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2020-2021 Nita M. Lowey 21 st Century Community Learning Center (CCLC)-Title IV, Part B Continuation Report Cohorts 9, 10, and 11 Missouri Department of Elementary & Secondary Education Afterschool Programs/Extended Learning Section P.O. Box 480 Jefferson City, MO 65102-0480 (573) 522-2627 [email protected] CAUTION: You must have last year’s application/continuation report in front of you as reference to complete this report.
Transcript
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2020-2021 Nita M. Lowey 21st Century Community

Learning Center (CCLC)-Title IV, Part B Continuation Report

Cohorts 9, 10, and 11

Missouri Department of Elementary & Secondary Education Afterschool Programs/Extended Learning Section

P.O. Box 480 Jefferson City, MO 65102-0480

(573) [email protected]

CAUTION: You must have last year’s application/continuation report in front

of you as reference to complete this report.

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Table of Contents

Continuation Details 1

DESE Communication to Grantees 1

Reminders 1

Special Needs 2

Definitions 2

Goals and Objectives 3

Training 3

Quality Improvement Resources 4

Cohorts 9 and 10 5

Cohort 11 5

Program Activity Plan 6

Reporting Requirements 6

Financial Guidance/Requirements 7

Budget Guidance 7

Indirect Costs 8

Continuation Submission Requirements

Continuation Submission Process

9

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CONTINUATION DETAILS This continuation report refers to the Missouri 21st CCLC/Afterschool Grants. It is understood that the grantee has on file a copy of their original Year 1 Invitation for Bid (IFB)/application for complete guidelines. If you do not have a copy, you may request an electronic copy from the Office of Extended Learning; however, there may be an order and printing charge that you will have to pay. All terms and conditions, requirements, and specifications of the original award and any subsequent continuation awards must remain the same and apply during the 2020-2021 continuation period. For the 2020-2021 Continuation Period:

Although an attempt has been made to provide accurate and up-to-date information, the DESE does not warrant or represent that information provided reflects all relationships or existing conditions related to the continuation report. Continuations are subject to any state and/or federal legislation, regulations, laws, and/or availability of funds.

The information provided in this continuation guidance only reflects changes to the original Year One award and any subsequent continuation years.

DESE COMMUNICATION TO GRANTEES The Afterschool Portal maintains all relevant and important information concerning your awarded/approved grant. It is the grantee’s responsibility to frequently check the Portal for announcements, updates, training information, reporting forms, procedures, etc. as the DESE office will no longer be sending out mass email messages. Failure to frequently check the Portal may result in missed deadlines, changes to grant requirements, funding updates or other announcements, additional information requested by DESE, etc.

Occasionally the DESE office will share resources or best practices with grantees. Please note these resources or best practices are provided in the event they may be of assistance to grantees; these are just resources and not grant requirements. You shall still follow all grant requirements as provided by the DESE office. If the DESE office changes a grant requirement, it will be noted as a requirement change when distributed. The DESE office will continue to notify grantees on an individual basis when it concerns the individual grant award or program.

REMINDERS Program Operation: Grantees must offer services no less than four (4) days per week during a typical school year and no less than 12 hours per week. Programs may be offered during non-school hours or periods when school is not in session (i.e. summer, breaks, holidays, or weekends, etc.). Programs may offer services to students during normal school hours only on days when school is not in session (e.g. school holidays or teacher professional development days). The minimum hours per week must not include transportation time, if offered. There are no minimum requirements for summer hours.

Note: While the number of required hours was reduced per week, the DESE still encourages programs to operate at least 15 hours per week. Programs should provide schedules to meet the needs of participating students and their families. In addition, in order to best serve the children of working families, programs should establish consistent and dependable hours of operation. The DESE also encourages programs to operate the length of the school year in order to accommodate working families. The extended learning time (ELT) option is not allowed with this grant award.

Cohort Original Award Year Grant Cycle for 2020-2021 Remaining Years (pending the availability of funds)

9 2016-2017 5th year of 5 year cycle 0 10 2017-2018 4th year of 5 year cycle 1 11 2019-2020 2nd year of 5 year cycle 3

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Staff: DESE encourages support of school administrators; however, paying school administrators (i.e., superintendents) to work in the afterschool program is discouraged as these positions are generally under contract to serve their schools at all times. It would be difficult to justify additional time and pay for afterschool programs in a school building.

Risk: Grantees who do not meet 80% of regular student attendance levels (based on proposed number of students served 30+ days or more in application) will be placed in moderate risk. Grantees who do not meet 50% of regular attendance levels will be placed in high risk. Budgets may be reduced based on previous year’s attendance results.

Grantees who do not spend 25% of awarded budget by December 25 will be placed in moderate financial expenditure risk. Grantees who do not spend 80% of awarded budget by April 25 will be placed in high financial expenditure risk.

Academic Services: Grantees must ensure that the academic services they provide are aligned with the school’s curriculum in the core subject areas of at least, but not limited to, math, reading/language arts and science.

Grantees provided an assurance that the proposed program was developed and will be carried out in active collaboration with the schools that participating students attend (including through the sharing of relevant data among the schools), all participants of the eligible entity, and any partnership entities, in compliance with applicable laws relating to privacy and confidentiality.

2019-20 Carry-Over Related to COVID-19: You must have received prior approval from your assigned DESE Afterschool Supervisor to carry-over 2019-20 21st CCLC grant awarded dollars. If approved, you MUST continue to track expenditures and services paid by the 2019-20 funds as part of the 2019-20 awarded program. Any approved 2019-20 carry-over funds must still be used for allowable and reasonable activities specific to the 21st CCLC program. You may NOT combine 2019-20 approved carry-over funds with 2020-21 awarded funds even if the date of service/purchase occurs during the 2020-21 grant year. Again, all awarded funds must be tracked separately and prior approval was required.

SPECIAL NEEDS All questions should be emailed (please do not include any personably identifiable information) to your assigned DESE Afterschool Supervisor who will then forward your inquiry directly to the Office of Special Education within DESE; each situation shall be handled on a case-by-case basis by the DESE Office of Special Education. By submitting your inquiry this way, it ensures the appropriate DESE office is reviewing and responding to your inquiry adequately as it relates to any laws, regulations, and/or funding requirements.

