This is a standard form required for use as a cover sheet for submission of pre-applications and applications and related information under discretionary programs. Some of the items are required and some are optional at the discretion of the applicant or the federal agency (agency). Required fields on the form are identified with an asterisk (*) and are also specified as “Required” in the instructions below. In addition to these instructions, applicants must consult agency instructions to determine other specific requirements.
1. Type of Submission: (Required) Select one type of submission in accordance with agency instructions.
Pre-application
Application
Changed/Corrected Application – Check if this submission is to change or correct a previously submitted application. Unless requested by the agency, applicants may not use this form to submit changes after the closing date.
2. Type of Application: (Required) Select one type of application in accordance with agency instructions.
New – An application that is being submitted to an agency for the first time.
Continuation - An extension for an additional funding/budget period for a project with a projected completion date. This can include renewals.
Revision - Any change in the federal government’s financial obligation or contingent liability from an existing obligation. If a revision, enter the appropriate letter(s). More than one may be selected. If "Other" is selected, please specify in text box provided.
Increase Award
Decrease Award
Increase Duration
Decrease Duration
Other (specify)
3. Date Received: Leave this field blank. This date will be assigned by the Federal agency.
4. Applicant Identifier: Enter the entity identifier assigned by the Federal agency, if any, or the applicant’s control number if applicable.
5a. Federal Entity Identifier: Enter the number assigned to your organization by the federal agency, if any.
5b. Federal Award Identifier: For new applications leave blank. For a continuation or revision to an existing award, enter the previously assigned federal award identifier number. If a changed/corrected application, enter the federal identifier in accordance with agency instructions.
6. Date Received by State: Leave this field blank. This date will be assigned by the state, if applicable.
7. State Application Identifier: Leave this field blank. This identifier will be assigned by the state, if applicable.
8. Applicant Information: Enter the following in accordance with agency instructions:
a. Legal Name: (Required) Enter the legal name of applicant that will undertake the assistance activity. This is the organization that has registered with the Central Contractor Registry (CCR). Information on registering with CCR may be obtained by visiting www.Grants.gov.
b. Employer/Taxpayer Number (EIN/TIN): (Required) Enter the employer or taxpayer identification number (EIN or TIN) as assigned by the Internal Revenue Service. If your organization is not in the US, enter 44-4444444.
c. Organizational DUNS: (Required) Enter the organization’s DUNS or DUNS+4 number received from Dun and Bradstreet. Information on obtaining a DUNS number may be obtained by visiting www.Grants.gov.
d. Address: Enter address: Street 1 (Required); city (Required); County/Parish, State (Required if country is US), Province, Country (Required), 9-digit zip/postal code (Required if country US).
e. Organizational Unit: Enter the name of the primary organizational unit, department or division that will undertake the assistance activity.
f. Name and contact information of person to be contacted on matters involving this application: Enter the first and last name (Required); prefix, middle name, suffix, title. Enter organizational affiliation if affiliated with an organization other than that in 7.a. Telephone number and email (Required); fax number.
9. Type of Applicant: (Required) Select up to three applicant type(s) in accordance with agency instructions.
A. State Government
B. County Government
C. City or Township Government
D. Special District Government
E. Regional Organization
F. U.S. Territory or Possession
G. Independent School District
H. Public/State Controlled Institution of Higher Education
I. Indian/Native American Tribal Government (Federally Recognized)
J. Indian/Native American Tribal Government (Other than Federally Recognized)
K. Indian/Native American Tribally Designated Organization
L. Public/Indian Housing Authority
M. Nonprofit
N. Private Institution of Higher Education
O. Individual
P. For-Profit Organization (Other than Small Business)
Q. Small Business
R. Hispanic-serving Institution
S. Historically Black Colleges and Universities (HBCUs)
T. Tribally Controlled Colleges and Universities (TCCUs)
U. Alaska Native and Native Hawaiian Serving Institutions
V. Non-US Entity
W. Other (specify)
10. Name Of Federal Agency: (Required) Enter the name of the federal agency from which assistance is being requested with this application.
