CERTIFICATE OF APPLICANT'S ATTORNEY APPENDIX D Form Approved (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 80-2041 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 NONPROFIT ORGANIZATION, INDICATE WHETHER IT HOLDS A CURRENT RULING FROM THE INTERNAL REVENUE SERVICE THAT IT IS TAX EXEMPT 8. 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. * 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 AUG 77) (REPLACES DEO FORM 440, DATED AUG 72, WHICH IS OBSOLETE.) GPO 919-407 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 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 spon. soring 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 sev eral 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. 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. 10b 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, subgrantees, and other payees. 10c 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. 311-166 0-92-16 |