Required Proprietary Institution Certification Form — HEERF III, American Rescue Plan Act of 2021

Summary

This is the Required Proprietary Institution Certification Form for the Higher Education Emergency Relief Fund (HEERF) III under the American Rescue Plan Act of 2021, OMB Control Number 1840-0855, with an expiration date of 12/31/2024. It says all proprietary institutions must complete and submit the form to receive funding under the ARP (a)(4) program. The directions say institution presidents or chief executive officers must complete the first certification and all owners with at least a 25% interest must complete the second. Section 1 asks the president or CEO to certify that the information is true and correct and that HEERF grant funds will be distributed to students in accordance with the Act and the terms of the agreement.

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                                                                                 OMB Control Number:
                                                                             1840-0855 Expiration Date:
                                                                                            12/31/2024


      Required Proprietary Institution Certification Form
                   Higher Education Emergency Relief Fund (HEERF) III
                         American Rescue Plan Act of 2021 (ARP)

Note: To receive funding under the ARP (a)(4) program, all proprietary institutions must
complete and submit this form to assist with management and oversight.

Directions: Proprietary institution presidents or chief executive officers (CEOs) must complete
the first certification and acknowledgement, and all owners that have at least a 25% interest in
the institution must complete the second certification and acknowledgement. If no owners have
at least a 25% interest in the institution, the institution president or CEO must certify to that
effect.

Proprietary institutions that received an (a)(4) award under the Coronavirus Response and Relief
Supplemental Appropriations Act, 2021 (CRRSAA) must email this completed form to
HEERFARP4@ed.gov. Proprietary institutions that are applying for an ARP (a)(4) award for the
first time must submit this document along with other required documents through the
Grants.gov application process.

If the institution believes there is proprietary business information contained within this
submission, it must indicate the specific information the institution considers proprietary in a
cover attachment to this form.

 Section 1: The institution’s president or CEO must provide the following certification
 and acknowledgement:

 To the best of my knowledge and belief, I certify that (1) all information in this certification is
 true and correct, (2) all HEERF grant funds made available pursuant to the ARP (a)(4) ALN
 84.425Q Supplemental Agreement (if receiving an (a)(4) supplemental grant award) or
 Certification and Agreement (if receiving a new (a)(4) grant award) will be distributed to
 students in accordance with the American Rescue Plan Act of 2021 (P.L. 117-2), the
 applicable laws, regulations, and terms and conditions described in my institution’s
 Supplemental Agreement or Certification and Agreement, and (3) my institution, on behalf of
 which the supplemental or new grant award was made, will remain in compliance with the
 terms and conditions of this grant described in the Supplemental Agreement or Certification
 and Agreement.

 I acknowledge that failure to submit true and correct information, failure to distribute HEERF
 grant funds in accordance with the provisions described in the paragraph above, or failure to
 remain in compliance with the terms and conditions of this grant may result in liability under
 the False Claims Act, 31 U.S.C. § 3729, et seq.; OMB Guidelines to Agencies on
 Governmentwide Debarment and Suspension (Nonprocurement) in 2 C.F.R. part 180, as
 adopted and amended as regulations of the Department in 2 C.F.R. part 3485; and 18 U.S.C. §
 1001, as appropriate, and/or other enforcement actions.



                                                  1
                                                                                    OMB Control Number:
                                                                                1840-0855 Expiration Date:
                                                                                               12/31/2024


I acknowledge that any person who knowingly provides false or misleading information in
this certification may be subject to a $250,000 fine per individual, a $500,000 fine per
organization, and/or imprisonment up to five years under the provisions of 18 U.S.C. § 1001.



Name: _________________________________________
President or CEO Signature: _________________________________________
Phone: _________________________________________
Email: _________________________________________
Date: _________________________________________
DUNS Number: _________________________________________
OPE ID: _________________________________________


Section 2: Each owner that has at least a 25% interest in the institution, either directly
or through their ownership interest in any entity (or entities) in the ownership chain,
must provide the following certification and acknowledgement:

To the best of my knowledge and belief, I certify that (1) all information in this certification is
true and correct, (2) all HEERF grant funds made available pursuant to the ARP (a)(4) ALN
84.425Q Supplemental Agreement (if receiving an (a)(4) supplemental grant award) or
Certification and Agreement (if receiving a new (a)(4) grant award) will be distributed to
students in accordance with the American Rescue Plan Act of 2021 (P.L. 117-2), the
applicable laws, regulations, and terms and conditions described in my institution’s
Supplemental Agreement or Certification and Agreement, and (3) my institution, on behalf of
which the supplemental or new grant award was made, will remain in compliance with the
terms and conditions of this grant described in the Supplemental Agreement or Certification
and Agreement.