DEFINITIONS LEA: local education agency (schools) Non-LEA: non local education agency (non-schools) CBO: community-based organization MASN: Missouri AfterSchool Network (MASN) QIR: Quality Improvement Resources ARE: Afterschool Regional Educator/coaches

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GOALS AND OBJECTIVES The Extended Learning Section developed three goals along with objectives that each grantee will be responsible for working towards. Applicants must write to how their program design and budget will help meet these goals (you do not need to write to the objectives).

Objective 1.1: The afterschool grantee will score satisfactory or above on the reading/English language arts

rubric. Objective 1.2: The afterschool grantee will score satisfactory or above on the math rubric. Objective 1.3: The afterschool grantee will score satisfactory or above on the science rubric. For each Goal 1 objective, a) rubric items include maintain or increase grades (all 30+), b) increase grades for students identified as “need”, c) state assessment scores, d) state end of course exams, e) efficacy.

Objective 2.1: The afterschool site(s) will score satisfactory or above on the program quality rubric. Objective 2.2: The afterschool sites(s) will score satisfactory or above on the broad array rubric. Objective 2.3: The afterschool site(s) will score satisfactory or above on the school day alignment rubric. Objective 2.4: The afterschool grantee will score satisfactory or above on the family engagement rubric. Goal 2 rubric items include Program Quality Assessment (PQA), documentation of ongoing coordination and communication with regular day, implementation of academic strategies based on individual student needs, daily and weekly schedules, lesson plans, social and emotional learning activities, meaningful opportunities for family engagement, and surveys from program staff, school administrators, families and youth.

Objective 3.1: The afterschool grantee will score satisfactory or above on the program attendance rubric.

Objective 3.2: The afterschool grantee will score satisfactory or above on personal and social skills rubric. Objective 3.3: The afterschool grantee will score satisfactory or above on the commitment to learning

rubric. Goal 3 rubric items include program attendance (proposed vs. actual, 30+, 45+, and 60+), school day attendance, school discipline data, and youth surveys.

TRAINING Training is an essential component for high-quality afterschool programs. The DESE will work with the Missouri AfterSchool Network (MASN), the Missouri Afterschool Resource Center (MOARC), Missouri Association for Adult Community and Continuing Education (MAACCE), Child Care Aware®, and other state and national organizations to provide training and support for Missouri’s 21st CCLC awarded programs (approved trainings will be posted on the Missouri Workshop Calendar for documentation of attendance and clock-hour credit). Please see the DESE Afterschool Portal for training opportunities.

Goal 1:  Support or increase student achievement and sense of competence in the areas of reading/English language arts, mathematics, and science.

Goal 2: Develop and maintain a quality program that includes a safe and supportive environment, positive interactions, and meaningful opportunities for engagement.

Goal 3:  Enhance youth’s career and life readiness skills and behaviors, including positive school behaviors, personal and social skills, and commitment to learning.

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All programs that are awarded will be required to attend (at a minimum): One State Training: must select either Missouri School Age Community Coalition (MOSAC2) Professional

Development Institute (PDI) (http://mosac2.org/) to be held at the Lake of the Ozarks, MO tentatively on November 20-22, 2020 or the MAACCE Conference (http://maacce.org/) to be held at the Lake of the Ozarks in June 2021 (dates to be determined). Registration cost is approximately $330.00 for MOSAC2 PDI and $260.00 for MAACCE; subject to change. You may attend both conferences if preferred.

Grantee Meeting: only new program directors/coordinators (not all grantees) will be required to attend a

one-day grantee meeting in October/November; mid-Missouri area. Registration cost is approximately $150.00. Additional details will be provided to those individuals required to attend.

One Advanced Planning with Data Meeting: You will be asked to bring a team of at least three staff per

site. The purpose of this meeting is to have site teams review their PQA observation scores, review the end of the year survey results (staff, parent, youth, etc.), and to develop site level action plans, including selecting Weikart Center PQA Methods Trainings. o Grantees may complete a 2-3 hour Mini Planning with Data (PWD), instead of the 6-hour Advanced

Planning with Data (APWD) session, as long as they have not experienced a high level of turnover since their previous APWD session. Grantees experiencing a high level of turnover should plan to attend the full 6-hour APWD session. AREs will work with each program to determine their eligibility to have a Mini PWD session instead of the full APWD session.

One Methods Training Per Grant: A two-hour training developed by the Weikart Center. The training will

be determined from your review of data during the Planning with Data Meeting. o Grantees will receive one Youth Work Methods training per grant. If a program wishes to receive more

than one training, they may be requested through MASN at an additional cost.

NOTE: If you are a provider who receives child care subsidies, the reauthorized Child Care Development Block Grant Act adds training requirements on health and safety related topics for caregivers, teachers, and directors. All grantees must comply with First Aid and Cardiopulmonary Resuscitation (CPR) training requirements as outlined by Section for Child Care Regulation, regardless of their status of licensing. Optional trainings (as a way of meeting the educational and training needs of programs/staff): Webinars: live webinars can be taken for clock hour credit and will be posted online for later viewing (non-

credit). Regional Trainings: based on the topics and opportunities to connect with other afterschool professionals.

One National Professional Development Training: related to afterschool; prior approval required.

Those attending training sessions are responsible for training appropriate program staff not in attendance. Therefore, grantees must budget reasonable and appropriate training dollars per year for the required trainings (at a minimum). Grantees may amend budgets appropriately if travel funds are not needed/expended for such training requirements. Please note: The DESE encourages grantees to seek additional local, regional, and/or state trainings to assist in meeting the needs of their 21st CCLC program and may therefore set aside additional training dollars, if reasonable and appropriate.

QUALITY IMPROVEMENT RESOURCES

The 21st CCLC grantees participate in an ongoing quality improvement process at both the site and program level using the Assess – Plan – Improve model. This process is referred to as the Quality Improvement Resources (QIR) and is implemented by the Missouri AfterSchool Network (MASN) as part of a contract for services between DESE and MASN. A variety of data is collected that is provided back to the program in site level reports. This information is then used for both quality action plans and external evaluations. Technical assistance, along with Youth Work Methods trainings, can be tailored to the identified needs of the program and/or individual sites.