11. Catalog Of Federal Domestic Assistance Number/Title: Enter the Catalog of Federal Domestic Assistance number and title of the program under which assistance is requested, as found in the program announcement, if applicable.
12. Funding Opportunity Number/Title: (Required) Enter the Funding Opportunity Number and title of the opportunity under which assistance is requested, as found in the program announcement.
13. Competition Identification Number/Title: Enter the competition identification number and title of the competition under which assistance is requested, if applicable.
14. Areas Affected By Project: This data element is intended for use only by programs for which the area(s) affected are likely to be different than the place(s) of performance reported on the SF-424 Project/Performance Site Location(s) Form. Add attachment to enter additional areas, if needed.
15. Descriptive Title of Applicant’s Project: (Required) Enter a brief descriptive title of the project. If appropriate, attach a map showing project location (e.g., construction or real property projects). For pre-applications, attach a summary description of the project.
16. Congressional Districts Of: 15a. (Required) Enter the applicant’s congressional district. 15b. Enter all district(s) affected by the program or project. Enter in the format: 2 characters state abbreviation – 3 characters district number, e.g., CA-005 for California 5th district, CA-012 for California 12 district, NC-103 for North Carolina’s 103 district. If all congressional districts in a state are affected, enter “all” for the district number, e.g., MD-all for all congressional districts in Maryland. If nationwide, i.e. all districts within all states are affected, enter US-all. If the program/project is outside the US, enter 00-000. This optional data element is intended for use only by programs for which the area(s) affected are likely to be different than place(s) of performance reported on the SF-424 Project/Performance Site Location(s) Form. Attach an additional list of program/project congressional districts, if needed.
17. Proposed Project Start and End Dates: (Required) Enter the proposed start date and end date of the project.
18. Estimated Funding: (Required) Enter the amount requested, or to be contributed during the first funding/budget period by each contributor. Value of in-kind contributions should be included on appropriate lines, as applicable. If the action will result in a dollar change to an existing award, indicate only the amount of the change. For decreases, enclose the amounts in parentheses.
19. Is Application Subject to Review by State Under Executive Order 12372 Process? (Required) Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process. Select the appropriate box. If “a.” is selected, enter the date the application was submitted to the State.
20. Is the Applicant Delinquent on any Federal Debt?
(Required) Select the appropriate box. This question applies to the applicant organization, not the person who signs as the authorized representative. Categories of federal debt include; but, may not be limited to: delinquent audit disallowances, loans and taxes. If yes, include an explanation in an attachment.
21. Authorized Representative: To be signed and dated by the authorized representative of the applicant organization. Enter the first and last name (Required); prefix, middle name, suffix. Enter title, telephone number, email (Required); and fax number. A copy of the governing body’s authorization for you to sign this application as the official representative must be on file in the applicant’s office. (Certain federal agencies may require that this authorization be submitted as part of the application.)
ED Supplemental Information for the SF-424
1. Project Director. Name, address, telephone and fax numbers, and e-mail address of the person to be contacted on matters involving this application. Items marked with an asterisk(*) are mandatory.
Novice Applicant. Check ''Yes" if you meet the definition for novice applicants specified in the regulations in 34 CFR 75.225 and included on the attached page entitled "Definitions for U.S. Department of Education Supplemental Information for the SF-424"). By checking "Yes" the applicant certifies that it meets these novice applicant requirements. Check "No" if you do not meet the definition for novice applicants.
This novice applicant information will be used by ED to: I) determine the amount and type of technical assistance that a novice might need, if funded, and 2) determine novice applicant eligibility in discretionary grant competitions that give special consideration to novice applications. Certain ED discretionary grant programs give special consideration to novice applications, either by establishing a special competition for novice applicants or by giving competitive preference to novice applicants under the procedures in 34 CFR 75.105(c)(2). If special consideration is being given to novice applications under a particular discretionary grant competition, the application notice for the competition published in the Federal Register will specify this information
Human Subjects Research. (See I. A. "Definitions" in attached page entitled "Definitions for U.S. Department of Education Supplemental Information for the SF-424.")
3a. If Not Human Subjects Research. Check "No" if research activities involving human subjects are not planned at any time during the proposed project period. The remaining parts of Item 3 are then not applicable.
3a. If Human Subjects Research. Check "Yes" if research activities involving human subjects are planned at any time during the proposed project period, either at the applicant organization or at any other performance site or collaborating institution. Check "Yes" even if the research is exempt from the regulations for the protection of human subjects. (See I. B. "Exemptions" in attached page entitled "Definitions for U.S. Department of Education Supplemental Information for SF-424.")
3b. If Human Subjects Research is Exempt from the Human Subjects Regulations. Check "Yes" if all the research activities proposed are designated to be exempt from the regulations. Check the exemption number(s) corresponding to one or more of the six exemption categories listed in I. B. ''Exemptions." In addition, follow the instructions in II. A. "Exempt Research Narrative" in the attached page entitled ''Definitions for U.S. Department of Education Supplemental Information for the SF-424."
3b. If Human Subjects Research is Not Exempt from Human Subjects Regulations. Check "No" if some or all of the planned research activities are covered (not exempt). In addition, follow the instructions in II. B. "Nonexempt Research Narrative" in the attached page entitled "Definitions for U.S. Department of Ed 1cation Supplemental Information for the SF-424."
3b. Human Subjects Assurance Number. If the applicant has an approved Federal Wide Assurance (FWA) on file with the Office for Human Research Protections (OHRP), U.S. Department of Health and Human Services, that covers the specific activity, insert the number in the space provided. (A list of current FWAs is available at: http://ohrp.cit.nih.gov/search/asearch.asp#ASUR). If the applicant does not have an approved assurance on file with OHRP, enter "None." In this case, the applicant, by signature on the SF-424, is declaring that it will comply with 34 CFR 97 and proceed to obtain the human subjects assurance upon request by the designated ED official. If the application is recommended/selected for funding, the designated ED official will request that the applicant obtain the assurance within 30 days after the specific formal request.
3c. If applicable, please attach your "Exempt Research" or "Nonexempt Research" narrative to your submission of the U.S Department of Education Supplemental Information for the SF-424 form as instructed in item II, "Instructions for Exempt and Nonexempt Human Subjects Research Narratives" in the attached page entitled "Definitions for U.S. Department of Education Supplemental Information for the SF-424."
Note about Institutional Review Board Approval. ED does not require certification of Institutional Review Board approval with the application. However, if an application that involves non-exempt human subjects research is recommended/selected for funding, the designated ED official will request that the applicant obtain and send the certification to ED within 30 days after the formal request. No covered human subjects research can be conducted until the study has ED clearance for protection of human subjects in research.
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 1894-0007. The time required to complete this information collection is estimated to average between 15 and 45 minutes per response, including the time 10 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 estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D. C. 20202-0170. 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.
Definitions for U.S. Department of Education Supplemental Information for the SF-424
Definitions:
Novice Applicant (See 34 CFR 75.225)
For discretionary grant programs, novice applicant means any applicant for a grant from ED that-
Has never received a grant or subgrant under the program from which it seeks funding;
Has never been a member of a group application, submitted in accordance with 34 CFR 75.127-75.129, that received a grant under the program from which it seeks funding: and
Has not had an active discretionary grant from the Federal government in the five years before the deadline date for applications under the program. For the purposes of this requirement, a grant is active until the end of the grant's project or funding period, including any extensions of those periods that extend the grantee's authority to obligate funds.
In the case of a group application submitted in accordance with 34 CFR 75.127-75.129, a group includes only parties that meet the requirements listed above.
PROTECTION OF HUMAN SUBJECTS IN RESEARCH
I. Definitions and Exemptions
A. Definitions.
A research activity involves human subjects if the activity is research, as defined in the Department's regulations, and the research activity will involve use of human subjects, as defined in the regulations.
