APPLICATION FOR SCHOOL SUPPORT FUNDS NORTH DAKOTA DEPARTMENT OF PUBLIC INSTRUCTION STUDENT SUPPORT & INNOVATION DIVISION SFN (3/2018) Part A General Information – Support Type If Comprehensive, Optional Public School Choice Targeted Comprehensive Yes No School District Mailing Address City State Zip Code Name of District Authorized Representative Telephone Number Email Name of Building Principal Telephone Number Email Part B Certification and Assurances – The applicant hereby assures the Superintendent of Public Instruction that: Upon approval, school support will be expended in compliance with the applicable federal laws and regulations and the NDDPI dated December 2017. (State Required) Ensure each school it commits to serve receives all of the state and local funds it would receive in the absence of the school support funds and resources are aligned with the interventions. (Federally Required) If the district chooses to implement public school choice, it assures compliance with §1111(d)(D). (Comprehensive schools only) The district assures partnership with stakeholders in the development and implementation of the school’s improvement plan. The district assures it will approve to implementation and periodically monitor each school’s improvement plan. The district assures it will provide to parents and the public a notice regarding the accountability system on the Interactive Dashboard, website notification of NDInsights, and notice of the school’s selection for school support. The signature of the Authorized Representative below indicates the awareness and agreement with the Certification and Assurances listed in this application. Signature of District Authorized Representative Date Signature of Building Principal Date Part C Approval (For Department Use Only) – Funding Period Total Amount Signature of Authorized Official Date Approved Approved SFN 52823 (03-2018) Page 2
APPLICATION FOR SCHOOL SUPPORT FUNDS NORTH DAKOTA DEPARTMENT OF PUBLIC INSTRUCTION STUDENT SUPPORT & INNOVATION DIVISION SFN (3/2018) Part A – General Information Support Type Targeted Comprehensive If Comprehensive, Optional Public School Choice Yes No School District Mailing Address City State Zip Code Name of District Authorized Representative Telephone Number Email Name of Building Principal Telephone Number Email Part B – Certification and Assurances The applicant hereby assures the Superintendent of Public Instruction that: Upon approval, school support will be expended in compliance with the applicable federal laws and regulations and the NDDPI dated December 2017. (State Required) Ensure each school it commits to serve receives all of the state and local funds it would receive in the absence of the school support funds and resources are aligned with the interventions. (Federally Required) If the district chooses to implement public school choice, it assures compliance with §1111(d)(D). (Comprehensive schools only) The district assures partnership with stakeholders in the development and implementation of the school’s improvement plan. The district assures it will approve to implementation and periodically monitor each school’s improvement plan. The district assures it will provide to parents and the public a notice regarding the accountability system on the Interactive Dashboard, website notification of NDInsights, and notice of the school’s selection for school support. The signature of the Authorized Representative below indicates the awareness and agreement with the Certification and Assurances listed in this application. Signature of District Authorized Representative Date Signature of Building Principal Date Part C – Approval (For Department Use Only) Funding Period Total Amount Approved Signature of Authorized Official Date Approved SFN 52823 (03-2018) Page 2
SFN52823.docx