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Cohort 9 and 10 ONLY: See the chart below for cost of the QIR based on number of grant funded sites. The QIR includes, but is not limited to PQA Assessments and Feedback Reports, Annual Surveys and College and Career Readiness reports, Teacher Surveys, Planning with Data sessions, and Youth Work Methods trainings. Note: Youth Work Methods training attendance is limited to approximately 25 participants to ensure quality training. Additional Youth Work Methods trainings may be scheduled at a cost of $300 per training. If a second training session is requested on the same day, or a second trainer is needed due to high attendance, the additional cost is $250 for the second session or trainer on the same day. Cohort 9 and 10 ONLY: Again this year, the cost for the certified evaluator to conduct the external evaluation is $2,200 for a grantee with one site and $400 per additional site after the first site (see chart below). The list of eligible certified evaluators will be made available by MASN later in the year. Grantees must select a certified evaluator from this list. It is the grantee’s responsibility to contract directly with their selected certified evaluator. Grantees may not use grant funds for any additional evaluators/evaluations. Cohort 11 ONLY: budget 5% of the subtotal of all direct costs (see example chart below) to cover the cost of the PQA Assessments and Feedback Reports, Annual Surveys and Leading Indicators/College and Career Readiness reports, Teacher Surveys, Youth Work Methods Training, Planning with Data sessions, and External Evaluation. Note: The 5% includes the external evaluation which will be paid directly to the external evaluator by the grantee. Again this year, the cost for the external evaluation is $2,200 for a grantee with one site and $400 per additional site after the first site. The list of eligible evaluators will be made available by MASN later in the year. Grantees must select a certified evaluator from this list. It is the grantee’s responsibility to contract directly with their selected certified evaluator. Grantees may not use grant funds for any additional evaluators/evaluations. When you receive the QIR invoice, MASN will have subtracted out the cost of the external evaluator (for programs to pay the evaluator directly); the remaining amount will then be invoiced by MASN.

Quality Improvement Resources - Cohorts 9 & 10 ONLY

External Evaluator - Cohorts 9 & 10 ONLY

1 site $2,200.00 $2,200.00 2 sites $4,100.00 $2,600.00 3 sites $6,000.00 $3,000.00 4 sites $7,900.00 $3,400.00 5 sites $9,800.00 $3,800.00 6 sites $11,700.00 $4,200.00

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See the example below for a program with two sites. Based on a Subtotal of $117,500, the 5% for QIR would be $5875. From this amount, you would pay $2600 to the external evaluator ($2200 + $400 for the second site) and the remaining $3275 would be paid to MASN for the other QIR items listed above.

Cohort 11 ONLY - Quality Improvement Resources and External Evaluators is 5% of the direct costs subtotal (prior to indirect). Categories Total All Sites Staffing $100,000.00Supplies $10,000.00Purchased Services $5,000.00 Professional Development $500.00 Others $2,000.00Subtotal $117,500.00 Purchased Services - Quality Improvement Resources and External Evaluation (5%) - multiply Subtotal by .05 $5,875.00 Direct Subtotal $123,375.00 Indirect Costs (if applicable) $- Total $123,375.00

PROGRAM ACTIVITY PLAN Program Activity Plan – Attachment A: now asks for the State Standard. This information is necessary because it ensures that the activities to be offered are “in alignment with the challenging State academic standards” (Sec. 4204 b.2.D.ii). Each subject area has its own naming convention so a spreadsheet is available on the DESE portal called“Basic Coding of Learning Standards” to use when completing this chart. For the purpose of filling out this chart,grantees may use the “afterschool code” (e.g., ELA-16) to show the basic standard rather than writing out the fulldescription (e.g., ELQ-Reading-Listening for Entertainment).

REPORTING REQUIREMENTS Grantees must submit the following reports/forms to the DESE for review and approval.

Key Staff Change form (if necessary and due as changes occur): notify the assigned DESE Afterschool grant supervisor of any key staff changes (i.e. primary contact person, program director/coordinator, and site directors/coordinators).

Budget Amendments (if necessary and due as needed): will not be accepted after March 25 for the purchase of supplies or equipment. Prior approval is required for all amendments.

Non-LEA’s will continue to use the paper report version of the budget amendment form. LEA’s will continue to enter amendments into ePeGS under budget revision. Must first complete the

supporting data page on what you want to remove and what you would like to replace it with, once that iscompleted the budget grid will appear, please go ahead and update your budget grid to match yourrequested revision.

Requests for Reimbursement/Payment (showing expenditures for reimbursement): please note the final requests for reimbursements date is July 15.

Non-LEA’s: RFR forms are due no later than the 25th of the month and reimbursement will be madearound the 22nd of the following month (DESE encourages RFR’s to be submitted between the 22nd and25th of the current month).

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LEA’s: Payment Requests must be put into ePeGS (by cumulative amounts) no later than the 1st of themonth and reimbursement will be made around the 22nd of the following month. (DESE encouragespayment requests to be submitted between the 22nd and 25th of the current month).

Final Expenditure Report form is due no later than July 25 for non-LEAs and will not generate a final payment. The due date for LEAs will be set in ePeGS and can generate a final payment. Any remaining funds will be allocated to other eligible entities. 2020-2021 21st CCLC grant funds may not be carried over.

Federal APR reporting: Through individual program data collected in KCC, grantees will supply federally-required data elements to the state agency who in turn will supply the data to the U.S. Department of Education. Data entry in KCC must be on-going and accurate. State/Federal reporting occurs three times per year (summer, fall, and spring). At the beginning of the year, data entry/reporting due dates will be provided.

Guided Reflection Document of the 2020-2021 21st CCLC program are due to the DESE no later than October 15, 2021. Please note: You must submit two (2) copies by mail or one electronic copy to DESE. In order to prepare the external evaluation summary report as part of this process, grantees will need submit additional items with the report such as: schedules, lesson plans, documentation of academic strategies, SEL summary, family activity summary, etc. Instructions will be posted in the DESE Afterschool Portal with the evaluation information.

Annual Surveys: will be provided by MASN mid-February.

Yearly Continuation Report: Must be submitted for each of the four continuation years. It is usually available in March/April and due back in April/May.

Any other forms and/or materials as required by the DESE.

FINANCIAL GUIDANCE/REQUIREMENTS 21st CCLC is 100% federal funding under CFDA#84.287c. All reimbursements/payments pending availability of funding.

In addition to the following information, requirements and guidance (including required written policies/procedures) can be found on the DESE general federal guidance page: https://dese.mo.gov/financial-admin-services/general-federal-guidance. This information is consistent across all federally funded programs (Title I, Perkins, Special Education, etc.). Additional Federal cost principle guidance is available in the Uniform Grant Guidance (2 C.F.R. Part 200).