--Research
The ED Regulations for the Protection of Human Subjects, Title 34, Code of Federal Regulations, Part 97, define research as "a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge. Activities which meet this definition constitute research whether or not they are conducted or supported under a program that is considered research for other purposes. For example, some demonstration and service programs may include research activities.
--Human Subject
The regulations define human subject as "a living individual about whom an investigator (whether professional or student) conducting research obtains ( 1) data through intervention or interaction with the individual, or (2) identifiable private information." (!)If an activity involves obtaining information about a living person by manipulating that person or that person's environment, as might occur when a new instructional technique is tested, or by communicating or interacting with the individual, as occurs with surveys and interviews, the definition of human subject is met. (2) If an activity involves obtaining private information about a living person in such a way that the information can be directly or indirectly linked to that individual, the definition of human subject is met [Private
information includes information about behavior that occurs in a context in which an individual can reasonably expect that no observation or recording is taking place, and information which has been provided for specific purposes by an individual and which the individual can reasonably expect will not be made public (for example, a school health record).]
B. Exemptions.
Research activities in which the only involvement of human subjects will be in one or more of the following six categories of exemptions are not covered by the regulations:
(I) Research conducted in established or commonly accepted educational settings, involving normal educational practices, such as (a) research on regular and special education instructional strategies, or (b) research on the effectiveness of or the comparison among instructional techniques, curricula, or classroom management methods. If an educational practice is being introduced to the site and is not widely used (or similar populations, it is not covered by this exemption.
(2) Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures or observation of public behavior, unless: (a) information obtained is recorded in such a manner that human subjects can be identified, directly or through identifiers linked to the subjects; and (b) any disclosure of the human subjects' responses outside the research could reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects' financial standing, employability, or reputation. If the subjects are children, exemption 2 applies only to research involving educational tests and observations of public behavior when the investigator(s) do not participate in the activities being observed.
Exemption 2 does not apply if children are surveyed or interviewed or if the research involves observation of public behavior and the investigator(s) participate in the activities being observed. [Children are defined as persons who have not attained the legal age for consent to treatments or procedures involved in the research, under the applicable law or jurisdiction in which the research will be conducted.]
Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures or observation of public behavior that is not exempt under section (2) above, if the human subjects are elected or appointed public officials or candidates for public office; or federal statute(s) require(s) without exception that the confidentiality of the personally identifiable information will be maintained throughout the research and thereafter.
Research involving the collection or study of existing data, documents, records, pathological specimens, or diagnostic specimens, if these sources are publicly available or if the information is recorded by the investigator in a manner that subjects cannot be identified, directly or through identifiers linked to the subjects. [This exemption applies only to retrospective studies using data collected before the initiation of the research.[
Research and demonstration projects which are conducted by or subject to the approval of department or agency heads, and which are designed to study, evaluate, or otherwise examine:
public benefit or service programs;
procedures for obtaining benefits or services under those programs;
possible changes in or alternatives to those programs or procedures; or
possible changes in methods or levels of payment for benefits or services under those programs.
[The standards of this exemption are rarely met because it was designed to apply only to specific research conducted by HHS at the time the regulations were established. We will strictly construe this exemption because it was not intended to app(v to ED research[
Taste and food quality evaluation and consumer acceptance studies, (a) if wholesome foods without additives are consumed or (b) if a food is consumed that contains a food ingredient at or below the level and for a use found to be safe, or agricultural chemical or environmental contaminant at or b(:low the level found to be safe, by the Food and Drug Administration or approved by the Environmental Protection Agency or the Food Safety and Inspection Service of the U.S. Department of Agriculture.
II. Instructions for Exempt and Nonexempt Human Subjects Research Narratives
If the applicant marked ·'Yes" for Item 3.b. of the U.S. Department of Education Supplemental Information for the SF 424, the applicant must attach a human subjects "exempt research" or "nonexempt research" narrative to the U.S. Department of Education Supplemental Information for the SF- 424 form. If you have multiple projects and need to provide more than one narrative, be sure to label each set of responses as to the project they address.
Exempt Research Narrative.
