MAC Cost Pool Certification_IGA level.xlsx

	A	C
1	ESD Name
2	Street Address	DATE:
3	City, State, Zip Code	MAC quarter
4	Phone # and Fax #	Total MAC Claim Amount
5		Agreement (IGA) No.
6		IGA Effective Date
7	Submit certification to:	IGA Expiration Date
8	Lasa Baxter
9	lasa.baxter@imesd.k12.or.us
10	(enter “MAC Cost Pool Certification” in the subject line)
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14	DESCRIPTION OF CERTIFICATION:
15	By signing here, I certifiy that all Federal Funds have been removed from the cost pool for the District/ESD identified above. In addition, no duplicate claiming of funds have occurred, including personnel in the cost pool that were part of the state approved ODE indirect rate computation. (Note: application of indirect rate is optional)
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17	Authorizing Signature:
18	Date:
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20	For questions regarding cost pool certification, contact, (Contact Person), (contact phone number)
21	(Contact e-mail address)
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23	Instructions: Prior to requesting OHA's review of your MAC claim, ESD's must acquire a signed cost pool certification
24	form from each of their participating Districts. Afterwhich, the ESD will then compile those certifications and submit
25	one certification to OHA on behalf of the complete ESD MAC cost pool. NOTE: Districts will not submit their cost pool certifications
26	to OHA separately.
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