Voluntary Decline of Higher Education Emergency Relief Funds (HEERF) Form

Summary

A form titled Voluntary Decline of Higher Education Emergency Relief Funds (HEERF), OMB Control Number 1840-0856 with an expiration date of 09/30/2024. An institution that wants to decline all or part of its American Rescue Plan Act of 2021 formula grant award under the HEERF programs completes it and sends it by September 30, 2024. The Department then deobligates the funds and redistributes them to institutions with greater needs by re-running the distribution formulas. Section 1 lists the grant programs with a yes or no and an amount to decline, and Section 2 is an authorized representative certification, which states that declining makes the institution ineligible for future redistribution.

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                                                                     OMB Control Number: 1840-0856
                                                                         Expiration Date: 09/30/2024

  Voluntary Decline of Higher Education Emergency Relief
                  Funds (HEERF) Form
Directions: This form may be completed by an institution that would like to decline all or a
portion of its American Rescue Plan Act of 2021 (ARP) formula grant award(s) under the Higher
Education Emergency Relief Fund (HEERF) grant programs. Institutions that have not received
HEERF grant funds should not complete this form. Completed forms must be emailed to
HEERFRefund@ed.gov by September 30, 2024.

Once received, the Department of Education will deobligate the funds the institution indicates in
Section 1 from the institution’s G5 account or, depending on the timing the form is received, will
not make ARP HEERF supplemental award(s) to the institution. Any funds that are declined by
the institution will be redistributed to other institutions with greater needs due to the coronavirus
by re-running the appropriate HEERF distribution formula(s) and making additional
supplemental awards to those institutions that have not declined funds.

 Section 1: Amount, source, and PR/award numbers of HEERF grant funds being
 declined
 Please indicate by Assistance Listing Number (ALN) the amount your institution is declining
 and the grant PR/Award number (found in box 2 of your ARP HEERF Grant Award
 Notification (GAN)). Please note that if the amount declined below is greater than the current
 balance in G5, the Department will deobligate the entire amount remaining in G5. Institutions
 declining student aid portion funds must not decline more than the amount of institutional
 funds they are declining.
  HEERF Formula Grant                Entire          If No,          PR/Award Number
  Program                            Amount to       Amount to
                                     Decline?        Decline
                                     (Yes/No)
  (a)(1) Student Aid Portion
  (84.425E)
  (a)(1) Institutional Portion
  (84.425F)
  (a)(2) HBCUs (84.245J)

  (a)(2) TCCUs (84.425K)

  (a)(2) MSIs (84.425L)

  (a)(2) SIP (84.425M)

  (a)(4) Proprietary Institution
  Grant Funds for Students
  (84.425Q)


                                                 1
                                                                   OMB Control Number: 1840-0856
                                                                       Expiration Date: 09/30/2024

  Total amount of funds being
  declined


 Section 2: Institution Authorized Representative Certification
 I, the undersigned authorized representative of the institution indicated below, request the
 United States Department of Education to deobligate ARP HEERF grant funds in the manner
 and amount indicated in Section 1 of this form. I acknowledge that agreeing to reallocate any
 amount of ARP HEERF grant funds makes my institution ineligible for the future
 redistribution of ARP HEERF grant funds to other institutions with greater needs due to the
 coronavirus.

 Institution Name: _________________________________________
 Authorized Representative (typed name): ______________________________________
 Authorized Representative Signature: ______________________________________
 Authorized Representative Title: _________________________________________
 UEI Number: _________________________________________
 OPE ID: _________________________________________
 Date: _________________________________________

Paperwork Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless such collection displays a valid OMB control number. The valid
OMB control number for this information collection is 1840-0856. Public reporting burden for
this collection of information is estimated to average 30 minutes per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. The obligation to respond
to this collection is voluntary (ARP (Pub. L. 117-2)). If you have any comments concerning the
accuracy of the time estimate, suggestions for improving this individual collection, or if you have
comments or concerns regarding the status of your individual form, application, or survey, please
contact Karen Epps, 400 Maryland Avenue, SW. Washington, D.C. 20202 directly.




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