Financial Report for the Endowment Challenge Grant Progr

FORM APPROVED

OMB No. 1840-0564

Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF EDUCATION,

OFFICE OF POSTSECONDARY EDUCATION

FINANCIAL REPORT FORM UNDER THE

ENDOWMENT CHALLENGE GRANTS PROGRAM (Title III, Part C)

AND ENDOWMENT ACTIVITIES UNDER THE

TITLE III PARTS A & B AND TITLE V PROGRAMS

NOTE TO ENDOWMENT CHALLENGE GRANT (ECG) RECIPIENTS ONLY. If you received your initial ECG award prior to 1987, your grant number will begin with GOO. After 1987, your grant number will begin with P031G. If your institution has been awarded more than one ECG, you must report on each grant separately, by completing this form using the respective project award and/or grant numbers.

NOTE TO TITLE III AND TITLE V GRANTEES THAT HAVE ENDOWMENT AS AN ACTIVITY: The Endowment Fund Corpus amount may change from year to year if you elected to use Federal funds for endowment building more than one year of your five year grant period and added to the original corpus rather than creating a different account for each drawdown. For example, if in year one you raised and matched $50,000 of Federal funds, and you invested $100,000 to form the endowment corpus, then in year two you elected to raise and match $25,000 of Federal funds for a total of $50,000 and decided to add this $50,000 to the original $100,000, your corpus then changes from $100,000 to $150,000. However, if you have chosen to develop a separate endowment corpus for each year, you must report on each individual investment separately, by completing this form for each.

NAME OF INSTITUTION:_________________________________________________

ADDRESS: _________________________________________________

CITY AND STATE: _________________________ ZIP CODE:____________­­_

GRANT NUMBER: _________________________________________________

CONTACT PERSON: _________________________________________________

E-MAIL: _________________________________________________

TELEPHONE NUMBER: _________________________________________________

FAX: _________________________________________________

1. Enter the initial fiscal year (FY) this grant was awarded: FY______

2. Enter the amount of the institution’s original Endowment Fund Corpus: $_______

3. In which fiscal year did the institution submit the “initial” financial report: FY_____

4. Enter your institution’s fiscal year or budget period covered by this report:

From ____________________ to ____________________

Month/Day/Year Month/Day/Year

5. This is report number _____ of 20

INVESTMENT DISTRIBUTIONS - FOR CORPUS ONLY

Reference: Section 628.43 of the program regulations

TYPE OF SAVINGS Amount Name of

ACCOUNT OR SECURITY Financial Institution

1. A federally insured

bank savings account: $____________ _______________________

2. A comparable interest

bearing account: $____________ _______________________

3. A money market fund: $____________ _______________________

4. Certificates of deposit: $____________ _______________________

5. Mutual funds: $____________ _______________________

6. Stocks: $____________ _______________________

7. Bonds: $____________ _______________________

(h) Exchange Traded Funds: $____________ _______________________

9. Other (please specify type of investment account):

_____________________ $____________ ________________________

_____________________ $____________ ________________________

TOTAL INVESTED (a-i): $____________

INCOME EARNED

Enter the amount of the endowment fund income earned during the 12-month period covered by this financial report. $______________

Enter the cumulative (aggregate) amount (to date) of all endowment fund income earned since the initial investment. $______________

INCOME USED

Enter in the appropriate space(s) below the amount of endowment fund income used, both for the 12-month period covered by this report, and the aggregate, for the following purposes:

CURRENT AGGREGATE

a) Operations and maintenance: $______________ $_____________

b) Administration and management

of the endowment fund: $______________ $_____________

c) Buying and selling securities: $______________ $_____________

d) Academic and support personnel: $______________ $_____________

e) Construction and renovation: $______________ $_____________

f) Community and student services

programs and technical assistance: $______________ $_____________

g) Scholarships / Student Financial $______________ $______________

Aid:

h) Other (Please specify below):

___________________________ $______________ $_____________

___________________________ $______________ $_____________

TOTAL (a-h): $______________ $_____________

CERTIFICATION

I certify that:

-No part of the endowment fund corpus has been invested in real estate (Section 628.43 of the regulations);

-No part of the endowment fund corpus has been withdrawn and/or expended (Section 628.44 of the regulations);

-Not more than fifty percent of aggregate endowment fund income has been withdrawn and/or expended (Section 628.45 of the regulations).

President (or Certified Official):

_________________________________ ______________________

(Signature) (Date)

(Name - Type or Print)

(Title -Type or Print)

(E-mail – Type or Print) (Phone Number)

WARNING: Any person who knowingly makes a false statement or misrepresentation on this form is subject to penalties which may include fines and/or imprisonment under the United States Criminal Code.

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 1840-0564.  Public reporting burden for this collection of information is estimated to average 1.25 hours 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 required to obtain or retain benefit (Pub.L. 98-95, Sec. 331).  If you have comments or concerns regarding the status of your individual submission of this form, please contact U.S. Department of Education, Office of Postsecondary Education, Institutional Service, Attention: Beverly Baker, 400 Maryland Ave., S.W., 2B204, Washington, D.C. 20202 directly. [Note: Please do not return the completed form to this address.]

This financial reporting form will be utilized for Title III, Part A, Title III Part B, Title V Program Endowment Activities, and Title III Part C Endowment Challenge Grant Programs. The purpose of this Annual Financial Report is to have the grantees report annually the kind of investments that have been made, the income earned and spent, and whether any part of the Endowment Fund Corpus has been spent. This information allows us to give technical assistance and determine whether the grantee has compiled with the statutory and regulatory investment requirements. Responses to the collection of information are required consistent with the provisions of P.L. 98-95, Section 331 under the Endowment Challenge Grant, HEA 1965, as amended. As these materials contain no confidential information, these application materials will become part of ED’s public records once submitted and approved in accordance with the regulations promulgated under the Paperwork Reduction Act (5 CFR 1320.8(b)(3)(v)).

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