Sample Application, ESC ESEA Title I, Part A - Texas ...

SAMPLE 

Application Status: Draft FORMULA Application ID: 0009820304140001 

Organization: 14 Region XIV ESC County District: 221950 

Campus/Site: N/A ESC Region: 14 

SAS#: ESCGAG11 

Vendor ID: 1751247833 School Year: 2010-2011 

2010-2011 ESC ESEA Title I Part A Grant Application 

Certify and Submit 

Application ID: 000982-030414-00-01 Status: Draft 

TEA Due Date: 7/1/2010 5:00:00 PM Application Type: Formula 

Organization: 14 Region XIV ESC 

Campus/Site: N/A SAS #: ESCGAG11 

Warning: 

Be sure to exit all schedules by using the Table of Contents button, 

NOT the browser BACK button. 

Amendment # Version # 

Form Description Required Last Updated 

General Information 

GS2100 - Applicant Information 

GS2300 - Negotiation Comments and Confirmation 

Program Description 

PS3110 - Needs and Objectives 

PS3210 - Narrative: Project Management 

PS3300 - Narrative: Performance Assess & Eval 

PS3400 - Equitable Access and Participation 

Program Budget 

BS6000 - Program Budget Summary and Support 

Provisions Assurances and Certifications 

CS7000 - Provisions, Assurances and Certifications 

* 

* 

* 

* 

* 

* 

* 

00 

01 

4/29/2010 9:05 AM 

Page 1 of 22

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Application Status: Draft FORMULA Application ID: 0009820304140001 





Certification and Incorporation Statement 


Certify and Submit 

Amendment # Version # 

I hereby certify that the information contained in this application is, to the best of my knowledge, correct and that the organization named 

above has authorized me as its representative to obligate this organization in a legally binding contractual agreement. I further certify that any 

ensuing program and activity will be conducted in accordance with all applicable Federal and State laws and regulations; application guidelines 

and instructions; provisions, assurances, and certification requirements, and the schedules submitted. It is understood by the applicant that 

this application constitutes an offer and, if accepted by the Texas Education Agency or renegotiated to acceptance, will form a binding 

agreement. 

Authorized Official 

First Name 30 of 30 Initial Last Name 30 of 30 Title 40 of 40 

Telephone 

Ext. 

Submitter Information 

Fax 

E-Mail 60 of 60 Confirm E-Mail 60 of 60 

First Name Last Name Approval ID Submit Date and Time 

Only the legally responsible party may submit this report. Certify and Submit 

00 

01 

Page 2 of 22

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Schedule Status: Complete FORMULA Application ID: 0009820304140001 





Part 1: Organization Information 

Applicant 

Organization Name 

14 Region XIV ESC 


General Information 

GS2100 - Applicant Information 

Mailing Address Line 1 Mailing Address Line 2 City State Zip Code 

PO BOX 3258 ABILENE TX 79604 

Federal Numbers 

U.S. Congressional District Number DUNS Number CCR CAGE Code 

TX-019 784720435 4LPW2 

School or Campus 

Organization Name 

Mailing Address Line 1 Mailing Address Line 2 City State Zip Code 

For Campus or site-based grants, enter the U.S. Congressional District Number for the physical address of the campus 

or site: 

Part 2: Applicant Contact 

Primary Contact 

First Name 24 of 30 

Sample 

Telephone 

123-123-1234 

Ext. 

Fax 

123-123-1234 

Mailing Address 1 20 of 35 

123 Sample Lane 

Secondary Contact 

First Name 24 of 30 


Telephone 

123-123-1234 

Mailing Address 1 

123 Sample Lane 

Ext. 

Fax 

123-123-1234 

20 of 35 

Initial Last Name 24 of 30 

E-Mail 


sample@sample.com 

43 of 60 

Help 

Title 34 of 40 


Confirm E-Mail 


Mailing Address 2 35 of 35 City 29 of 35 

Initial Last Name 24 of 30 


E-Mail 43 of 60 



State 

TX 

Zip Code 

00000 

43 of 60 

Title 34 of 40 


Confirm E-Mail 43 of 60 


Mailing Address 2 35 of 35 City 29 of 35 


State 

TX 

Zip Code 

00000 

- 

- 

Page 3 of 22

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Schedule Status: New FORMULA Application ID: 0009820304140001 





Part 1: Target Population 

Part 2: Needs, Objectives, and Strategies 



PS3110 - Needs and Objectives 

This section is not applicable for this grant. 