LEA’s must accurately code their financial expenditures and revenues according to the federal requirements created by 34 C.F.R. 200.35 and DESE. It is important to work with the district bookkeeper to ensure that this is done correctly. For further information you may go to the DESE School Finance Home Page: https://dese.mo.gov/financial-admin-services/school-finance/fy-2019-accounting-changes

BUDGET GUIDANCE NEW: the 2020-21 continuation report budget pages are now only at the grantee level, there is not a separate per site budget as part of the continuation report process. Grantees should still follow plans per site as identified and awarded in year one competitive application. Changes in sites are not allowed without prior approval.

Please note the following for completing budgets:

Do not use acronyms for budget items. If items are not clearly spelled out, or if there is any confusion as towhat they stand for, such budget items may be at risk of not being approved for funding.

Be realistic when developing your budgets. They will be reviewed based on the number of students to beserved to demonstrate the most cost effective use of these funds.

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Minor budget amendments (in line with program design, intent, etc.) may be submitted for prior approvalthroughout the year.

All budget items should pertain to a specific budget category provided on the budget pages.

Budget, where appropriate, for any training expenses whether required or optional (e.g. travel, hotel,registration, etc.).

Salaries and Benefits - provide details by each title/role in the programo Certificated Salaries - The amount regularly paid for full-time and part-time teachers in Missouri who

have a valid teaching certificate.o Non-certificated Salaries - Full-time and prorated portions of the costs for work performed by typically

non-certificated employees and certificated employees who are employed in non-instruction relatedpositions of a permanent nature.

Transportation - specify by each type of transportation (i.e. field trip transportation; bussing transportationto/from home and center; staff travel other than to professional development, etc.). If you are requesting afield trip(s) you must specify where EACH trip is to, what it is for and why you are taking the trip (youmay need to attach an additional page if more space is needed. They should be connected to the academicor enrichment program and provide an educational experience from which students can grow academically orculturally. The program should document how all field trips are linked to academic learning and how the tripwill assist with meeting program goals outlined in the afterschool program plan. Reminder: entertainment isnot allowed with 21st CCLC funding.

Supplies & Materials - supplies (and materials) are items which are either consumed in nature, have a usefullife of less than one year, cost less than $1,000 per unit, and/or are more feasibly replaced than repaired. Mostcomputers, iPads, tablets, cameras, etc. fall under the supply category; however, since they are consideredattractive or easily pilfered, they are subject to inventory management and control. NOT ALL SUPPLIESARE CONSUMABLE.

Capital Outlay (Equipment) - Equipment means tangible personal property (including information technologysystems) having a useful life of more than one year and a per-unit acquisition cost which equals or exceeds$1,000. Purchases of items greater than $1,000 or items which have the potential to be shared with regularschool day activities must have a cost share in place and obtain written approval from the DESE prior topurchase (i.e. Smart Boards, 3D printer, fitness equipment, robotics, etc.).All equipment purchased with this grant must be listed and maintained in equipment inventory records so theDepartment can validate its use for CCLC Programs (this includes any items budgeted undermaterials/supplies that are considered attractive or easily pilfered/walk‐away items; i.e. iPads,computers, cameras, etc.).

Professional Development - should include all required training registration specified in the application, aswell as, any additional professional development to be provided. This also includes your travel to such events.

Purchased Services - specify all services in which grant funds are paying for (i.e. evaluator).

Indirect Cost - based on your expenditures and not the amount of funds you are requesting. CapitalOutlay/Equipment cannot be included in your indirect cost.

INDIRECT COSTS Indirect costs are based on your expenditures and not the amount of funds you are requesting. Capital Outlay/Equipment cannot be included in your indirect costs. A cost may not be allocated to a federal award as an indirect cost if any other cost incurred for the same purpose, in like circumstances, has been assigned to a Federal award as a direct cost (Please Note: you do not have to request indirect costs for purposes of this application).

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Local Education Agency (LEA): Indirect cost rates for schools must not exceed the certified indirect cost rates as established with the School Finance Section of the DESE.

For the list of approved rates go to: 1. Missouri Comprehensive Date System Home Page at: https://apps.dese.mo.gov/MCDS/home.aspx2. Select Reports and Resources at the top/middle of the page.3. On the left hand navigational tree select Districts, Charters, & Schools.4. Select School Finance Data5. Indirect Cost Rate for 2019-2020 (unless the 2020-21 list becomes available; DESE will use the most

current list/rates at the time of finalizing the awards)6. Must use the restricted indirect cost rate

Non-LEA’s If the applicant is a non-LEA, the applicant may request up to 8% for indirect costs.

CONTINUATION SUBMISSION REQUIREMENTS The following items shall be attached and submitted along with the continuation report. Failure to submit any portion of the required documentation may delay your award until it has been received.

1. Program Activity PlanForm must be completed with a detailed description (ATTACHMENT A).

2. Federal Funding Accountability and Transparency Act (FFATA)This form must be completed and return with the continuation form (it is the last page of the continuationform) and labeled ATTACHMENT B. Please complete the entire form except for the award amount. TheDESE will fill in the award amount once the continuation form and process is complete.

3. Changes to ProgramFor any changes to programming or staff, please attach explanation of changes and label ATTACHMENT C.

4. Number all pages (this can be hand written)

SUBMISSION PROCESS Due to COVID-19 and potential building closures or teleworking around the state, exceptions to the 2020-21 continuation report submission process are being allowed, see below:

1. All signatures may be original, electronic, or they may be printed, signed, and scanned for submission.2. Submissions are preferred via email to [email protected]. They can be mailed, but please be aware of

potential delays in mail delivery.3. BE SURE TO KEEP A COPY IN YOUR FILES.4. If you are not able to complete the report prior to the deadline, please contact your assigned DESE

Afterschool Supervisor indicating the reason for the delay.

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INSTRUCTIONS The issued date for the award is May 19, 2020; due no later than June 19, 2020 at 3:00 p.m. Central Time.

QUESTIONS contact: Kim Wolf, 573-522-2627, [email protected].

