CARES Act 18004(a)(1) Reserve Fund Application

O MB #1840-NEW

Expiration XX/XX/XXXX

INSTITITIONS OF HIGHER EDUCATION REQUEST FOR FUNDS UNDER THE HIGHER EDUCATION EMERGENCY RELIEF FUND Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying documents will be subject to penalties which may include fines, imprisonment, or both, under the U.S. Criminal Code and 20 U.S.C. 1097.

SECTION 1: INSTRUCTIONS

The deadline for eligible institutions of higher education to submit this request for an allocation under Section 18004(a)(1) of the Coronavirus Aid, Relief, and Economic Security Act (the “CARES Act”), Pub. L. 116-136, for the reason described in Section 3 is August 15, 2020. Type or print using dark ink. REMEMBER TO SIGN AND DATE THE FORM AND ATTACH THE REQUIRED DOCUMENTATION. Email the completed form and all required documentation to HEERF@ed.gov. For help with this form, contact HEERF@ed.gov or 202-377-3711.

SECTION 2: INSTITUTION IDENTIFICATION

Institution’s Name

Street Address

City/State/Zip Code

Institution’s DUNS Number

OPEID Number

SECTION 3: ALLOCATION REQUEST

My institution is requesting an allocation under the Higher Education Emergency Relief Fund, Section 18004(a)(1). My institution is not a foreign institution and has an active Federal Student Aid Participation Agreement with the Department but has not received a notice that it is eligible for an allocation of funds.

SECTION 4: REQUIRED DOCUMENTATION

Please provide the following data for the Department to calculate your institution’s award: Full-time equivalent total enrollment for the 2018-19 academic year and the percentage of students enrolled exclusively in distance education; and Full-time equivalent enrollment of Pell recipients for the 2018-19 academic year and the percentage of Pell recipients enrolled exclusively in distance education. Note: If an institution did not have enrollment in AY 2018-19, please report the most recent data for AY 2019-2020 that exists before March 13, 2020 .

SECTION 5: INSTITUTION’S ASSURANCES

I understand that my institution—

• may have to submit additional documentation to substantiate its request; and

• must register with https://www.grants.gov.

SECTION 6: SUBMISSION INSTRUCTIONS

Submit the completed form and all required documentation to HEERF@ed.gov.

Note that if you are provided an allocation, your institution will be required to complete two Certification and Agreement (Agreement) documents in order to receive your full allocation under Section 18004(a)(1) of the CARES Act, which has two portions. The first Agreement must be completed and submitted for the Emergency Financial Aid Grants to Students (the student portion), and another Agreement must be completed and submitted for the Institutional Emergency Relief Funds (the institutional portion).

SECTION 7: AUTHORIZED REPRESENTATIVE CERTIFICATION

Authorized Representative is a legal representative of the institution with the legal authority to take all actions and make all certifications required to be taken and made by the Authorized Representative on behalf of the institution under the provisions of the institution’s organizational documents. In most cases, the Authorized Representative is the institution’s chancellor, president, or vice president or chancellor for finance and administration.

By signing below, I certify that I am authorized by my institution to request an allocation under the CARES Act, the information that I provided in Sections 2, 3, and 4 above are true and correct, and I have read and understand Sections 5, 6, and 7.

Please type or clearly print Authorized Representative’s Name:
Print Authorized Representative’s Title:
Telephone Number:		Fax Number:
Email Address:
Authorized Representative Signature:			Date:

SECTION 8: 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-XXXX. The time required to complete this information collection is estimated to be XXXX total burden hours. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: Hilary Malawer, 400 Maryland Avenue, SW, Washington, D.C. 20202.

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