Michigan Department of Treasury
5734 (10-20), Page 1 of 1
Teacher and School Support Sta COVID-19 Grants Certication
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 nonprot nonpublic school subject to the eligibility requirements.
Read the attached instructions before completing the application. Certications must be submitted to the School District or Nonprot
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 Nonprot 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 Identication 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 nonprot 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 nonprot 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 eectively 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 eectively 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 nonprot 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 nonprot nonpublic schools for 7 years.
Submit your completed application to the School District or Nonprot Nonpublic School by the deadline listed on the application in the
form and manner established by the school district or nonprot nonpublic school.
DO NOT send this form directly to the Michigan Department of Treasury.