RETURN BY THE DUE DATE ABOVE TO: [email protected]

or by mail to: MISSOURI DEPARTMENT OF ELEMENTARY ANDSECONDARY EDUCATION EXTENDED LEARNING SECTION P.O. BOX 480 JEFFERSON CITY MO 65102-0480

(Print or type 21st CCLC Continuation Report on the lower left hand corner of the envelope or package.) CONTINUATION PERIOD July 1, 2020 – June 30, 2021

ASSURANCES The grantee hereby declares understanding, agreement, and certification of compliance to provide the items and/or services, at the prices quoted, in accordance with all requirements and specifications contained herein and the Terms and Conditions of the continuation. The grantee further agrees that the language of this continuation shall govern in the event of a conflict with his/her proposal. The grantee further agrees that upon receipt of an authorized purchase order from the DESE or when this continuation is countersigned by an authorized official of the state of Missouri, a binding contract shall exist between the grantee and the DESE.

AUTHORIZED SIGNATURE DATE

PRINTED NAME (Include Dr., Mr., Mrs., Ms., or Miss) TITLE

DISTRICT OR ORGANIZATION NAME COUNTY DIST CODE (LEA’S) or FEDERAL TAX ID NUMBER (CBO/FBO)

MAILING ADDRESS COUNTY

CITY STATE ZIP

PHONE NO. EMAIL ADDRESS

CONTRACTOR’S DUNN AND BRADSTREET (DUNS) NUMBER (By signing this contract you acknowledge a current registration with SAM.gov):

DESE USE ONLY ACCEPTED BY STATE OF MISSOURI AS FOLLOWS:

TITLE

Chris Neale, Ed. D., Assistant Commissioner

DATE

TOTAL AMOUNT AWARDED:

NONDISCRIMINATION: It is the policy of the Missouri Department of Elementary and Secondary Education not to discriminate on the basis of race, color, religion, gender, sexual orientation, national origin, age, veteran status, mental or physical disability, or any other basis prohibited by statute in its programs or employment practices as required by Title VI and VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Title II of the Americans with Disabilities Act of 1990, and the Americans with Disabilities Act Amendments Act of 2008 (ADAAA), the Genetic Information Non-Discrimination Act (GINA), or USDA Title VI.

Direct inquiries related to DESE employment practices to the Jefferson State Office Building, Human Resources Director, 205 Jefferson Street, Jefferson City, Missouri 65102-0480; telephone number 573-751-9619. Inquiries related to Department programs and to the location of services, activities, and facilities that are accessible by persons with disabilities may be directed to the Jefferson State Office Building, Director of Civil Rights Compliance and MOA Coordinator (Title VI/Title VII/Title IX/504/ADA/ADAAA/Age Act/GINA/USDA Title VI), 5th Floor, 205 Jefferson Street, P.O. Box 480, Jefferson City, MO 65102-0480; telephone number 573-526-4757 or TTY 800-735-2966; fax number 573-522-4883; email [email protected].

MO 500-3138 (05/20)

MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION OFFICE OF QUALITY SCHOOLS – EXTENDED LEARNING

21ST CENTURY COMMUNITY LEARNING CENTERS-TITLE IV, PART B CONTINUATION REPORT FORM 

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21st Century Community Learning Center (CCLC)-Title IV, Part B Continuation Report Checklist

Grantee Name Cohort: 9 10 11

Required Documents Checked by Grantee

Authorized signature on continuation cover page Yes

Included DUNS number on continuation cover page Yes

Continuation report checklist Yes

Program Activity Plan is attached, detailed and labeled (Attachment A) Yes

FFATA is completed in its entirety, signed, attached and labeled (Attachment B) Yes

Program modification explanations are attached and labeled (Attachment C) – if applicable Yes N/A

Summer afterschool program description attached and labeled (Attachment D) – if applicable Yes N/A

Itemized budget is detailed Lack of detail in budgets frequently causes delays in award notices. All field trips are listed and include descriptions.

Yes

Cohorts 9 and 10 ONLY: Budget includes: Quality Improvement Resources (QIR) - see page 5 for budget amounts

Yes

Budget includes: Youth Work Methods Training - ($300 per grant) Yes

Budget includes: Certified Evaluator - ($2,200 first site plus $400 each additional site) Yes

Cohort 11 ONLY: Quality Improvement Resources (QIR) – budget includes 5% of total direct costs

Yes

Report completed in its entirety Yes

Budgeted for at least one required State Conference (MOSAC2 PDI and/or MAACCE) Yes

All pages are numbered (can be hand written) Yes

Funding requested is not more than projected five year budget page in the original grant and is more than $50,000 minimum

Yes N/A

(Cohort 9 and 10) Funding requested is not more than the diminished amount that was emailed to the primary grant contact. Please contact your DESE Supervisor if you have not received.

Yes N/A

Copy of this continuation report made in its entirety and will be maintained by the grantee Yes

Name of Person Completing the Report

Signature of Person Completing the Report

Title Date

DESE Comments

MO 500-3138 (05/20)

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CONTACT INFORMATION

Grantee Name (name of district/LEA or CBO/organization/entity awarded grant)

Primary Grant Contact Person Title Is this person the Program Director/Coordinator (or other similar title)? Yes No

Hours per week_____ % paid by grant: ____

Since last year (2019-20) has the lead program director/coordinator changed? Yes No

District or Organization Name (for contact person), if different than awardee name

Mailing Address State Zip Code

Primary Grant Contact’s Email Phone Ext.

Program Director/Coordinator Name, if different

Program Director/Coordinator Email Phone Ext.

Fiscal Contact Person (or Bookkeeper)

Fiscal Contact Email Phone Ext.

Board President (non/LEAs only) Email

PROGRAM INFORMATION

List each site you were approved to serve last year (2019-20):

Do you plan to serve this SAME site in 2020-2021?

If no, list new site name and explain why the change:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Certified Evaluator selected for 2019-2020 (Note: Please make sure that your evaluator is on the list of certified evaluators found on the DESE Portal. It is ok to select a new certified evaluator different from the one you have used in the past or different for different sites.)

Do you plan to fully spend your awarded grant dollars last year (2019-2020)? If no, why and how much will not be spent?

Will you be carrying over your 2019-20 grant funds? No Yes, email your DESE afterschool supervisor a separate request detailing your plans and amount of funds to be carried over (prior approval required).