If you marked "Yes" for item 3.b. and designated exemption numbers(s), attach the "exempt research" narrative to the U.S. Department of Education Supplemental Information for the SF-
424. The narrative must contain sufficient information about the involvement of human subjects in the proposed research to allow a determination by ED that the designated exemption(s) are appropriate. The narrative must be succinct.
Nonexempt Research Narrative.
If you marked "No" for item 3.b. you must attach the "nonexempt research" narrative to the U.S. Department of Education Supplemental Information for the SF-424. The narrative must address the following seven points. Although no specific page limitation applies to this section of the application, be succinct.
(I) Human Subjects Involvement and Characteristics: Provide a detailed description of the proposed involvement of human subjects. Describe the characteristics of the subject population, including their anticipated number, age range, and health status. Identify the criteria for inclusion or exclusion of any subpopulation. Explain the rationale for the involvement of special classes of subjects, such as children, children with disabilities, adults with disabilities, persons with mental disabilities, pregnant women, prisoners, institutionalized individuals, or others who are likely to be vulnerable
Sources of Materials: Identify the sources of research material obtained from individually identifiable living human subjects in the form of specimens, records, or data. Indicate whether the material or data will be obtained specifically for research purposes or whether use will be made of existing specimens, records, or data.
Recruitment and Informed Consent: Describe plans for the recruitment of subjects and the consent procedures to be followed. Include the circumstances under which consent will be sought and obtained, who will seek it, the nature of the information to be provided to prospective subjects, and the method of documenting consent. State if the Institutional Review Board (IRB) has authorized a modification or waiver of the elements of consent or the requirement for documentation of consent.
Potential Risks: Describe potential risks (physical, psychological, social, legal, or other) and assess their likelihood and seriousness. Where appropriate, describe alternative treatments and procedures that might be advantageous to the subjects.
Protection Against Risk: Describe the procedures for protecting against or minimizing potential risks, including risks to confidentiality, and assess their likely effectiveness. Where appropriate, discuss provisions for ensuring necessary medical or professional intervention in the event of adverse effects to the subjects. Also, where appropriate, describe the provisions for monitoring the data collected to ensure the safety of the subjects.
Importance of the Knowledge to be Gained: Discuss the importance of the knowledge gained or to be gained as a result of the proposed research. Discuss why the risks to subjects are reasonable in relation to the anticipated benefits to subjects and in relation to the importance of the knowledge that may reasonably be expected to result.
Collaborating Site(s): If research involving human subjects will take place at collaborating site(s) or other performance site(s), name the sites and briefly describe their involvement or role in the research.
Copies of the Department of Education's Regulations for the Protection of Human Subjects, 34 CFR Part 97 and other pertinent materials on the protection of human subjects in research are available from the Office of the Chief Financial Officer, U.S. Department of Education, Washington, D.C. 20202-4331, telephone: (202) 245-8090, and on the U.S. Department of Education's Protection of Human Subjects in Research Web Site: http:!lwww.ed.gov/aboutloffices!listlocfolhumansub.html
NOTE: The State Applicant Identifier on the SF-424 is for State Use only. Please complete it on the SF-424 in the upper right comer of the form (if applicable).
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 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 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.
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.
Identify the status of the covered Federal action.
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.
Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification 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.
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.
Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard.
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.
Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Included prefixes, e.g., “RFP-DE-90-001.”
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.
(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).
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
Application for Federal Assistance SF-424
1. Type of Submission
2. Type of Application:
Preapplication
Application
Changed/Corrected Application
If Revision, select appropriate letters(s)
New
Continuation
Revision
Other (Specify)
3. Date Received:
4. Applicant Identifier:
Completed 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:
State:
Province:
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:
Fax
Number:
Email
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.):
15. Descriptive Title of Applicant's Project:
Attach supporting documents as specified in agency instructions.
Attachment:
Title
:
File:
Attachment:
Title
:
File:
Attachment:
Title
:
File:
16. Congressional Districts Of:
a.
Applicant:
b.
Program/Project:
Attach an additional list of Program/Project Congressional Districts if needed.