Needs 3400 of 3400 

Objectives/Strategies 3400 of 3400 

Help 

Help 

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Part 1: Program Component Description 




Partnership/Involvement of School Staff, Parents, and Community/Business Leaders 1500 of 1500 

Management of Grant Activities 1500 of 1500 

Internal Communications, Coordination, and Reporting 1500 of 1500 

Grant Project Manager Qualifications 1500 of 1500 

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Help 

Help 

Help 

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Part 1: Program Component Description (continued) 




Grant Personnel Qualifications 1500 of 1500 

Resource Management 1500 of 1500 

Supplement-Not-Supplant 1500 of 1500 

Program Continuation/Sustainability 1500 of 1500 

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Help 

Help 

Help 

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Part 2: Budgeted Costs for Project Management Activities 

Part 3: Activity Timeline 

# 

1 gfedc 

2 gfedc 

3 gfedc 

4 gfedc 

5 gfedc 

6 gfedc 

7 gfedc 

8 gfedc 

9 gfedc 

10 gfedc 





Major Project Management Activities Proposed 

Grant funds will be used to pay only for activities occurring between the beginning 

and ending date of the grant as specified on the notice of grant award. 

Beginning 

Date 

Help 

Proposed 

Ending 

Date 

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Part 1: Program Component Description 




Ongoing Monitoring / Correction of Deficiencies / Continuous Improvement 2160 of 2160 

Qualitative and Quantitative Data Collection Methods 2160 of 2160 

Formative Evaluation 2160 of 2160 

Help 

Help 

Help 

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Part 2: Budgeted Costs for Performance Assessment and Evaluation Activities 

Part 3: Activity Timeline 



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Part 4: Performance Measures 

# 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

gfedc 


Performance Measures 



Data Source, 

Collection 

Instrument or 

Tool 

Projected for 

Last Project 

Year 

Yes The applicant agrees to comply with all reporting and evaluation requirements as established by TEA. 

Actual 

to Date 

Target/Goal 

Next Project 

Year 

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Barriers and Strategies 




Help 

All Students Teachers Others 

000 The applicant assures that no barriers exist to equitable access and participation for: gfedc gfedc gfedc gfedc 

Barrier: Gender-specific Bias 

# Strategies for Gender-specific Bias Students Teachers Others 

A01 Expand opportunities for historically under-represented groups to fully participate. gfedc gfedc gfedc 

A02 Provide staff development on eliminating gender bias. gfedc gfedc gfedc 

A03 Ensure strategies and materials used with students do not promote gender bias. gfedc gfedc gfedc 

A04 

A05 

A06 

Develop and implement a plan to eliminate existing discrimination and the effects of past 

discrimination on the basis of gender. 

Ensure compliance with the requirements in Title IX of the Education Amendments of 1972, which 

prohibits discrimination on the basis of gender. 

Ensure students and parents are fully informed of their rights and responsibilities with regard to 

participation in the program. 

gfedc gfedc gfedc 



A99 Other: gfedc gfedc gfedc 

Barrier: Cultural, Linguistic, or Economic Diversity 

# Strategies for Cultural, Linguistic, or Economic Diversity Students Teachers Others 

B01 Provide program information/materials in home language. gfedc gfedc gfedc 

B02 Provide interpreter/translator at program activities. gfedc gfedc gfedc 

B03 

B04 

Increase awareness and appreciation of cultural and linguistic diversity through a variety of 

activities, publications, etc. 

Communicate to students, teachers, and other program beneficiaries an appreciation of students' 

and families' linguistic and cultural backgrounds. 



B05 Develop/maintain community involvement/participation in program activities. gfedc gfedc gfedc 

B06 Provide staff development on effective teaching strategies for diverse populations. gfedc gfedc gfedc 

B07 

B08 

Ensure staff development is sensitive to cultural and linguistic differences and communicates an 

appreciation for diversity. 

Seek technical assistance from Education Service Center, Technical Assistance Center, Title I, Part 

A School Support Team, or other provider. 



