HEP GPRA Form

Grantee Name: ________________ Grant Year: ☐Y1 Y2 ☐Y3 ☐Y4 ☐Y5

PR Number: S141A_ _ _ _ _ _ Reporting Period: 07/01/2012 — 06/30/2013

HEP GPRA 1 Documentation Form

Directions: Please complete the table below by providing the following information.

For Final Performance Reports, the table should reflect the students who attained a high school equivalency (HSE) certification during the Year 5 reporting period.

• Student Name. Provide the first name, middle initial, and last name of each student who attained a HSE high school equivalency certification during the current reporting period.

• HSE Credential Number or other Identification Number (ID). If the State issues a HSE credential (or certificate), provide the unique credential number. If the State does not issue a credential, provide the unique ID that is associated with the attainer’s transcript. Please keep a copy of the credential or the transcript that is being used for this attestation.

• The date of the last sub-test taken. Provide the exact date that the HSE attainer took the last sub-test in order to pass the HSE. Provide this information in the form of Month/Day/Year (e.g. 03/29/2011).

• Did the date of the last sub-test occur during this reporting period? Provide a “Yes” or “No” answer to this question. All HSE attainers that you count in this report (all students that are listed on this page) should have taken the last sub-test during this reporting period of the APR.

	Student Name	HSE Credential Number, OR Other Identification Number if the State does not issue a HSE Credential	The date of the last sub-test taken and passed that yielded the HSE certificate (MO/DAY/YR)	Did the date of the last sub-test occur during the current reporting period? (Yes/No)
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Directions: Provide the appropriate signatures below so that the HEP director and HEP authorized representative attest to the accuracy of the information provided above. Please read the statement below and provide the required signatures.

I have verified and attest to the fact that all students who are listed above were enrolled in the ______________________________ HEP project and attained their HSE during the current reporting period.

________________________________________________________ _________________

(Signature of HEP Director) (Signature Date)

_________________________________________________________ _________________

(Signature of HEP Authorized Representative) (Signature Date)

This list must be:

1. Completed as a MS Word document;

2. Verified and signed by the Director and the Authorized Representative;

3. Scanned/converted into PDF format (to capture authorizing signatures); and

4. Email the PDF copy to OME with three additional APR files (total 4 files) in a single email.

OMB No. 1810-0684 HEP GPRA 1 Documentation Form Page 14 of 14 Exp. 03/31/2017