MO 500‐3138 (05/20) 

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Has there been a change in any of the following? If yes, please attach on a separate piece of paper with a description of the change and label as Attachment C. Please identify in the description which area you are changing (e.g. if change in partners, please label change “Partners”).

Grade levels to be served Yes No Proposed Services to Students

Yes No

Schedule Yes No Program Scope Must have prior approval

Yes No

Community/Parents Need Yes No Target Audience (grades served) Must have prior approval

Yes No

Program Transportation Yes No Feeder Schools Yes No

PARENT FEES/PROGRAM INCOME (attach an additional page if more space is needed)

Does your program collect parent fees (program income)? Yes No

List sites that collect program income: How often does this site collect fees? (monthly, yearly, etc.)

What is the estimated amount collected by this site?

Do You Collect Parent Fees and/or Subsidy?

Parent Fee Subsidy

Parent Fee Subsidy

Parent Fee Subsidy

If yes, specify what allowable grant purposes you intend to use the program income for. (Do not state “sustainability”, you must clearly explain how these dollars will be expended by the end of the five-year grant cycle.)

COVID-19 (attach an additional page if more space is needed) Last day of 2019-20 regular on-site 21st CCLC programming before school closure due to COVID-19? Did you provide any services during the COVID-19 school closures? Yes No

If yes, summarize what you provided and when.

If relevant, describe how 21st CCLC grant funding made it possible to provide services during COVID-19 that would otherwise not have been possible without the funding.

PROGRAM MODIFICATION

MO 500‐3138 (05/20) 

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PROGRAM ACTIVITIES – PRIOR TO COVID-19 (attach an additional page if more space is needed) Describe how you ensured that enrichment activities (academic support) were provided in the core academic subjects of math, reading/ language arts, and science in your weekly programming (tutoring and/or homework help do not count). (Reference 2 C.F.R. 4201(a)(1)) Describe how these activities are expected to improve student academic achievement as well as overall student success. (Reference 2 C.F.R. 4204(b)(2)(B)) Describe how you ensured that a broad array of activities were offered (i.e. cultural programs, financial literacy, environmental literacy, nutrition and health education, drug and violence prevention programs, physical fitness and wellness programs, etc.). Reference 2 C.F.R. 4201(a)(2) Describe how your program targeted activities to the students’ academic needs and aligned them to the instruction students receive during the school day. (Reference 2 C.F.R. 4201(b)(1)(A)(ii)) Describe how you aligned your activities to the State academic standards. (Reference 2 C.F.R. 4204(b)(2)(D)(ii))

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COMMUNITY PARTNERSHIPS (attach an additional page if more space is needed) Please list and describe your most active/involved community partners for 2019-2020 (minimum of two).

Will you have the same partners as listed above in 2020-2021? Yes No If no, explain.

Did your partners do what you agreed for them to do in 2019-2020? Yes No If no, explain?

COORDINATION WITH OTHER PROGRAMS Describe how the 21st CCLC program has been coordinated with other federal, state, and/or local programs to make the most effective use of public resources.

Describe how the 21st CCLC program and the districts it serves work together to ensure academic data is provided to meet the grant requirements for federal reporting.

AUDITS--CBO’S ONLY (NON-LEA’S) Did your entity expend $750,000 or more in total federal funds in your last fiscal year, regardless if you have the 21st CCLC grant only, or multiple federal funding sources (i.e. 21st CCLC, CACFP meal program, CCDF, CDBG, AmeriCorps, etc.)? Yes No

If yes, how much in total federal funds did you expend during your last fiscal year (include ALL federal funds)?

If yes, when does your fiscal year end?

If yes, when will your single audit (formerly A-133 audit) be completed?

SUCCESS STORIES (attach an additional page if more space is needed)

Provide an example of a successful component, event and/or child/family impact of your program that would not have been possible without this grant funding (i.e. successful partnership, family engagement event, successful activity/club, etc.) – prior to COVID-19.

MO 500‐3138 (05/20) 

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MO 500‐3138 (05/20) 

PROGRAM SCHEDULE/HOURS FOR 2020-2021 Note: Please ensure the start and end times are accurate, as they are used for technical assistance visits and PQA assessors.

Day of the Week

Regular School Year Summer (if applicable)

AM Start

AM End

PM Start

PM End

# of hours

AM Start

AM End

PM Start

PM End

# of hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Total Hours per Week Total Hours per Week

SITE INFORMATION: Complete one site information (four pages) for each of your sites for 2020-2021. If more than one site, grantees should copy these pages for additional sites and attach it directly behind this page. Site Name

Site Director’s Name Email

Phone

Ext. Is this the same person who currently serves as site director?

Yes No

Check all that apply for 2020-2021: Afterschool Before school Summer Weekends Holidays

Who will provide the daily services? (as on page 1) awarded grantee other, specify entity name:

DATES OF OPERATION FOR 2020-2021 Regular school year-Do not include summer Regular School Start Date Regular School End Date Total # of days

Before School Program Start Date Before School Program End Date Total # of days

Afterschool Program Start Date Afterschool Program End Date Total # of days

SUMMER PROGRAMMING - If more than one summer school program, copy this page for each program.

Include an Attachment D only if summer afterschool services will be provided describing the type of service to be provided, location, and participants. If offering summer programming, please indicate your dates: If located at different site, please indicate which site:

July , 2020 – July , 2020

May , 2021 – May , 2021

August , 2020 – August , 2020

June , 2021 – June , 2021

If you do not offer summer programming using 21st CCLC funds, please check the reason(s) why:

building not available

funding not available

lack of enrollment

staffing

not included in approved budget

other funding being used

other, explain:

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MO 500‐3138 (05/20) 

SITE INFORMATION CONTINUED (page 2 of 4) Site Name

2020-2021 PROPOSED NUMBERS TO SERVE Only complete one row per site. If a site covers more than one age group, use age group with most students being served. Be realistic as these are the numbers that you must report your status on next year. Total

Enrolled 30+ days 45+ days 60+ days

Elementary (K-5 or K-6) or (K-12 or K-8)

Middle School/Junior High (5-8) or Middle School/High School (6-12)

High School (9-12)

Grade Levels to be Served at this site in 2020-2021:

PK K 1 2 3 4 5 6 7 8 9 10 11 12

Are these the same grade levels as last year? Yes No

(prior approval required for changes)

FEEDER SCHOOLS FOR AFTERSCHOOL PROGRAM List all schools that will be sending students to this site in 2020-2021 for the Afterschool Program

School Name District Name New from previous year? If yes attach explanation

Yes No

Yes No

Yes No

Yes No

Yes No

GRADES What grade scale is used by the school(s) you serve at this site? Grade Level(s)

A-F

Check +, Check, Check -

Excellent, Satisfactory, Unsatisfactory

Mastery, Near Mastery, Remediation

Other, please describe

How often does the school(s) report grades this site serves?

