MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION
STANDARD CONTRACT FORM AND APPLICATION FOR PROGRAM GRANTS
PART I – GENERAL
A. APPLICANT:
District Code:
ADDRESS:
TELEPHONE: (
)
B. APPLICATION FOR PROGRAM FUNDING
FUND
CODE
PROGRAM NAME
FY2016
STATE – ALLOCATION GRANT
administered by
LEARNING SUPPORTS AND EARLY LEARNING
FROM
TO
632
Academic Support Services Allocation Grant Program
– School Year Program
Upon Approval
6/30/2016
PROJECT DURATION
AMOUNT
REQUESTED
(no earlier than
9/1/2015)
C. I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS CORRECT AND COMPLETE; THAT THE APPLICANT
AGENCY HAS AUTHORIZED ME, AS ITS REPRESENTATIVE, TO FILE THIS APPLICATION; AND THAT I UNDERSTAND THAT FOR ANY
FUNDS RECEIVED THROUGH THIS APPLICATION THE AGENCY AGREES TO COMPLY WITH ALL APPLICABLE STATE AND FEDERAL
GRANT REQUIREMENTS COVERING BOTH THE PROGRAMMATIC AND FISCAL ADMINISTRATION OF GRANT FUNDS.
AUTHORIZED SIGNATORY:
TITLE:
TYPED NAME:
DATE:
DATE DUE: APPLICATIONS MUST BE EMAILED AND POSTMARKED NO LATER THAN 5:00 p.m.,
THURSDAY, NOVEMBER 5, 2015 FOR THE FUND CODE: 632 (SCHOOL YEAR PROGRAM).
NOTE: If proposing services that start before mid-October, applications should be submitted at least 15
business days prior to the proposed start of the program to allow sufficient time for review, resolution of
issues, and processing in order to comply with the state finance regulation 815 CMR 2:00, section 2.05, (4)(b).
Email the proposal listed on this signature page to achievement@doe.mass.edu AND MAIL TO:
Donna Pisaturo, Office of Learning Supports and Early Learning
Massachusetts Department of Elementary and Secondary Education
75 Pleasant Street
Malden, MA 02148-4906
Number of sets: Mail two (2) sets, each with an original signature of the
Superintendent/Executive Director
DO NOT WRITE BELOW THIS LINE
MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION USE ONLY
GRANTS MANAGEMENT
For the Department Authorized Signatory:
Date: