ___________________________

6. Name of Data Entry Person: ______________________________________________________

10. Phone Number: ________________________ E-mail Address: ________________________

B. Certification: We certify that the performance report information reported and submitted electronically on __________ is readily verifiable. The information reported is accurate and complete to the best of our knowledge.

________________________________________ ______________________________________

Name of Project Director (Print) Name of Certifying Official (Print)

__________________________________ _________________________________

Signature and Date Signature and Date

C. Warnings: Any person who knowingly makes a false statement or misrepresentation on this report is subject to penalties which may include fines, imprisonment, or both, under the United States Criminal Code and 20 U.S.C. 1097. Further Federal funds or other benefits may be withheld under this program unless this report is completed and filed as required by existing law (20 U.S.C.) 1231a) and regulations (34 CFR 75.590 and 75.720).

Authority: Public Law 102-325, as amended.

Paperwork Reduction Act Notice

According to the Paperwork Reduction Act of 1995, 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 1840-0525 and expires XX/XX/XXXX. The time required to complete this information collection is estimated to average 6 hours per response, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection. Responses to this collection of information are required to maintain benefits. 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 the form, write directly to: Federal TRIO Programs, U.S. Department of Education, 1990 K Street, N.W., Suite 7000, Washington, D.C. 20006-8510.