Quarterly Trimester Semester Only Other, describe:

If you are serving elementary at this site, what grade does the school(s) begin taking Science grades?

Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade Not applicable

SNACK/MEAL Which of the following do you provide at this site?

Snack Meal Both Snack & Meal None

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MO 500‐3138 (05/20) 

SITE INFORMATION CONTINUED (page 3 of 4) Site Name:

2019-2020 REPORTING (Note: DESE will utilize Kids Care Center (KCC) data for your proposed vs actual student attendance numbers.)

Have you met (or plan to meet) your proposed 30 plus days in 2019-2020 (prior to school closings-COVID-19)? Yes No If no, why? Have you met or plan to meet your proposed number of attendees 60 plus days (prior to school closings-COVID-19)? Yes No If no, why? Did you meet hours/weeks of operation in 2019-2020 (prior to school closings-COVID-19)? Yes No If no, why?

SERVICES TO ADULT FAMILY MEMBERS (this does not include family nights) (Reference 2 C.F.R. 4201(a)(3))

List the activities/services that were provided to adult family members (of students served) during the 2019-2020 program year

Date the events occurred Number of adult family

members served

List the activities/services that you plan to offer to adult family members (of students served) during the 2020-2021 program year.

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MO 500‐3138 (05/20) 

SITE INFORMATION CONTINUED (page 4 of 4)

Services that advance student achievement. Programs must provide a broad array of services, programs, and activities. Check all that apply for this site:

Reading or literacy Tutoring services Language Arts Internship or apprenticeship programs Mathematics education activities Mentoring programs Science education activities Assistance to truant, suspended, or expelled students Arts Expanded library service hours Music Drug and violence prevention programs Counseling programs Career readiness and awareness activities Business education STEM activities, including computer science Remedial education activities Nutrition/health education Financial literacy programs Environmental literacy programs Character education programs Service-learning/community service Entrepreneurial education programs Services for individuals with disabilities Credit recovery or attainment Cultural programs Telecommunications & technology

education programs Parenting skills programs that promote parental

involvement and family literacy Career and technical programs Youth development activities Partnering with in-demand fields of the

local workforce or build career competencies and career readiness

Activities for English learners that emphasize language skills and academic achievement

Other (Please list): Other (Please list):

Will this site be located in an elementary or secondary school building? yes no

If no, what is its geographic proximity to such school?

If no, why is this site not located in school building? If no, explain how this location is a safe and easily accessible facility. If no, how will students be transported from school to site location?

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MO 500‐3138 (05/20) 

2020-2021

CUMULATIVE BUDGET SUMMARY Grantee Name:

Directions: List the “cumulative” amount in the “Dollars Requested from DESE” column. In cases of multiple sites, grantee shall add all sites and only list the cumulative amount on this page. Amounts must be necessary, reasonable, and allocable to the grant. Cohort 11 – Refer to original grant. Cohort 9 and 10 – Your DESE supervisor should have emailed your diminished funds amount.

BUDGET CATEGORY GRANT DOLLARS REQUESTED

PROVIDE A JUSTIFICATION PER CATEGORY FOR THE FUNDS BEING REQUESTED

Certificated Salaries $

Non-certificated Salaries $

Benefits $

Transportation $

Supplies and Materials $

Capital Outlay (Equipment - Over $1,000 per unit cost) $

Professional Development (Training/Conferences & Associated Travel)

$

Purchased Services $

SUBTOTAL Direct Costs (all costs above)

$

Cohort 11 ONLY – Quality Improvement Resource Costs (5% of Subtotal-Direct Costs)

$

SUBTOTAL Direct Costs $

Indirect Costs-restricted rate (do not include Capital Outlay (equipment) category amount in this calculation) -not required to request indirect costs

Calculated at % $

GRAND TOTAL (Direct Costs PLUS Indirect Costs) $

DESE Approval

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MO 500‐3138 (05/20) 

Itemized Budget Grantee Name

New: See page 7. Provide a detailed itemized budget for the 2020-2021 grant year. Items must be allocable, reasonable, and necessary. Failure to detail items will delay continuation process. If additional space is needed, copy this page; however, no substitute page designs or reformatting are allowed. Each page must be totaled with the grand total only provided on the first page. .

BUDGET CATEGORY BUDGET CALCULATION EXPLANATION/PURPOSE OF ITEM OR SERVICE

TOTAL PRICE

Certificated Salaries (list by each title/role)

Example: 15 hours at $20/hour for 44 weeks.

Example: Staffing needed to operate afterschool site based on number of students proposed.

Example: Total Price

Subtotal (Salaries)* $

Non-certificated Salaries (list by each title/role)

Example: 15 hours at $10/hour for 44 weeks.

Example: Staffing needed to operate afterschool site based on number of students proposed.

Example: Total Price

Subtotal (Non-certificated Salaries)*

$

Benefits (list by each title/role) Example: 10.95% each Example: Required federal/state withholdings Example: Total Price

Subtotal (Benefits)* $

Transportation Example: 3 busses at $35/day x 74 days

Example: Daily Transportation Example: Total Price

Subtotal (Travel & Tran.)* $

Supplies Example: Consumable supplies $300/teacher x 3 teachers

Example: Supplies for hands-on enrichment activities

Example: Total Price

Subtotal (Supplies)* $

*If you have additional pages beyond the first two pages, you must put the total of all pages for each budget category on the appropriate subtotal line of the first two pages. Do not put the total on additional pages you may leave the box blank.

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MO 500‐3138 (05/20) 

Equipment (specify numbers of each piece and prices per item type unless priced as a unit) Note: Equipment should also be listed in Program Activity Plan.

