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APPENDIX C

OFFICE OF ECONOMIC OPPORTUNITY

Community Action Program

Assurance of Compliance with the Office of
Economic Opportunity's Regulations under
Title VI of the Civil Rights Act of 1964

(Name of Applicant or Delegate Agency)

(hereinafter called the "Applicant'')

AGREES THAT it will comply with title VI of the Civil Rights Act of 1964 (P.L. 88-352) and the Regulations of the Office of Economic Opportunity issued pursuant to that title (45 C.F.R. Part 1010), to the end that no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Applicant receives Federal financial assistance either directly or indirectly from the Office of Economic Opportunity; and HEREBY GIVES ASSURANCE THAT it will immediately, in all phases and levels of programs and activities, install an affirmative action program to achieve equal opportunities for partici pation, with provisions for effective periodic self-evaluation.

In the case where the Federal financial assistance is to provide or improve or is in the form of personal property, or real property or interest therein or structures thereon, the assurance shall obligate the Applicant, or, in the case of a subsequent transfer, the transferee, for the period during which the property is used for a purpose for which the Federal financial assistance is extended or for another purpose involving the provision of similar services and benefits, or for as long as the Applicant retains ownership or possession of the property, whichever is longer. In all other cases, this assurance shall obligate the Applicant for the period during which the Federal financial assistance is extended to it.

THIS ASSURANCE is given in consideration of and for the purpose of obtaining either directly or indirectly any and all Federal grants, loans, contracts, property, or discounts, the referral or assignment of VISTA volunteers, or other Federal financial assistance extended after the date hereof to the Applicant by the Office of Economic Opportunity, including installment payments after such date on account of applications for Federal financial assistance which were approved before such date. The Applicant recognizes and agrees that such Federal financial assistance will be extended in reliance on the representations and agreements made in this assurance, and that the United States shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the Applicant, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Applicant.

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CERTIFICATE OF APPLICANT'S ATTORNEY

APPENDIX D

(For Health Demonstration Programs under Section 222, Research and Pilot Programs under
Section 232, and Special Impact Programs under Section 151 of the Economic Opportunity Act)

Form Approved

OMB No. 116-RO 198

This certificate is required when applying for a new grant; or upon CSA's request, for the continuation of an existing grant. 1. NAME OF APPLICANT AGENCY

2. IS THE APPLICANT AN INSTITUTION OF HIGHER EDUCATION AS DEFINED IN SECTION 401 (F) OF THE HIGHER EDUCATION ACT OF 1983, PUBLIC LAW 88-2047

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AN ORGANIZATION CHARTERED AS A NONPROFIT CORPORATION UNDER THE LAWS OF THE STATE OF

A NONPROFIT UNINCORPORATED ASSOCIATION.

OTHER (Explain in Item 6, below.)

4. IF THE APPLICANT IS A NON PROFIT ORGANIZATION, INDICATE WHETHER IT HOLDS A CURRENT RULING FROM THE INTERNAL REVENUE SERVICE THAT IT IS TAX EXEMPT

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8. HAS ANY OFFICIAL OF THE INTERNAL REVENUE SERVICE INDICATED THAT THE APPLICANT MAY NOT QUALIFY FOR SUCH A RULING?

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In my opinion, the above information accurately describes the applicant agency, and that agency has the authority, under applicable principles of law, to carry out the program described in this application.

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* Do not complete when filing final report or in annual reports for individual projects which will not be refunded.

CERTIFICATION

The undersigned certifies that this report has been completed in accordance with applicable instructions; that it is true to the best of his/her knowledge, information and belief; and that it has been approved, or reviewed and approved, as indicated in Item 6, below. THIS REPORT HAS BEEN (Check appropriate box.)

APPROVED BY GRANTEE'S
GOVERNING BOARD

7. DATE OF

APPROVAL

REVIEWED BY GRANTEE'S ADMINISTERING BOARD
AND APPROVED BY ITS GOVERNING OFFICIALS

10. DATE

1. TYPED NAME & TITLE OF PRINCIPAL GOVERNING OFFICIAL 9. SIGNATURE OR PRINCIPAL OFFICER OF GOVERNING BOARD

CSA FORM 440

(REV. AUG 77) (REPLACES OEO FORM 440, DATED AUG 72, WHICH IS OBSOLETE.)

GPO $18-407

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INSTRUCTIONS

Please type or print legibly. Items 1, 2; 3, 6, 7, 9, 10d, 10e, 10g, 10i, 101, 11a, and 12 are self-explanatory, specific instructions for other items are as follows:

Item

Entry

Item

Entry

4

5

8

10

10a

10b

Enter the employer identification number assigned by the U.S. Internal Revenue Service or FICE (institution) code, if required by the Federal sponsoring agency.

This space is reserved for an account number or other identifying numbers that may be assigned by the recipient.

Enter the month, day, and year of the beginning and ending of this project period. For formula grants that are not awarded on a project basis, show the grant period.

The purpose of vertical columns (a) through (f) is to provide financial data for each program, function, and activity in the budget as approved by the Federal sponsoring agency. If additional columns are needed, use as many additional forms as needed and indicate page number in space provided in upper right; however, the totals of all programs, functions or activities should be shown in column (g) of the first page. For agreements pertaining to several Catalog of Federal Domestic Assistance programs that do not require a further functional or activity classification breakdown, enter under columns (a) through (f) the title of the program. For grants or other assistance agreements containing multiple programs where one or more programs require a further breakdown by function or activity, use a separate form for each program showing the applicable functions or activities in the separate columns. For grants or other assistance agreements containing several functions or activities which are funded from several programs, prepare a separate form for each activity or function when requested by the Federal sponsoring agency.

Enter the net outlay. This amount should be the same as the amount reported in Line 10e of the last report. If there has been an adjustment to the amount shown previously, please attach explanation. Show zero if this is the initial report.

Enter the total gross program outlays (less rebates, refunds, and other discounts) for this report period, including disbursements of cash realized as program income. For reports that are prepared on a cash basis, outlays are the sum of actual cash disburse. ments for goods and services, the amount of indirect expense charged, the value of in-kind contributions applied, and the amount of cash advances and payments made to contractors and subgrantees. For reports prepared on an accrued expenditure basis, outlays are the sum of actual cash disbursements, the amount of indirect expense incurred, the value of inkind contributions applied, and the net increase (or decrease) in the amounts owed by the recipient for goods and other property received and for services performed by employees, contractors, subgrantses, and other payees.

10c

10f

10h

10j

10k

Enter the amount of all program income realized in this period that is required by the terms and conditions of the Federal award to be deducted from total project costs. For reports prepared on a cash basis, enter the amount of cash income received during the reporting period. For reports prepared on an accrual basis, enter the amount of income earned since the beginning of the reporting period. When the terms or conditions allow program income to be added to the total award, explain in remarks, the source, amount and disposition of the income.

Enter amcunt pertaining to the non-Federal share of program outlays included in the amount on line e.

Enter total amount of unliquidated obligations for this project or program, including unliquidated obligations to subgrantees and contractors. Unliquidated obliga. tions are:

Cash basis obligations incurred but not paid;

Accrued expenditure basis-obligations incurred but for which an outlay has not been recorded.

Do not include any amounts that have been included on lines a through g. On the final report, line h should have a zero balance.

Enter the Federal share of unliquidated obligations shown on line h. The amount shown on this line should be the difference between the amounts on lines h and i.

Enter the sum of the amounts shown on lines g and j. If the report is final the report should not contain any unliquidated obligations.

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