B09 Provide parenting training. gfedc gfedc gfedc 

B10 Provide a parent/family center. gfedc gfedc gfedc 

B11 Involve parents from a variety of backgrounds in decision making. gfedc gfedc gfedc 

B12 

Offer "flexible" opportunities for parent involvement including home learning activities and other 

activities that don't require parents come to the school. 


B13 Provide child care for parents participating in school activities. gfedc gfedc gfedc 

B14 

Acknowledge and include family members' diverse skills, talents, and knowledge in school 

activities. 


B15 Provide adult education, including GED and/or ESL classes, or family literacy program. gfedc gfedc gfedc 

B16 Offer computer literacy courses for parents and other program beneficiaries. gfedc gfedc gfedc 

B17 Conduct an outreach program for traditionally "hard to reach" parents gfedc gfedc gfedc 

B18 Coordinate with community centers/programs gfedc gfedc gfedc 

B19 Seek collaboration/assistance from business, industry, or institution of higher education. gfedc gfedc gfedc 

B20 

B21 

B22 

Develop and implement a plan to eliminate existing discrimination and the effects of past 

discrimination on the basis of race, national origin, and color. 

Ensure compliance with the requirements in Title VI of the Civil Rights Act of 1964, which prohibits 

discrimination on the basis of race, national origin, and color. 

Ensure students, teachers, and other program beneficiaries are informed of their rights and 

responsibilities with regard to participation in the program. 




B23 Provide mediation training on a regular basis to assist in resolving disputes and complaints. gfedc gfedc gfedc 

B99 Other: gfedc gfedc gfedc 

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Barrier: Gang-related Activities 

# Strategies for Gang-related Activities Students Teachers Others 

C01 Provide early intervention. gfedc gfedc gfedc 

C02 Provide counseling. gfedc gfedc gfedc 

C03 Conduct home visits by staff. gfedc gfedc gfedc 

C04 Provide flexibility in scheduling activities. gfedc gfedc gfedc 

C05 Recruit volunteers to assist in promoting gang-free communities. gfedc gfedc gfedc 

C06 Provide mentor program. gfedc gfedc gfedc 

C07 Provide before/after school recreational, instructional, cultural, or artistic programs/activities. gfedc gfedc gfedc 

C08 Provide community service programs/activities. gfedc gfedc gfedc 

C09 Conduct parent/teacher conferences. gfedc gfedc gfedc 

C10 Strengthen school/parent compacts. gfedc gfedc gfedc 

C11 Establish partnerships with law enforcement agencies. gfedc gfedc gfedc 

C12 Provide conflict resolution/peer mediation strategies/programs. gfedc gfedc gfedc 

C13 Seek collaboration/assistance from business, industry, or institution of higher education. gfedc gfedc gfedc 

C14 

Provide training/information to teachers, school staff, and parents to deal with gang-related 

issues. 


C99 Other: gfedc gfedc gfedc 

Barrier: Drug-related Activities 

# Strategies for Drug-related Activities Students Teachers Others 

D01 Provide early identification/intervention. gfedc gfedc gfedc 

D02 Provide counseling. gfedc gfedc gfedc 

D03 Conduct home visits by staff. gfedc gfedc gfedc 

D04 Recruit volunteers to assist in promoting drug-free schools and communities. gfedc gfedc gfedc 

D05 Provide mentor program. gfedc gfedc gfedc 

D06 Provide before/after school recreational, instructional, cultural, or artistic programs/activities. gfedc gfedc gfedc 

D07 Provide community service programs/activities. gfedc gfedc gfedc 

D08 Provide comprehensive health education programs. gfedc gfedc gfedc 

D09 Conduct parent/teacher conferences. gfedc gfedc gfedc 

D10 Establish school/parent compacts. gfedc gfedc gfedc 

D11 Develop/maintain community partnerships. gfedc gfedc gfedc 

D12 Provide conflict resolution/peer mediation strategies/programs. gfedc gfedc gfedc 

D13 Seek collaboration/assistance from business, industry, or institution of higher education. gfedc gfedc gfedc 

D14 

Provide training/information to teachers, school staff, and parents to deal with drug-related 

issues. 