Example: 2 computers at $850 each Example: Provide STEM activities as listed in the project activity plan

Example: Total Price

Subtotal (Equipment)* $

Professional Development (education/training, conferences, and associated travel) (break out by each Professional Development Activity/training)

Example: MO School Age Community Conference $250 x 3 people

Example: Required state conference Example: Total Price

Grantee Meeting New Directors/Coordinators ONLY (budget $150 registration fee per person)-Required

State Conference (MOSAC2 PDI and/or MAACCE)-One Required

Other (list separately)

Subtotal (Prof. Dev.)* $

Purchased Services Example: Evaluator $2000 per year Example: Required per grant Example: Total Price Quality Improvement Resources (see page 5 for accurate budget amount)-Required for Cohort 9 and 10 ONLY

Evaluator ($2,200/first site plus $400 for each additional site; see page 5)-Required for Cohort 9 and 10 ONLY

Other (list separately)

Subtotal (Purchased Services)* $

SUBTOTAL DIRECT COSTS (all costs above)

$

Required for Cohort 11 ONLY – Quality Improvement Resources (Purchased Services) - see page 6

Calculated at 5% (of Subtotal Direct Costs line above)

$

SUBTOTAL DIRECT COSTS

$

INDIRECT COSTS-if applicable (Do not include equipment category amount in this calculation.)

Calculated at % (see page 9)

$

GRAND TOTAL (Subtotal of Direct Costs + Indirect Costs)

$

*If you have additional pages beyond the first two pages for Year 1 budget, you must put the total of all pages for each budget category on the appropriate subtotal line of the first two pages. Do not put the total on additional pages.

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MO 500‐3138 (05/20) 

2020-2021 Budget Narrative (Detailed) Grantee Name:

Provide a narrative of your 2020-2021 budget for each of the following:

Describe how budget requested is reasonable in relationship to the number of students to be served.

Describe how the salary costs are reasonable and necessary to the number of students served and overall program design.

If you requested field trips in your 2020-2021 budget, please specify for each field trip where the trip is to and why you are taking the trip (you may need to attach an additional page with this information). Field trips must be connected to the academic or enrichment program and must provide an educational experience from which students can grow academically or culturally. The program should document how all field trips are linked to academic learning and how the trip will assist with meeting program goals. (This includes swimming.) Field trips for entertainment purposes are not allowed.

Are other federal funds (other than 21st CCLC) utilized to supplement any component of your afterschool program? Yes No If yes, please explain:

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MO 500‐3138 (05/20) 

ATTACHMENT A

Program Activity Plan for 2020-2021 (Copy this page for additional activities and/or additional sites)

The Program Activity Plan should give a detailed description of all the proposed regular/reoccurring programming/activities (not one time activities). These activities should include your enrichment provided in the core subject areas of math, reading/language arts, and science as well as give a good picture of the broad array of activities your site will do on a daily/weekly/monthly basis. There should be an appropriate distribution between tutoring/homework help and enrichment activities.

Site Name:

Proposed Planned Activities

Subject Area(s) (i.e. math, science, reading/ language arts, social studies,

technology, tutoring, health and nutrition, music and arts,

character Ed, STEM, Career Ed)

State Standard or Afterschool Code (see

Basic Coding of Learning Standards

Posted on Portal with Evaluation

Information)

Equipment (if needed, to be

purchased with grant funds)

Performed by Grantee or Outside

Agency/Partner (state the outside agency or

partner)

Timeframe (i.e. weekly,

monthly, etc.)

Target Audience (i.e. What age group

will participate?)

Example: Kids in the Kitchen

Math, nutrition, health, reading M-6 ELA-8

No grant funded equip needed/will use equip at school

4-H Extension Office Once per week throughout the school year (Sept. to May)

3-4 grade

Did you provide all the activities you were approved for in the 2019-2020 school year? Yes No If no, explain?

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MO 500‐3138 (05/20) 

ATTACHMENT B

21ST CENTURY COMMUNITY LEARNING CENTERS-TITLE IV, PART B

FFATA Reporting

FEDERAL AWARDING AGENCY U.S. Department of Education CFDA# 84.287C SUBGRANTEE

DOING BUSINESS AS

DUNS NUMBER +4 The +4 extension to a DUNS number is created by registrants when there is a need for more than one bank/Electronic Funds Transfer (EFT) account for a location.

PARENT DUNS NUMBER The parent DUNS number is the subgrantee’s parent organization’s 9-digit Data Universal Numbering System (DUNS) number.

ADDRESS

CITY STATE ZIP PRINCIPAL PLACE OF PERFORMANCE

CITY STATE ZIP The principal place of performance is the primary site where work will be performed. SUBGRANTEE: LEA (school/school district) Community-Based Organization Other, specify:

AWARD AMOUNT Congressional District (two-digit) (DESE will fill in award amount)

PROJECT DESCRIPTION

     

The description should capture the overall purpose of the subaward and, if there are multiple funding actions, sufficient description to define the need for each funding action.

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MO 500‐3138 (05/20) 

Include the names and total compensation of each of the five most highly compensated executives for the sub-grantee’s preceding completed fiscal year, if:

1. 80% or more of its annual gross revenues from Federal procurement contracts (and subcontracts) and Federal financial assistance subject to the Transparency Act, as defined at 2 CFR 170.320 (and sub awards); and

2. $25,000,000 or more in annual gross revenues from Federal procurement contracts (and subcontracts), and Federal financial assistance subject to the Transparency Act (and sub awards); and

3. the public does not have access to this information about the compensation of the senior executives of the entity through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. §§ 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986. See FFATA § 2(b)(1).

Exemption: If, in the previous tax year, you had gross income, from all sources, under $300,000, you are exempt from the requirements to report total compensation of the five most highly compensated executives.

This district/organization meets the above three items (must complete box below)

This district/organization does NOT meet the above three items (do not complete box below)

This district/organization is exempt based on the exemption definition above (do not complete box below)

Name of Executive Compensation of Executive

The above-named organization desires to continue to operate United States Department of Education (USDOE) 21st Century Community Learning Centers Programs. The above-named organization, being the authority having supervision and control over the operation of the 21st Century Community Learning Centers Grant Award agrees to furnish the DESE with all information needed to facilitate compliance with the Federal Funding Accountability and Transparency Act of 2006 reporting requirements. In addition to the items explicitly outlined herein, the above-named organization is bound by the original grant application and grant guidelines. Signatures: Signature of Authorized Representative Signature of DESE Representative Cindy Heislen Print/Type Name of Representative Print/Type Name of Representative Director, Extended Learning Title of Representative Title of Representative Date Date

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