Wisconsin Department of Public Instruction INSTRUCTIONS: To be recognized as a partnering organization,

EXTERNAL ORGANIZATION NOMINATIONS FOR 21ST complete the following form and return to:
CENTURY COMMUNITY LEARNING CENTERS WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION
PI-9580-IV-B (New 12-16) STUDENT SERVICES, PREVENTION AND WELLNESS TEAM
125 SOUTH WEBSTER STREET
PO BOX 7841
MADISON, WI 537077841
For questions regarding this form, contact Student Services, Prevention and
Wellness Team (608) 266-8960. Send electronic copy to: clc@dpi.wi.gov

The Elementary and Secondary Education Act was reauthorized under the title of the Every Student Succeeds Act (ESSA). With that reauthorization,
significant new requirements for being awarded a 21st Century Community Learning Center (21st CCLC) grant and for implementing a grant funded
program under Title IV, Part B are being established (see pages 181-192 at https://www.gpo.gov/fdsys/pkg/BILLS-114s1177enr/pdf/BILLS-
114s1177enr.pdf). Under Section 4203(a)(11)(B) of the ESSA, the Wisconsin Department of Instruction (WI DPI) is required to provide a list of
external organizations with whom grantees may choose to work. In order to facilitate this ESSA requirement, the WI DPI is soliciting nominations of
such external organizations from current grantees.
As the WI DPI reviews the nominees information and finds that it is complete, organizations will be added to the WI DPI 21st Century Community
Learning Centers website for a period of two years, at which time organizations must reapply. This list of agencies is intended to serve as a resource
for 21st CCLC programs looking for potential partners in their region.
NOTE: The finalized document will not be an exhaustive list nor will it comprise an endorsement or certification of quality from the WI DPI.

I. GENERAL INFORMATION

Name of Organization Email Address

Humane Animal Welfare Society khris@hawspets.org

Mailing Address Street, City, State, Zip Telephone Area/No.

701 Northview Road, Waukesha, WI 53188 262-542-8851 x118

Geographic Areas Served County/Zip Codes

Waukesha County, WI

II. NONPROFIT STATUS

Check the box that best describes your organizations nonprofit status.

501(c)(3) Other tax exempt entity Not a nonprofit

III. CERTIFICATION/SIGNATURES

I CERTIFY that this information is true and correct to the best of my knowledge and that I am authorized to sign this document on behalf of the
organization listed above.

Name of Organization Representative Representatives Title

Khris Erickson Humane Education Manager

Signature of Organization Representative Date Signed Mo./Day/Yr.

1/18/17

Name of Grantee Grantees Title

Signature of Grantee Date Signed Mo./Day/Yr.

Page 2 PI-9580-IV-B

IV. CERTIFICATION COVERING DEBARMENT

Must be submitted for discretionary projects only. However, agencies receiving funds under any of the other grant programs must collect this
certificate whenever they enter into a covered transaction with a grantee. (Refer to instructions for more information.)
Certification Regarding
Debarment, Suspension, Ineligibility, and Voluntary Exclusion
Lower Tier Covered Transactions

This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 34 CFR Section 180, Participants'
responsibilities. Copies of the regulations may be obtained by contacting the person to whom this proposal is submitted.

1. The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.

2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall
attach an explanation to this proposal.

LEA/Agency/Company Name

Name and Title of Authorized Representative

Signature Date Signed Mo./Day/Yr.

INSTRUCTIONS FOR CERTIFICATION

1. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is
later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to
the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension
and/or debarment. 2 C.F.R. 180.360.
2. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the
prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed
circumstances. 2 C.F.R. 180.265
3. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not
knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by the department or agency with which this transaction originated. 2 C.F.R. 180.305
4. The prospective lower tier participant further agrees by submitting this proposal that it will include the clause titled "Certification Regarding
Debarment, Suspension, Ineligibility, and Voluntary Exclusion-Lower Tier Covered Transaction," without modification, in all lower tier covered
transactions and in all solicitations for lower tier covered transactions. 2 C.F.R. 180.300.
5. A participant in a covered transaction is responsible for determining whether a prospective participant in a lower tier covered transaction is not
debarred, suspended, ineligible, or voluntarily excluded from the covered transaction. A participant may decide the method and frequency by which
it determines the eligibility of its principals. Each participant may, but is not required to, check the Nonprocurement List (202-786-0688). 2 C.F.R.
180.320.

The terms "covered transaction, "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person," "primary covered
transaction, "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and coverage
sections of rules implementing Executive Order 12549. These definitions can be found in Subparts B and I of 180. 2 C.F.R. 180.110.
 V. MISSION STATEMENT

Provide your organizations mission statement.

Page 4 PI-9580-IV-B
PI-9580-IV-B Page 5
V. MISSION STATEMENT (contd)

VI. SUMMARIZATION

Summarize your organizations record of success in running or working with before and after school (or summer recess) programs and activities
(brief narrative paragraph, no attachments).

VII. SUPPORT SERVICES

Page 6 PI-9550-IV-B
V. MISSION STATEMENT (contd)

Describe the services, support, or expertise your organization is qualified to offer (brief narrative paragraph).
 Wisconsin Department of Public Instruction INSTRUCTIONS: To be recognized as a partnering organization,
EXTERNAL ORGANIZATION NOMINATIONS FOR 21ST complete the following form and return to:
CENTURY COMMUNITY LEARNING CENTERS WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION
PI-9580-IV-B (New 12-16) STUDENT SERVICES, PREVENTION AND WELLNESS TEAM
125 SOUTH WEBSTER STREET
! PO BOX 7841
MADISON, WI 537077841
For questions regarding this form, contact Student Services, Prevention and Send electronic copy to: clc@dpi.wi.gov
Wellness Team (608) 266-8960.

The Elementary and Secondary Education Act was reauthorized under the title of the Every Student Succeeds Act (ESSA). With that
reauthorization, significant new requirements for being awarded a 21st Century Community Learning Center (21st CCLC) grant and for implementing
a grant funded program under Title IV, Part B are being established (see pages 181-192 at https://www.gpo.gov/fdsys/pkg/BILLS-114s1177enr/pdf/
BILLS-114s1177enr.pdf). Under Section 4203(a)(11)(B) of the ESSA, the Wisconsin Department of Instruction (WI DPI) is required to provide a list of
external organizations with whom grantees may choose to work. In order to facilitate this ESSA requirement, the WI DPI is soliciting nominations of
such external organizations from current grantees.
As the WI DPI reviews the nominees information and finds that it is complete, organizations will be added to the WI DPI 21st Century Community
Learning Centers website for a period of two years, at which time organizations must reapply. This list of agencies is intended to serve as a resource
for 21st CCLC programs looking for potential partners in their region.
NOTE: The finalized document will not be an exhaustive list nor will it comprise an endorsement or certification of quality from the WI DPI.

I. GENERAL INFORMATION

Name of Organization Email Address

Mailing Address Street, City, State, Zip Telephone Area/No.

Geographic Areas Served County/Zip Codes

II. NONPROFIT STATUS

Check the box that best describes your organizations nonprofit status.

501(c)(3) Other tax exempt entity Not a nonprofit

III. CERTIFICATION/SIGNATURES

I CERTIFY that this information is true and correct to the best of my knowledge and that I am authorized to sign this document on behalf of the
organization listed above.

Name of Organization Representative Representatives Title

Signature of Organization Representative Date Signed Mo./Day/Yr.

Name of Grantee Grantees Title

Signature of Grantee Date Signed Mo./Day/Yr.

IV. CERTIFICATION COVERING DEBARMENT

Must be submitted for discretionary projects only. However, agencies receiving funds under any of the other grant programs must collect this
certificate whenever they enter into a covered transaction with a grantee. (Refer to instructions for more information.)
Certification Regarding
Debarment, Suspension, Ineligibility, and Voluntary Exclusion
Lower Tier Covered Transactions
Page 2 PI-9580-IV-B
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 34 CFR Section 180, Participants'
responsibilities. Copies of the regulations may be obtained by contacting the person to whom this proposal is submitted.

1. The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.

2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall
attach an explanation to this proposal.

LEA/Agency/Company Name

Name and Title of Authorized Representative

Signature Date Signed Mo./Day/Yr.

INSTRUCTIONS FOR CERTIFICATION

1. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is
later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to
the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension
and/or debarment. 2 C.F.R. 180.360.
2. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the
prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed
circumstances. 2 C.F.R. 180.265
3. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not
knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by the department or agency with which this transaction originated. 2 C.F.R. 180.305
4. The prospective lower tier participant further agrees by submitting this proposal that it will include the clause titled "Certification Regarding
Debarment, Suspension, Ineligibility, and Voluntary Exclusion-Lower Tier Covered Transaction," without modification, in all lower tier covered
transactions and in all solicitations for lower tier covered transactions. 2 C.F.R. 180.300.
5. A participant in a covered transaction is responsible for determining whether a prospective participant in a lower tier covered transaction is not
debarred, suspended, ineligible, or voluntarily excluded from the covered transaction. A participant may decide the method and frequency by which
it determines the eligibility of its principals. Each participant may, but is not required to, check the Nonprocurement List (202-786-0688). 2 C.F.R.
180.320.

The terms "covered transaction, "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person," "primary covered
transaction, "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and coverage
sections of rules implementing Executive Order 12549. These definitions can be found in Subparts B and I of 180. 2 C.F.R. 180.110.
 V. MISSION STATEMENT

Provide your organizations mission statement.

Page 4 PI-9580-IV-B

PI-9580-IV-B Page 5
V. MISSION STATEMENT (contd)

VI. SUMMARIZATION

Summarize your organizations record of success in running or working with before and after school (or summer recess) programs and activities
(brief narrative paragraph, no attachments).

VII. SUPPORT SERVICES

Describe the services, support, or expertise your organization is qualified to offer (brief narrative paragraph).

Page !6 PI-9550-IV-B
V. MISSION STATEMENT (contd)