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APPENDIX C

OFFICE OF ECONOMIC OPPORTUNITY

Community Action Program

Assurance of Complianco with the Office of
Economio Opportunity's Regulations under

Titlo VI of the Clvil Rights Aot of 1964

(hereinafter called the "Applicant") (Name of applicant or Delegace Agency) AGREES THAT it will comply with eitle VI of the Civil Rights Act of 1964 (P.L. 88-352) and the Regulacions of the Office of Economic Opportunity issued pursuant to chat citle (45 C.F.R. Part 1010), to the end that no person in the United States shall, on che ground of race, color, or nacional origin, be excluded from partici: pacion ia, 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 accivities, install an affirmative action program to achieve equal opportunities for panici. pacion, 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 obligace the Applicant, or, in the case of a subsequent transfer, the transferee, for che 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 recains ownership or possession of the propo erty, whichever is longer. In all ocher cases, this assurance shall obligate the Applicant for the period duro ing which che Federal financial assistance is extended to it.

THIS ASSURANCE is given in consideration of and for the purpose of obca ining either directly or indirectly day and all Federal graats, loans, contracts, property, or discounts, the referral or assignment of VISTA volunteers, or other Federal financial assiscance 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 chat such Federal financial assistance will be extended in reliance on the representacions and agreements made in this assurance, and that the United Scates shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the Applicant, its successors, cransferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Applicant.

Date

(Name of Applicant or Delegare Agency)

By

(President, Chairman of Board, or comparable authorized official)

(Mailing Address)

CAP FORM 11. (REV. JUN 69)

PREVIOUS EDITIONS ARE OBSOLETE.

US GOVERNMENT PRINTING OFIICE 1991 U-156-16

907.40

APPENDIX D

CERTIFICATE OF APPLICANT'S ATTORNEY
(For Heala 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 cenificue is required when applying for a new greet; or upon (SA's requese, for the continuation of an existing grans.

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 IS, PUILIC LAV 80-204) rves

JNO
IF "YES", WAS IT IN EXISTENCE ON AUGUST 20. 1950! YES NO
3. THE APPLICANT IS

O A PUBLIC AGENCY
O AN ORGANIZATION CHARTERED AS A NONPROFIT CORPORATION UNDER THE LAWS OF THE STATE OF
O A NONPROFIT UNINCORPORATED ASSOCIATION.
C] OTHER (Explain in ltem 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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HAS ANY OFFICUL OF THE INTERNAL REVENUE SERVICE INDICATED THAT THE APPLICANT MAY NOT QUALIFY FOR
SUCM A RULING!
Oves (Esplain in Item 6. below.) O NO .

6. REMARKS

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. TYPEO NAME OF ATTORNEY

MEMBER OF THE IAR OF SIGNATURE
(State)

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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 MAS BEEN (Check appropriate box.)

7. DATE OF

APPROVAL APPROVED SY GRANTER'S

DREVIEWED IY GRANTE T'S ADMINISTERING BOARD GOVERNING BOARO

OY ITS GOVERNINO OFFICIALS

AND APPROVED

.. TYPEO NAME I TITLE OF PRINCIPAL GOVERNING OFFICIAL

OR PRINCIPAL OFFICER OF OOVERNING IOARD

9. SIONATURE

10. DATE

CSA FORM 440 (REV. AUO 77) (REPLACES OEO FORM 440, DATED AUO 12, WHICH IS OBSOLETE)

GPO 1.-407

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APPENDIX F

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STANDARD FORM 289 (7-76) Prescribed by Ofice of Management and Sudget CH, NO A-110

INSTRUCTIONS

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

Item

Entry

Item

Entry

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Enter the

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 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 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.

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Enter amcunt 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 (0) 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 ate 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 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.

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10. 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 unobligated balance of Federal funds. This amount should be the difference between lines k and I.

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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, outlays 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 goods and other 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 ong 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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