I acknowledge that failure to submit true and correct information, failure to distribute HEERF
grant funds in accordance with the provisions described in the paragraph above, or failure to
remain in compliance with the terms and conditions of this grant may result in liability under
the False Claims Act, 31 U.S.C. § 3729, et seq.; OMB Guidelines to Agencies on
Governmentwide Debarment and Suspension (Nonprocurement) in 2 C.F.R. part 180, as
adopted and amended as regulations of the Department in 2 C.F.R. part 3485; and 18 U.S.C. §
1001, as appropriate, and/or other enforcement actions.

I acknowledge that any person who knowingly provides false or misleading information in
this certification may be subject to a $250,000 fine per individual, a $500,000 fine per
organization, and/or imprisonment up to five years under the provisions of 18 U.S.C. § 1001.




                                                 2
                                                                         OMB Control Number:
                                                                     1840-0855 Expiration Date:
                                                                                    12/31/2024

First Owner:
Indicate percentage owned: ______________
Print name of entity or individual: _________________________________________
If entity, name and title of entity’s authorized representative:
_________________________________________
Signature of owner (individual or authorized representative):
_________________________________________
Entity or individual’s address: _________________________________________
Entity Tax ID (if not an individual): _________________________________________
Phone: _________________________________________
Email: _________________________________________
Date: _________________________________________


Second Owner:
Indicate percentage owned: ______________
Print name of entity or individual: _________________________________________
If entity, name and title of entity’s authorized representative:
_________________________________________
Signature of owner (individual or authorized representative):
_________________________________________
Entity or individual’s address: _________________________________________
Entity Tax ID (if not an individual): _________________________________________
Phone: _________________________________________
Email: _________________________________________
Date: _________________________________________


Third Owner:
Indicate percentage owned: ______________
Print name of entity or individual: _________________________________________
If entity, name and title of entity’s authorized representative:
_________________________________________


                                                 3
                                                                                   OMB Control Number:
                                                                               1840-0855 Expiration Date:
                                                                                              12/31/2024

Signature of owner (individual or authorized representative):
_________________________________________
Entity or individual’s address: _________________________________________
Entity Tax ID (if not an individual): _________________________________________
Phone: _________________________________________
Email: _________________________________________
Date: _________________________________________


Fourth Owner:
Indicate percentage owned: ______________
Print name of entity or individual: _________________________________________
If entity, name and title of entity’s authorized representative:
_________________________________________
Signature of owner (individual or authorized representative):
_________________________________________
Entity or individual’s address: _________________________________________
Entity Tax ID (if not an individual): _________________________________________
Phone: _________________________________________
Email: _________________________________________
Date: _________________________________________

If no owners have at least a 25% interest in the institution, the President or CEO must
certify by checking the box and signing below:

 ☐        I hereby certify that there are no owners of this institution that have at least a 25%
          interest in the institution.

Name: _________________________________________
President or CEO Signature: _________________________________________
Phone: _________________________________________
Email: _________________________________________
Date: _________________________________________




                                                 4
                                                                                   OMB Control Number:
                                                                               1840-0855 Expiration Date:
                                                                                              12/31/2024

Submission of Proprietary Information
FOIA exempts from mandatory disclosure any “trade secrets or commercial or financial
information obtained from a person and privileged or confidential.” 5 U.S.C. 552(b)(4)
(Exemption 4). In accordance with Exemption 4, the Department will maintain as confidential
any documents submitted by you, or prepared by the institution, that are both customarily and
actually treated as private by the institution, or closely held and not publicly disseminated. If
you feel that some or all of this submission falls within the scope of Exemption 4 and is entitled
to confidential treatment, you must indicate the specific information the institution considers
proprietary in a cover attachment to this form. Please note that your designations of exempt
material are not binding on the Department.

Paperwork Burden Statement
According to the Paperwork Reduction Act of 1995 (PRA), 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 1840-0855. 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 required to obtain or retain a benefit (ARP (Pub. L. 117-2)). If you have any
comments concerning the accuracy of the time estimate or 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, U.S. Department of
Education, 400 Maryland Avenue, SW, Washington, DC 20202.




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