D99 Other: gfedc gfedc gfedc 

Barrier: Visual Impairments 

# Strategies for Visual Impairments Students Teachers Others 

E01 Provide early identification and intervention. gfedc gfedc gfedc 

E02 Provide program materials/information in Braille. gfedc gfedc gfedc 

E03 Provide program materials/information in large type. gfedc gfedc gfedc 

E04 Provide program materials/information on audio tape. gfedc gfedc gfedc 

E05 Provide staff development on effective teaching strategies for visual impairment. gfedc gfedc gfedc 

E06 Provide training for parents. gfedc gfedc gfedc 

E07 Format materials/information published on the internet for ADA-accessibility. gfedc gfedc gfedc 

E99 Other: gfedc gfedc gfedc 

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Barrier: Hearing Impairments 

# Strategies for Hearing Impairments Students Teachers Others 

F01 Provide early identification and intervention. gfedc gfedc gfedc 

F02 Provide interpreters at program activities. gfedc gfedc gfedc 

F03 Provide caption video material. gfedc gfedc gfedc 

F04 Provide program materials and information in visual format. gfedc gfedc gfedc 

F05 Use communication technology, such as TDD/relay. gfedc gfedc gfedc 

F06 Provide staff development on effective teaching strategies for hearing impairment. gfedc gfedc gfedc 

F07 Provide training for parents. gfedc gfedc gfedc 

F99 Other: gfedc gfedc gfedc 

Barrier: Learning Disabilities 

# Strategies for Learning Disabilities Students Teachers Others 

G01 Provide early identification and intervention. gfedc gfedc gfedc 

G02 Expand tutorial/mentor programs. gfedc gfedc gfedc 

G03 Provide staff development in identification practices and effective teaching strategies. gfedc gfedc gfedc 

G04 Provide training for parents in early identification and intervention. gfedc gfedc gfedc 

G99 Other: gfedc gfedc gfedc 

Barrier: Other Physical Disabilities or Constraints 

# Strategies for Other Physical Disabilities or Constraints Students Teachers Others 

H01 

Develop and implement a plan to achieve full participation by students with other physical 

disabilities/constraints. 


H02 Provide staff development on effective teaching strategies. gfedc gfedc gfedc 

H03 Provide training for parents. gfedc gfedc gfedc 

H99 Other: gfedc gfedc gfedc 

Barrier: Inaccessible Physical Structures 

# Strategies for Inaccessible Physical Structures Students Teachers Others 

J01 

Develop and implement a plan to achieve full participation by students with other physical 

disabilities/constraints. 


J02 Ensure all physical structures are accessible. gfedc gfedc gfedc 

J99 Other: gfedc gfedc gfedc 

Barrier: Absenteeism/Truancy 

# Strategies for Absenteeism/Truancy Students Teachers Others 

K01 Provide early identification/intervention. gfedc gfedc gfedc 

K02 Develop and implement a truancy intervention plan. gfedc gfedc gfedc 

K03 Conduct home visits by staff. gfedc gfedc gfedc 

K04 Recruit volunteers to assist in promoting school attendance. gfedc gfedc gfedc 

K05 Provide mentor program. gfedc gfedc gfedc 

K06 Provide before/after school recreational or educational activities. gfedc gfedc gfedc 

K07 Conduct parent/teacher conferences. gfedc gfedc gfedc 

K08 Strengthen school/parent compacts. gfedc gfedc gfedc 

K09 Develop/maintain community partnerships. gfedc gfedc gfedc 

K10 Coordinate with health and social services agencies. gfedc gfedc gfedc 

K11 Coordinate with the juvenile justice system. gfedc gfedc gfedc 

K12 Seek collaboration/assistance from business, industry, or institution of higher education. gfedc gfedc gfedc 

K99 Other: gfedc gfedc gfedc 

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Barrier: High Mobility Rates 

# Strategies for High Mobility Rates Students Teachers Others 

L01 Coordinate with social services agencies. gfedc gfedc gfedc 

L02 Establish partnerships with parents of highly mobile families. gfedc gfedc gfedc 

L03 Establish/maintain timely record transferal system. gfedc gfedc gfedc 

L99 Other: gfedc gfedc gfedc 

Barrier: Lack of Support from Parents 

# Strategies for Lack of Support from Parents Students Teachers Others 

M01 Develop and implement a plan to increase support from parents. gfedc gfedc gfedc 

M02 Conduct home visits by staff. gfedc gfedc gfedc 

M03 Recruit volunteers to actively participate in school activities. gfedc gfedc gfedc 

M04 Conduct parent/teacher conferences. gfedc gfedc gfedc 

M05 Establish school/parent compacts. gfedc gfedc gfedc 

M06 Provide parenting training. gfedc gfedc gfedc 

M07 Provide a parent/family center. gfedc gfedc gfedc 

M08 Provide program materials/information in home language. gfedc gfedc gfedc 

M09 Involve parents from a variety of backgrounds in school decision making. gfedc gfedc gfedc 

M10 

Offer "flexible" opportunities for involvement, including home learning activities and other 

activities that don't require coming to school. 


M11 Provide child care for parents participating in school activities. gfedc gfedc gfedc 

M12 

Acknowledge and include family members' diverse skills, talents, and knowledge in school 

activities. 


M13 Provide adult education, including GED and/or ESL classes, or family literacy program. gfedc gfedc gfedc 

M14 Conduct an outreach program for traditionally "hard to reach" parents. gfedc gfedc gfedc 

M99 Other: gfedc gfedc gfedc 

Barrier: Shortage of Qualified Personnel 

# Strategies for Shortage of Qualified Personnel Students Teachers Others 

N01 Develop and implement a plan to recruit and retain qualified personnel. gfedc gfedc gfedc 

N02 Recruit and retain personnel from a variety of racial, ethnic, and language minority groups. gfedc gfedc gfedc 

N03 Provide mentor program for new personnel. gfedc gfedc gfedc 

N04 Provide intern program for new personnel. gfedc gfedc gfedc 

N05 Provide an induction program for new personnel. gfedc gfedc gfedc 

N06 Provide professional development in a variety of formats for personnel. gfedc gfedc gfedc 

N07 Collaborate with colleges/universities with teacher preparation programs. gfedc gfedc gfedc 

N99 Other: gfedc gfedc gfedc 

Barrier: Lack of Knowledge regarding Program Benefits 

# Strategies for Lack of Knowledge regarding Program Benefits Students Teachers Others 

P01 

Develop and implement a plan to inform program beneficiaries of program activities and 

benefits. 


P02 Publish newsletter/brochures to inform program beneficiaries of activities and benefits. gfedc gfedc gfedc 

P03 Provide announcements to local radio stations and newspapers about program activities/benefits. gfedc gfedc gfedc 

P99 Other: gfedc gfedc gfedc 

Barrier: Lack of Transportation to Program Activities 

# Strategies for Lack of Transportation to Program Activities Students Teachers Others 

Q01 Provide transportation for parents and other program beneficiaries to activities. gfedc gfedc gfedc 

Q02 

Offer "flexible" opportunities for involvement, including home learning activities and other 

activities that don't require coming to school. 


Q03 Conduct program activities in community centers and other neighborhood locations. gfedc gfedc gfedc 

Q99 Other: gfedc gfedc gfedc 

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Barrier: Other Barrier 

# Strategy for Other Barrier Students Teachers Others 

Z99 

Other Barrier: 

Other Strategy: 


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Statutory Authority Fund Code: 

Elementary and Secondary Education Act of 1965, as amended by No Child Left Behind Act of 2001, P.L. 107-110, 

Title I, Part A. 211 

Part 1: Applicant Funding Information 

Available Funding Amount 

The Minimum Total Budget that Can Be Included in this Application 0 

The Maximum Total Budget that Can Be Included in this Application 795,000 

Part 2: Budget Summary by Class/Object Code 

6100 Payroll Costs 

Class/Object Code and Description 

6200 Professional and Contracted Services 

6300 Supplies and Materials 

6400 Other Operating Costs 

6500 Debt Service 

6600 Capital Outlay 

6629 Building Purchase, Construction, or Improvements 

SubTotal 

Maximum Allowable 

Indirect Costs: $ 0 

Grand Total 

2.333 

% Indirect Costs 

Help 

Total Direct Costs: 

Program 

Cost 

Admin 

Cost 

Total 

Budget 

Total Budgeted Costs: 0 0 0 

Cost Per Student: 

Shared Services Arrangements (Footnote only - Should Be Included in Budgeted Costs Above) 

6493 Payments to Member Districts of Shared Services Arrangements 

Part 3: Justification for Itemized Costs not Explained Elsewhere (Parts 4- 9) 3000 of 3000 

Cost 

Share 

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Part 4: Itemized 6100 Payroll Costs No Payroll Cost 

Employee Position Titles Justification 

Instructional Staff 

1 Teacher 

2 Educational Aide 

3 Tutor 

Program Management and Administration 

4 Principal 

5 Assistant Principal 

6 Teacher Facilitator 

7 Teacher Supervisor 

8 Project Director 

9 Project Coordinator 

10 Secretary/Administrative Assistant 

11 Data Entry Clerk 

12 Grant Bookkeeper 

13 Evaluation Specialist 

Auxilliary Staff 

14 Counselor 

15 Social Worker 

16 Child Care Provider 

17 

Community Liaison/Parent 

Coordinator 

18 Bus Driver 

19 Cafeteria Staff 

20 Librarian 

21 School Nurse 

Education Service Center Staff (for ESC Application only) 

22 ESC Specialist/Consultant 

ESC 

23 

Coordinator/Manager/Supervisor 

Other Employee Positions 

24 Title: 







Subtotal 

Other Payroll-Related Costs 

6112 Substitute Pay 

6119 Professional Staff Extra-Duty Pay 

6121 Support Staff Extra-Duty Pay 

6140 Employee Benefits 

61XX Tuition Remission (Allowable only for IHEs) 

Pre-Award Payroll 

61XX 

Costs 

Subtotal 

Grand Total 

Specify: 

#Full-Time 

Effort 

#Part-Time 

Effort 

Employee Payroll: 

Other Payroll-Related Costs: 

Payroll Budget : 

gfedc 

Total 

Budget 

Cost 

Share 

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Part 5: Itemized 6200 Professional and Contracted Services Costs Requiring Specific Approval 

Expense Item Description 

6212 Audit Costs (Other than Audits Required under OMB Circular A-133) 

6269 Rental or Lease of Buildings, Space in Buildings, or Land 

Specify purpose and provide 

calculation: 

6299 Contracted Publication and Printing Costs (Specific Approval Required Only for Nonprofits) 

Specify purpose: 

6299 Scholarships and Fellowships (Not Allowed for Nonprofit Organizations) 

62XX Pre-Award Professional and Contracted Services Costs 


Help 

Amount 

Budgeted 

Professional and Consulting Services (6219/6239) or Subgrants (6290) Less than $10,000 

# Topic/Purpose/Service Subgrant Payment 

1 gfedc 

2 gfedc 

3 gfedc 

4 gfedc 

5 gfedc 

6 gfedc 

7 gfedc 

8 gfedc 

9 gfedc 

10 gfedc 

11 gfedc 

12 gfedc 

Subtotal 

Professional and Consulting Services or Subgrants Less than $10,000 0 

Professional and Consulting Services (6219/6239) or Subgrants (6290) Greater than or Equal to $10,000 

1. Topic/Purpose/Service gfedc Subgrant 

Class/Object Code and Description #Positions Cost 


Title: 




6600 Capital Outlay (Subgrants Only) 

Total Payment 

Total Payment: 0 









Total Payment 










Total Payment 










Total Payment 


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Total Payment 













Total Payment 










Total Payment 

Subtotal 

Grand Total 










Total Payment 










Total Payment 










Total Payment 


Professional and Consulting Services Greater than or Equal to $10,000 0 

Total Costs That Require Specific Approval Other Than Professional and Consulting Services and Subgrants: 

Total Professional and Consulting Services: 0 

Total Subgrants: 0 

Remaining 6200 - Professional and Contracted Services That Do Not Require Specific Approval: 0 

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Part 6: Itemized 6300 Supplies and Materials Costs Requiring Specific Approval 

6399 Technology Hardware - Not Capitalized 

Expense Item Description Amount 

# Type Purpose Quantity 

1 

2 

3 

4 

5 

6399 Technology Software - Not Capitalized 

6399 Supplies and Materials Associated with Advisory Council or Committee 

63XX Pre-award Supplies and Materials Specify: 