Attachment:
Title
:
File:
17. Proposed Project:
a.
Start
Date:
b.
End
Date:
18. Estimated Funding ($):
Federal $
Applicant $
State $
Local $
Other $
Program Income $
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
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.
Process
for
review
on
20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes", provide explanation.)
Yes
No
Please provide the explanation below.
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:
Date Signed:
Application for Federal Assistance SF-424
Applicant Federal Debt Delinquency Explanation
The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debt. Maximum number of characters that can be entered is 4,000. Try and avoid extra spaces and carriage returns to maximize the availability of space and avoid extra spaces and carriage returns to maximize the availability of space.
SUPPLEMENTAL INFORMATION REQUIRED FOR DEPARTMENT OF EDUCATION GRANTS
OMB No. Exp.
SUPPLEMENTAL INFORMATION
REQUIRED FOR
DEPARTMENT OF EDUCATION GRANTS
1. Project Director:
Prefix
First Name
Middle Name
Last Name
Suffix
Address:
Street1:
Street2:
City:
County:
State:
Zip / Postal Code:
Country: USA
Phone Number (give area code)
Fax Number (give area code)
Email Address:
Applicant Experience
Novice Applicant:
Yes
No
Not applicable
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:
Title:
File:
OPE- Fulbright-Hays Item #22
Name of Individual Applicants
Last Name, First Name MI
Disciplines
Country(ies) of Research Use a semicolon to separate countries
Human Subjects Activities1
Amount Requested
Total $
Standard Form 424B ASSURANCES - NON-CONSTRUCTION PROGRAMS
ASSURANCES - NON-CONSTRUCTION PROGRAMS
Standard Form 424B (Rev.7-97)
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:
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.
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.
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.
Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.
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).
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. 1681-1683, 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. 101-6107), 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 ee 3), 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.
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.
Will comply, as applicable, with the 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.
Will comply, as applicable, with the provisions of the Davis-Bacon 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. 327-333), regarding labor standards for federally assisted construction sub-agreements.
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 (Clear Air) Implementation Plans under Section 176(c) of the Clear 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. 93-205).
Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. 1721 et seq.) related to protecting components or potential components of the national wild and scenic rivers system.
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.).
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.
Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. 131 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.
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.
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."
Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program.
Signature of Authorized Certifying Representative:
Name of Authorized Certifying Representative:
Title:
Applicant Organization:
Date Submitted:
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:
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 any 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.
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.
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 $10,000 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 or 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 subject 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:
Last Name:
Suffix:
Title:
Date:
Signature:
ED 80-0013 03/04
Disclosure of Lobbying Activities
Disclosure of Lobbying Activities
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
Type of Federal Action:
Contract
Grant
Cooperative Agreement
Loan
Loan Guarantee
Loan Insurance
N/A
Status of Federal Action:
Bid/Offer/Application
Initial Award
Post-Award
N/A
Report Type:
Initial Filing
Material Change
N/A
For Material Change only:
Year
Quarter
Date of Last Report
Name and Address of Reporting Entity:
Prime
Subawardee
N/A Tier, if known:
Name:
Address: City:
State:
Zip:
Zip+4:
Congressional District, if known:
If Reporting Entity in No. 4 is a Subawardee, Enter Name and Address of Prime:
Name:
Address: City: State:
Zip:
Zip+4:
Congressional District, if known:
Federal Department/Agency:
Federal Program Name/Description:
CFDA Number, if applicable:
8. Federal Action Number, if known:
9. Award Amount, if known: $
a. Name of Lobbying Registrant (if individual, last name, first name, MI): Address:
City:
State:
Zip:
Zip+4:
Individuals Performing Services (including address if different from No. 10a)
(last name, first name, MI):
Address:
City: State:
Zip:
Zip+4:
Name:
Title:
Applicant:
Date:
Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact 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 than $10,000 and not more than $100,000 for each such failure.
Federal Use Only:
Authorized for Local Reproduction
Standard Form LLL (Rev. 7-97)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Ingalls, Katrina |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |