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APPENDIX D

CERTIFICATE OF APPLICANT'S ATTORNEY
(For Healal Demonstration Programs under Section 222, Rescored and Pilot Progress under
Section 232, and Special Impact Programs under Section 1S) of the Economic Opportunity Act)

Form Approved
OUB No. 116-DIN

This certificate is required when applying for a ner praat; or upon CSA's request, for the continuation of an existing great. T. NAME OF APPLICANT AGENCY

2. IS THE APPLICANT AN INSTITUTION OF WIGHER EDUCATION AS DEFINED IN SECTION 101 (P) OF THE HIGHER EDUCATION ACT
OF ISI, PUOLIC LAI ..-204
OVES

ONO
IF "YES", VAS IT IN EXISTENCE ON AUGUST 20. INS41 DYES ONO
J. THE APPLICANT IS

O A PUOLIC AGENCY
O AN ORGANIZATION CHARTERED AS A NONPROFIT CORPORATION UNDER THE LAUS OF THE STATE OF
O A NONPROFIT UNINCORPORATED ASSOCIATION,
O OTHER (Explain in hem 6, below.)

4. IF THE APPLICANT IS A NON PROFIT ORGANIZATION, INDICATE WHETHER IT WOLOS A CURRENT RULING FROM THE INTERNAL

REVENUE SERVICE THAT IT IS TAX EXEMPT

D YES (Date of Ruling). S. IF ANSWER TO ITEM 4. ABOVL IS "NO"

A, IS IT YOUR OPINION THAT THE APPLICANT QUALIFIES FOR SUCH A RULING!

Ores ONO

.. MAS ANY OFFICUL OF THE INTERNAL REVENUE SERVICE INDICATED THAT THE APPLICANT MAY NOT QUALIFY FOR SUCH A RULINO!

res (Explain in ltem 6. below.) ONO

6. RCMARKS

OPINION

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 knowledre, information and belief; and that it has been approved, or

reviewed and approved, as indicated in Item 6, below. .. THIS REPORT WAS BEEN (Check appropriate box.)

7. DATE OF

APPROVAL O APPROVED BY ONANTEO'S

UNEVIEWED HY GAANTEC'S ADMINISTERING BOARD GOVERNING BOARD

AND APPROVto OY ITI GOVEANING OFFICIALI

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APPENDIX F 1. FEDERAL AGENCY AND ONGANIZATIONAL CLEMENT TO WHICH REPONT 18 BOWITTED 2. FEDERAL GRANT OR OTHER IDENTIFYING OMB Approved

No. 80-RO180

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EMPLOYER IDENTIFICATION NUMBER I NECIPIENT ACCOUNT NUMBER OR IDENTIFYING NUMBER . FINAL REPORT

7. BASIS Yes NO

CASH
CHOJECT/ORANT REMOD (Ser Intrerons)

PEROD COVERED BY THIS REPORT
FRON (Month des

FROM (Menth daw. wer)

TO (Mouth. der. )

769 107

STANDARD PON 10 (1-78) Prescribed by Omice of Management and Sugo CH, No A-110

INSTRUCTIONS

Please type or print legibly. Items 1. 2: 3, 6, 7, 9, 100, 10e. 10g, 101, 101, 11a, and 12 are self-explanatory, specific instructions for other items are as follows:

Item

Entry

Ilom

Entry

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Enter the amount of all program incomo realized in this period that is required by the terms and con. ditions of the Federal award to be deducted from total project costs. For reports prepared on a cesh 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.

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

10

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The purpose of vertical columns (a) through (i) is to provide financial data for each program, function, and activity in the budget as approved by the Federal spon. soring agency. If additional columns He 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 (8) 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 on the title of the program. For grants or other assistance agreements containing multiplo 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.

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100 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.

100 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, out lays are the sum of actual cash disbursements, the amount of indirect expense incurred, the value of in. kind contributions applied, and the net increase (or decrease) in the amounts owed by the recipient for foods and property received and for services performed by employees, contractors, subgrantees, and other payees.

Enter amount of the Federal share charged during the report period.

If more than one rate was applied during the project period, include a separate schedule showing bases against which the indirect cost rates were applied, the respective indirect rates the month, day, and year the indirect rates were in effect. amounts of indirect ex pense charged to the project, and the Federal share of indirect expense charged to the project to date.

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