Application Forms

							                             2009 Title I School Improvement Grant

                       Grant Period: January 1, 2009 to August 31, 2009

                                            COVER PAGE

                                            LEA BEDS Code



 Name of LEA:                                           District # (NYC only):
 Address:

 Program
 Contact Person:                                              Telephone:
 Address of Contact:

 E-mail Address:                                              Fax:


List all schools in need of improvement with the category of identification (including SURR identified
under NCLB) in the LEA. Indicate the amount of funding. (Duplicate as needed.)
    Name of School        Category of      Amount of         If a school is not funded, indicate the reason
                          Identification   Allocation




 Total Amount
 Requested for all
 Schools




                                                    1
                                       Statement of Assurances

As Chief School Officer, I attest to compliance with all of the following statements:

   1. The program will be administered in accordance with all applicable statutes, regulations,
      program plans and applications;

   2. Each LEA shall assure its compliance with all supplement not supplant requirements;

   3. (a) The control of funds provided under each program and title to property acquired with
      program funds will be in a public agency or in a non-profit private agency, institution,
      organization, or Indian tribe, if the law authorizing the program provides for assistance to those
      entities; (b) the public agency, nonprofit private agency, institution or organization, or Indian
      tribe will administer the funds and property to the extent required by the authorizing statutes;

   4. The applicant will adopt and use proper methods of administering each such program, including
      (a) the enforcement of any obligations imposed by law on agencies, institutions, organizations,
      and other recipients responsible for carrying out each program; and (b) the correction of
      deficiencies in program operations that are identified through audits, monitoring, or evaluation;

   5. The applicant will cooperate in carrying out any evaluation of each such program conducted by
      or for the State educational agency, the Secretary, or other Federal officials;

   6. The applicant will use such fiscal control and fund accounting procedures as will ensure proper
      disbursement of, and accounting for, Federal funds paid to the applicant under each such
      program;

   7. The applicant agrees to comply with the following civil rights authorities, their implementing
      regulations, and appropriate federal and State guidelines: Title VI of the Civil Rights Act of
      1964, Title IX of the Federal Educational Amendments of 1972, Section 504 of the
      Rehabilitation Act of 1973, and the Age Discrimination Act of 1975.



   Print Name of Superintendent

   Superintendent's Signature

   Date




                                                    2
                       CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION AND OTHER
                         RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE REQUIREMENTS

Applicants should refer to the regulations cited below to determine the certification to which they are required to attest. Applicants
should also review the instructions for certification included in the regulations before completing this form. Signature of this form
provides for compliance with certification requirements under 34 CFR Part 82, "New Restrictions on Lobbying," and 34 CFR Part 85,
"Government-wide Debarment and Suspension (Nonprocurement) and Government-wide Requirements for Drug-Free Workplace
(Grants)." The certifications shall be treated as a material representation of fact upon which reliance will be placed when the
Department of Education determines to award the covered transaction, grant, or cooperative agreement.


 1. LOBBYING                                                        (b) Have not within a three-year period preceding this
                                                                    application been convicted of or had a civil judgement
 As required by Section 1352, Title 31 of the U.S. Code, and        rendered against them for commission of fraud or a criminal
 implemented at 34 CFR Part 82, for persons entering into a         offense in connection with obtaining, attempting to obtain, or
 grant or cooperative agreement over $100,000, as defined at        performing a public (Federal, State, or local) transaction or
 34 CFR Part 82, Sections 82.105 and 82.110, the applicant          contract under a public transaction; violation of Federal or
 certifies that:                                                    State antitrust statutes or commission of embezzlement, theft,
                                                                    forgery, bribery, falsification or destruction of records, making
 (a) No Federal appropriated funds have been paid or will be        false statements, or receiving stolen property;
 paid, by or on behalf of the undersigned, to any person for
 influencing or attempting to influence an officer or employee of   (c) Are not presently indicted for or otherwise criminally or
 any agency, a Member of Congress, an officer or employee of        civilly charged by a governmental entity (Federal, State, or
 Congress, or an employee of a Member of Congress in                local) with commission of any of the offenses enumerated in
 connection with the making of any Federal grant, the entering      paragraph (2)(b) of this certification; and
 into of any cooperative agreement, and the extension,
 continuation, renewal, amendment, or modification of any           (d) Have not within a three-year period preceding this
 Federal grant or cooperative agreement;                            application had one or more public transaction (Federal, State,
                                                                    or local) terminated for cause or default; and
 (b) If any funds other than Federal appropriated funds have
 been paid or will be paid to any person for influencing or         B. Where the applicant is unable to certify to any of the
 attempting to influence an officer or employee of any agency, a    statements in this certification, he or she shall attach an
 Member of Congress, an officer or employee of Congress, or         explanation to this application.
 an employee of a Member of Congress in connection with this
 Federal grant or cooperative agreement, the undersigned shall      3. DRUG-FREE WORKPLACE
 complete and submit Standard Form - LLL, "Disclosure Form           (GRANTEES OTHER THAN INDIVIDUALS)
 to Report Lobbying," in accordance with its instructions;
                                                                    As required by the Drug-Free Workplace Act of 1988, and
 (c) The undersigned shall require that the language of this        implemented at 34 CFR Part 85, Subpart F, for grantees, as
 certification be included in the award documents for all           defined at 34 CFR Part 85, Sections 85.605 and 85.610 -
 subawards at all tiers (including subgrants, contracts under
 grants and cooperative agreements, and subcontracts) and           A. The applicant certifies that it will or will continue to provide
 that all subrecipients shall certify and disclose accordingly.     a drug-free workplace by:

                                                                    (a) Publishing a statement notifying employees that the
 2.   DEBARMENT, SUSPENSION,                     AND      OTHER     unlawful manufacture, distribution, dispensing, possession, or
 RESPONSIBILITY MATTERS                                             use of a controlled substance is prohibited in the grantee's
                                                                    workplace and specifying the actions that will be taken against
 As required by Executive Order 12549, Debarment and                employees for violation of such prohibition;
 Suspension, and implemented at 34 CFR Part 85, for
 prospective participants in primary covered transactions, as       (b) Establishing an on-going drug-free awareness program to
 defined at 34 CFR Part 85, Sections 85.105 and 85.110--            inform employees about:

 A. The applicant certifies that it and its principals:             (1) The dangers of drug abuse in the workplace;

 (a) Are not presently debarred, suspended, proposed for            (2) The grantee's policy of maintaining a drug-free workplace;
 debarment, declared ineligible, or voluntarily excluded from
 covered transactions by any Federal department or agency;          (3) Any available drug counseling, rehabilitation, and
                                                                    employee assistance programs; and




                                                                     3
   (4) The penalties that may be imposed upon employees                 (g) Making a good faith effort to continue to maintain a
   for drug abuse violations occurring in the workplace;                drug-free workplace through implementation of
                                                                        paragraphs
                                                                         (a), (b), (c), (d), (e), and (f).
   (c) Making it a requirement that each employee to be
   engaged in the performance of the grant be given a                   B. The grantee may insert in the space provided below
   copy of the statement required by paragraph (a);                     the site(s) for the performance of work done in
                                                                        connection with the specific grant:
   (d) Notifying the employee in the statement required by
   paragraph (a) that, as a condition of employment under               Place of Performance (Street address. city, county,
   the grant, the employee will:                                        state, zip code)

   (1) Abide by the terms of the statement; and

   (2) Notify the employer in writing of his or her conviction
   for a violation of a criminal drug statute occurring in the
   workplace no later than five calendar days after such
   conviction;
                                                                        Check [ ] if there are workplaces on file that are not
                                                                        identified here.
   (e) Notifying the agency, in writing, within 10 calendar
   days after receiving notice under subparagraph (d)(2)
   from an employee or otherwise receiving actual notice                DRUG-FREE WORKPLACE
   of such conviction. Employers of convicted employees                 (GRANTEES WHO ARE INDIVIDUALS)
   must provide notice, including position title, to: Director,
   Grants Policy and Oversight Staff, U.S. Department of                As required by the Drug-Free Workplace Act of 1988,
   Education, 400 Maryland Avenue, S.W. (Room 3652,                     and implemented at 34 CFR Part 85, Subpart F, for
   GSA Regional Office Building No. 3), Washington, DC                  grantees, as
   20202-4248. Notice shall include the identification                  defined at 34 CFR Part 85, Sections 85.605 and
   number(s) of each affected grant;                                    85.610-
   (f) Taking one of the following actions, within 30                   A. As a condition of the grant, I certify that I will not
   calendar days of receiving notice under subparagraph                 engage in the unlawful manufacture, distribution,
   (d)(2), with respect to any employee who is so                       dispensing, possession, or use of a controlled
   convicted:                                                           substance in conducting any activity with the grant; and
   (1) Taking appropriate personnel action against such an              B. If convicted of a criminal drug offense resulting from
   employee, up to and including termination, consistent                a violation occurring during the conduct of any grant
   with the requirements of the Rehabilitation Act of 1973,             activity, I will report the conviction, in writing, within 10
   as amended; or                                                       calendar days of the conviction, to: Director, Grants
                                                                        Policy and Oversight Staff, Department of Education,
   (2) Requiring such employee to participate satisfactorily            400 Maryland Avenue, S.W. (Room 3652, GSA
   in a drug abuse assistance or rehabilitation program                 Regional Office Building No. 3), Washington, DC
   approved for such purposes by a Federal, State, or                   20202-4248. Notice shall include the identification
   local health, law enforcement, or other appropriate                  number(s) of each affected grant
   agency;

As the duly authorized representative of the applicant, I hereby certify that the applicant will comply
with the above certifications.

LEA                                                                   PR/Award Number and/or Project Name
__________________________________                                    Title I School Improvement 2009

Name of Superintendent _____________________________________________________

Signature of Superintendent __________________________________________________

Date: ________________________




                                                                  4
                                                             School Chart – January 1, 2009 to August 31, 2009

Complete this chart for each school to be funded. Check the status of the school. Duplicate this form as needed.
Name of School: _______________ SINI (1)             SINI (2)        CA (1)      CA (2) -Planning for Restructuring
                                       Restructured Year-1  Restructured Year-2 Restructured Year-3 Restructured Year-4

Grant Amount: ____________________
List all of the area(s) identified for school improvement. Include the subgroup, grade(s) and subject area(s).

1.                                                                                 4.

2.                                                                                 5.

3.                                                                                 6.


     Activities to be Funded: Provide a cost breakdown for each activity to be funded. Describe what it is and how it will address the school’s                Cost of Activity
     academic issues that caused the school to be identified, including the subgroup(s) identified. If the school is in CA (2) - Planning for Restructuring,
     describe how these funds will be used to support the planning and restructuring of the school. If the school is a Restructured School – Year 1 or Year
     2, funds should be used to support the implementation of the Restructuring Plan.




                                                                                                           Total Grant Amount to School



                                                                                             5
7