Mr. John C. Finley, Acting Regional Direc- Dr. W. Astor Kirk, Regional Director, CSA Mr. Glenwood Johnson, Regional Director, 1 2 3 4 5 6 For family units with more than 6 members, add $1,713 for each additional member in a non-farm family and $1,450 for each additional member in a farm family. Mr. Ben T. Haney, Regional Director, CSA Idaho, Oregon, Washington. 3 4 5 6 For family units with more than 6 members, add $1,575 for each additional member in a non-farm family and $1,338 for each additional member in a farm family. APPENDIX C OFFICE OF ECONOMIC OPPORTUNITY Community Action Program Assurance of Compliance with the Office of (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 partici pation 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 participation, 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 prop erty, whichever is longer. In all other cases, this assurance shall obligate the Applicant for the period dur ing 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. APPENDIX D Form Approved OMB No. 116-RO 198 CERTIFICATE OF APPLICANT'S ATTORNEY (For Health Demonstration Programs under Section 222, Research and Pilot Programs under 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 1963, PUBLIC LAW 88-2047 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 B. HAS ANY OFFICIAL OF THE INTERNAL REVENUE SERVICE INDICATED THAT THE APPLICANT MAY NOT QUALIFY FOR SUCH A RULING? 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. TYPED NAME OF ATTORNEY MEMBER OF THE BAR OF SIGNATURE ADDRESS CSA FORM 393 JUN 75 (FORMERLY OEO FORM 393, DATED NOV 71, DATE * 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. CSA FORM 440 (REV. AUG 77) (REPLACES OEO FORM 440, DATED AUG 72, WHICH IS OBSOLETE.) GPO 919-407 |