Form CSREES-665 Assurance of Compliance with the Department of Agricultu

OMB Approval 0524-0026
Expires 8/31/2006

UNITED STATES DEPARTMENT OF AGRICULTURE
COOPERATIVE STATE RESEARCH, EDUCATION, AND EXTENSION SERVICE

ASSURANCE OF COMPLIANCE
with the

DEPARTMENT OF AGRICULTURE REGULATIONS
ASSURING CIVIL RIGHTS COMPLIANCE
Legal name of the proposed applicant
(Hereinafter called the
Applicant) hereby agrees that it will offer its programs to all eligible persons without regard to race, color, national
origin, sex, disability, age, political beliefs, religion, marital status, or familial status and that people will not be
excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any
program or activity for which the Applicant receives Federal financial assistance from the Department of Agriculture;
and hereby gives assurance that it will immediately take any measures necessary to effectuate this agreement.
This assurance is given in consideration of and for the purpose of obtaining any and all Federal grants, loans,
contracts, property, discounts or other Federal financial assistance extended after the date hereof to the Applicant by
the Department, including installment payments after such date on account of applications for Federal financial
assistance which were approved before such date. The Applicant recognizes and agrees that such Federal assistance
will be extended in reliance on the representations and agreements made in this assurance, and that the United States
shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the Applicant, its
successors, transferees, and assignees.
TYPED NAME AND TITLE OF AUTHORIZED ORGANIZATIONAL REPRESENTATIVE

S IG N A T U R E

DATE

APPLICANT’S MAILING ADDRESS

Acc ording to the Pap erw ork Re duc tion Ac t of 1995, an agen cy m ay not con duc t or spo nso r, and a p erso n is no t required to resp ond to a collec tion of inform ation un less it
displays a valid OMB control number. The valid OMB control number for this information collection is 0524-0026. The time required to complete this information
co llec tion is estim ated to avera ge .5 hou rs p er re sp ons e, inc ludi ng th e tim e for re viewi ng in stru ctio ns , sea rch ing e xisting data sou rce s, ga theri ng a nd m ainta inin g the data
needed, and completing and reviewing the collection of information.

FOR M CSREES-665
Revised 8/2003