Voluntary Decline Extension form 9.20.2021

OMB Control Number: 1840-0856

Expiration Date: 11/30/2021

Voluntary Decline of Higher Education Emergency Relief Funds (HEERF) Form

Directions: This form may be completed by an institution that would like to decline all or a portion of its American Rescue Plan Act of 2021 (ARP) formula grant award(s) under the Higher Education Emergency Relief Fund (HEERF) grant programs. Institutions that have not received HEERF grant funds should not complete this form. Completed forms must be emailed to HEERFRefund@ed.gov by [insert date].

Once received, the Department of Education will deobligate the funds the institution indicates in Section 1 from the institution’s G5 account or, depending on the timing the form is received, will not make ARP HEERF supplemental award(s) to the institution. Any funds that are declined by the institution will be redistributed to other institutions with greater needs due to the coronavirus by re-running the appropriate HEERF distribution formula(s) and making additional supplemental awards to those institutions that have not declined funds.

Section 1: Amount, source, and PR/award numbers of HEERF grant funds being declined

Please indicate by Assistance Listing Number (ALN) the amount your institution is declining and the grant PR/Award number (found in box 2 of your ARP HEERF Grant Award Notification (GAN)). Please note that if the amount declined below is greater than the current balance in G5, the Department will deobligate the entire amount remaining in G5. Institutions declining student aid portion funds must not decline more than the amount of institutional funds they are declining.

HEERF Formula Grant Program	Entire Amount to Decline? (Yes/No)	If No, Amount to Decline	PR/Award Number
(a)(1) Student Aid Portion (84.425E)
(a)(1) Institutional Portion (84.425F)
(a)(2) HBCUs (84.245J)
(a)(2) TCCUs (84.425K)
(a)(2) MSIs (84.425L)
(a)(2) SIP (84.425M)
(a)(4) Proprietary Institution Grant Funds for Students (84.425Q)
Total amount of funds being declined

Section 2: Institution Authorized Representative Certification

I, the undersigned authorized representative of the institution indicated below, request the United States Department of Education to deobligate ARP HEERF grant funds in the manner and amount indicated in Section 1 of this form. I acknowledge that agreeing to reallocate any amount of ARP HEERF grant funds makes my institution ineligible for the future redistribution of ARP HEERF grant funds to other institutions with greater needs due to the coronavirus.

Institution Name: _________________________________________

Authorized Representative (typed name): ______________________________________

Authorized Representative Signature: ______________________________________

Authorized Representative Title: _________________________________________

DUNS Number: _________________________________________

OPE ID: _________________________________________

Date: _________________________________________

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 1840-0856. Public reporting burden for this collection of information is estimated to average 30 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. The obligation to respond to this collection is voluntary (ARP (Pub. L. 117-2)). If you have any comments concerning the accuracy of the time estimate, suggestions for improving this individual collection, or if you have comments or concerns regarding the status of your individual form, application, or survey, please contact Karen Epps, 400 Maryland Avenue, SW. Washington, D.C. 20202 directly.

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