Funds Awarded Form

Please complete and submit the form below.

All fields are required.

"*" indicates required fields

Local Government Name*

Entity’s Taxpayer Identification Number*

DUNS number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Authorized Representative's Information

Name*

Representative's Title*

Email*

Contact Person's Information

Name*

Representative's Title*

Phone*

Email*

Allocation of Funding

The NEU has the option to transfer funds to the State under Section 603(c)(4) of the Act. As part of this process, the NEU must provide a signed notice to the State, which the State must transmit to Treasury. If the NEU does not provide such notice, it will remain legally obligated under the award with respect to accounting for the uses of the funds and the reporting on such uses.

Does the organization choose to accept or decline the funding allocation?*

If the NEU selects to decline the allocation of funds, the Treasury will consider this action as a cancellation of the award on the part of the eligible NEU.

My organization chooses to accept the funds

My organization chooses to DECLINE the funds

Financial Institution Information

Number*

Institution Name*

Phone*

Email*

Total NEU Budget*

This is defined as the annual total operating budget, including general fund and other funds, in effect as of January 27, 2020 or top-line expenditure total (in exceptional cases in which the NEU does not adopt a formal budget). Documentation in support of the reported budget will have to be provided to Treasury along with the NEU's first report due by October 31, 2021.

Is the amount of money the organization is receiving more than 75% of the organization's annual budget?*

No, the amount we are receiving is less than 75%

Yes, the amount we are receiving is more than 75%

Award Terms and Conditions Agreement*

As provided by the Treasury, please download to sign the form here. [PDF]

Accepted file types: pdf, Max. file size: 100 MB.

Assurances of Compliance with Title VI of the Civil Rights Act of 1964*

Please download to sign the form here. [PDF]

Accepted file types: pdf, Max. file size: 100 MB.

Signature

Date

Phone

This field is for validation purposes and should be left unchanged.