Fill - Free fillable Teacher and School Support Sta COVID-19 Grants Certication (Michigan) PDF form

Michigan Department of Treasury

5734 (10-20), Page 1 of 1

Teacher and School Support Sta COVID-19 Grants Certication

Issued under authority of Public Act 166 of 2020, Article 5.

This form is to be used by classroom teachers and school support sta to certify eligibility for the COVID-19 Grants Program funding

made available for eligible K-12 classroom teachers and school support sta employed by or assigned to regularly and continuously

work under contract in a public school operated by the district or in a nonprot nonpublic school subject to the eligibility requirements.

Read the attached instructions before completing the application. Certications must be submitted to the School District or Nonprot

Nonpublic School no later than December 4, 2020. This form is not to be sent to the Michigan Department of Treasury. Please pay

particular attention to accurately including the residency address and social security number.

PART 1: BACKGROUND INFORMATION

Local School District Name or Nonprot Nonpublic School Name Intermediate School District Name (if applicable)

Requestor’s First Name Requestor’s Last Name Requestor’s E-mail Address

Mailing Address City State ZIP Code

Requestor’s Social Security Number Personal Identication Code (According to the Registry of Educational Personnel

“REP”)

PART 2a: CLASSROOM TEACHER CLASSIFICATION (See instructions for Eligibility Status)

Are you an eligible “Classroom Teacher” applying for the Teacher COVID-19 Grant?

Yes No

If you answered “Yes,” please complete Section 3a to certify you meet all the grant requirements.

If you checked “No,” see Section 2b.

PART 2b: SCHOOL SUPPORT STAFF CLASSIFICATION (See instructions for Eligibility Status)

Are you eligible “School Support Sta” applying for the School Support COVID-19 Grant?

Yes No

If you answered “Yes,” please complete Section 3b to certify you meet all the grant requirements.

If you checked “No” for both Sections 2a and 2b, visit www.michigan.gov/TSSC19Grants for the Teacher and School Support COVID-19 Grant

eligibility requirements.

PART 3a: AFFIRMATION OF GRANT ELIGIBILITY REQUIREMENTS - CLASSROOM TEACHER

(Check each box to verify all requirements below are met)

Prior to the issuance of Executive Order 2020-35 on April 2, 2020, I performed at least 75% of my standard instructional

workload in a brick and mortar classroom at a district or nonprot nonpublic school

After issuance of Executive Order 2020-35 on April 2, 2020, I developed tools and methods to deliver distance learning, take-

home packets, or other methods described in the district or nonprot nonpublic school’s continuity of learning plan

I worked additional time spent outside of normal working hours, experienced hazardous conditions, or incurred additional costs

related to ensuring students could eectively participate in the school’s continuity of learning plan

PART 3b: AFFIRMATION OF GRANT ELIGIBILITY REQUIREMENTS - SCHOOL SUPPORT STAFF

(Check each box to verify all requirements below are met)

Prior to the issuance of Executive Order 2020-35 on April 2, 2020, I performed at least 75% of my workload in a brick and

mortar school building at a district

I worked additional time spent outside of normal working hours, experienced hazardous conditions, or incurred additional costs

related to ensuring students could eectively participate in the school’s continuity of learning plan

PART 4: CERTIFICATION

I hereby certify to the best of my knowledge that the information provided in this Application is true and that I am eligible to receive the

above-stated COVID-19 Grant pursuant to P.A. 166 of 2020, Article 5, Section 949p or 949q.

Eligible Teacher or Support Sta Signature Date

This form is subject to audit by the Michigan Department of Treasury. The district or nonprot nonpublic school is required to review

that the requester meets all the eligibility requirements for the Teacher COVID-19 Grant or Support Sta COVID-19 Grant. This form

must be retained by the district or nonprot nonpublic schools for 7 years.

Submit your completed application to the School District or Nonprot Nonpublic School by the deadline listed on the application in the

form and manner established by the school district or nonprot nonpublic school.

DO NOT send this form directly to the Michigan Department of Treasury.

Reset Form

Instructions for Completing Form 5734,

Teacher and School Support Sta COVID-19 Grants Certication

The Teacher COVID-19 Grant program was created by Public Act 166 of 2020 to recognize the additional time

classroom teachers in a district or nonprot nonpublic school spent outside of normal working hours and additional costs

classroom teachers have incurred or experienced to provide a continuity of learning during the period of school closure in

2019-2020 as a result of the COVID-19 pandemic. The program was funded under Article 5, Section 949p for grants to

eligible K-12 classroom teachers.

The School Support COIVD-19 Grant program was created by Public Act 166 of 2020 for grants to eligible K-12 school

support sta

to recognize the additional time spent outside of normal working hours, hazardous conditions, and additional

costs school support sta have incurred or experienced to provide services to students during the period of school closure

in 2019-2020 as a result of the COVID-19 pandemic. Please note if you work for a nonprot nonpublic school you

are not eligible for this grant. The program was funded under Article 5, Section 949q for grants to eligible K-12 school

support sta.

Denitions

Classroom teacher means a full-time or part-time teacher with an assigned class who provided continuity of learning to

students during the 2019-2020 period of school closure that resulted from COVID-19. For the purposes of this section,

classroom teacher does not include substitute teachers, para-professionals, support sta, or administrators.

School support sta means a full-time or part-time para-professional, aide, or non-instructional sta, according to the

registry of educational personnel, who provided services to students during the 2019-2020 period of school closure that

resulted from COVID-19. School support sta does not include substitute teachers or classroom teachers.

District means a local school district as that term is dened in section 6 of the revised school code, 1976 PA 451, MCL

380.6, or a public school academy as that term is dened in section 5 of the revised school code, 1976 PA 451, MCL

380.5.

Regularly and continuously work under contract means that term as defined in section 1230e of the revised school code,

1976 PA 451, MCL 380.1230e.

PART 1: BACKGROUND INFORMATION

Complete all fields. The district or nonprofit public school listed in the background information should be the district or

nonprofit public school that identified you as an eligible grant recipient. If you work for multiple districts or nonprofit

nonpublic schools, then the eligible grant recipient needs to file this form with each district or nonprofit public school that

identifies the requester as an eligible grant recipient.

PART 3a: AFFIRMATION OF ELIGIBILITY – CLASSROOM TEACHER

This section is to be completed by a classroom teacher applying for the Teacher COVID-19 Grant Program provided

under Article 5, Section 949p. Check all boxes that apply.

PART 3b: AFFIRMATION OF ELIGIBILITY – SCHOOL SUPPORT STAFF

This section is to be completed by school support staff applying for the School Support Staff COVID-19 Grant Program

provided under Article 5, Section 949q. Check all boxes that apply.

PART 4: CERTIFICATION

Sign and date in the indicated fields. Electronic signature is acceptable.

MAILING INFORMATION

Submit your completed application to the School District or Nonprofit Nonpublic School by the deadline listed on the

application in the form and manner established by the school district or nonprofit nonpublic school.

DO NOT send this form directly to the Michigan Department of Treasury.

More information on these grant programs, including a detailed Frequently Asked Questions (FAQ) guide, can be found

on the Teacher and School Support COVID-19 Grant Website at www.michigan.gov/TSSC19Grants

Fill Online, Printable, Fillable, Blank Teacher and School Support Sta COVID-19 Grants Certication (Michigan) Form

Related forms

Fillable Teacher and School Support Sta COVID-19 Grants Certication (Michigan)

Fill Online, Printable, Fillable, Blank Teacher and School Support Sta COVID-19 Grants Certication (Michigan) Form

Related forms

First 20 documents completely FREE!