Grand Total 

Part 7 : Itemized 6400 Other Operating Costs Requiring Specific Approval 

6411 

6412 

6413 

6419 

6411/ 

6419 

Out-of-State Travel for Employees (includes registration fees) 

Specify Purpose: 

Help 

Total Supplies and Materials Requiring Specific Approval: 0 

Remaining 6300 - Supplies and Materials That Do Not Require Specific Approval: 0 

Expense Item Description Amount 

Travel for Students (includes registration fees; does not include field trips) (specific approval required only for nonprofit 

organizations) 


Stipends for Non-Employees (specific approval required only for nonprofit organizations) 


Travel for Non-Employees (includes registration fees; does not include field trips) (specific approval required only for 

nonprofit organizations) 


Travel Costs for Executive Director (6411), Superintendents (6411), or Board Members (6419) (includes registration 

fees) 


6429 Actual Losses Which Could Have Been Covered by Permissible Insurance 

6490 Indemnification Compensation for Loss or Damage 

6490 

Advisory Council/Committee Travel or Other Expenses (explain purpose of committee on PS3210 Narrative: Project 

Management) 

6499 Membership Dues on Civic or Community Organizations (not allowable for university applicants) 

64XX 

Grand Total 

Specify name and purpose 

of organization: 

Publication and Printing Costs - If Reimbursed (specific approval required only for nonprofit organizations) 


Pre-Award Other Operating Costs 


Help 

Total 6400 - Operating Costs Requiring Specific Approval: 0 

Remaining 6400 - Other Operating Costs That Do Not Require Specific Approval: 0 

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Part 8 : Itemized 6600 Capital Outlay - Capital Assets Regardless of Unit Cost 

6669 - Library Books and Media (Capitalized and Controlled by Library) 

1 

66XX - Technology Hardware - Capitalized 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

66XX - Technology Software - Capitalized 

12 

13 

14 

15 

16 

17 

18 

66XX - Equipment, Furniture, or Vehicles 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

66XX - Pre-Award Capital Outlay Costs 

29 

30 

31 

32 

33 

Description/Purpose Unit Cost Quantity Amount 

Capital Expenditure for Improvements to Land, Buildings or Equipment which Materially Increase Their Value or Useful Life 

34 

Grand Total 

Total 6600 - Capital Outlay Costs: 

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gfedc 

gfedc 

gfedc 

gfedc 

gfedc 

gfedc 

gfedc 

gfedc 


Provisions Assurances 

CS7000 - Provisions, Assurances and Certifications 

General and Fiscal Guidelines 

I certify my acceptance and compliance with all General and Fiscal Guidelines. 

Program Guidelines 

I certify my acceptance and compliance with all Program Guidelines. 

General Provisions and Assurances 

I certify my acceptance and compliance with all General Provisions and Assurances requirements. 

NCLB Provisions and Assurances 

I certify my acceptance and compliance with No Child Left Behind Provisions and Assurances requirements. 

Debarment and Suspension Certification 

I certify I am not debarred or suspended. 

I also certify my acceptance and compliance with all Debarment and Suspension Certification requirements. 

Program-Specific Provisions and Assurances 

I certify my acceptance and compliance with all Program-Specific Provisions and Assurances requirements. 

Lobbying Certification 

I certify that this organization does not spend federal appropriated funds for lobbying activities and certify my acceptance and 

compliance with all Lobbying Certification requirements. 

This organization spends non-federal funds on lobbying activities and has attached the required OMB Disclosure of Lobbying Activities 

form, as described below*. 

* Follow the procedure below to complete and attach the Disclosure of Lobbying Activities form. OMB's 

Disclosure of Lobbying Activities can be located using the following link. 

1. Click on the link above. 

http://www.whitehouse.gov/omb/grants/sfillin.pdf 

2. To complete the online form, follow the instructions on Page 2 of the form. 

3. Click the yellow Print button on the bottom of Page 1. 

4. Sign the form. 

5. Scan the signed form (for additional help on scanning, see the eGrants User Guide). 

6. Save the scanned form to your desktop. 

7. 

Use the Attach File button on the Application Menu page to attach your signed form to this eGrants 

application. 

Page 22 of 22

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