State Programs - Internet Safety Certification form

INTERNET SAFETY CERTIFICATION FOR APPLICANT PUBLIC
LIBRARIES PUBLIC ELEMENTARY AND SECONDARY SCHOOL
LIBRARIES, and CONSORTIA WITH PUBLIC AND/OR PUBLIC
SCHOOL LIBRARIES

As the duly authorized representative of the applicant library, I hereby certify that the
library is (check only one of the following boxes)

A. CIPA Compliant (The applicant library has complied with the requirements of
20 U.S.C. § 9134(f)(1) et seq.
OR
B. The CIPA requirements do not apply because no funds made available under the
LSTA program are being used to purchase computers to access the Internet, or to
pay for direct costs associated with accessing the Internet.

Signature of Authorized Representative

Printed Name of Authorized Representative

Title of Authorized Representative

Date

Name of Applicant Library/Program
OMB No. 3137-0071; Expiration Date: 8/31/2013