Form 3 Form 3 Form 3

Form 3 OMB No. 0930-0080

Uniform Application for FY 2007 Substance Abuse Prevention and Treatment Block Grant

Funding Agreements/Certifications

as Required by the Public Health Service (PHS) Act

As part of the annual application for Block Grant funds, it is required under Title XIX, Part B, Subpart II of the Public Health Services Ac The PHS Act, as amended, requires the chief executive officer (or an authorized designee) of the applicant organization to certify that the State will comply with the following specific citations as summarized and set forth below, and with any regulations or guidelines issued in conjunction with this Subpart except as exempt by statute.

We will accept a signature on this form as certification of agreement to comply with the cited provisions of the PHS Act. If signed by a designee, a copy of the designation must be attached.

I. Formula Grants to States, Section 1921

Grant funds will be expended “only for the purpose of planning, carrying out, and evaluating activities to prevent and treat substance abuse and for related activities” as authorized.

II. Certain Allocations, Section 1922

• Allocations Regarding Primary Prevention Programs, Section 1922(a)

• Allocations Regarding Women, Section 1922(b)

III. Intravenous Drug Abuse, Section 1923

• Capacity of Treatment Programs, Section 1923(a)

• Outreach Regarding Intravenous Substance Abuse, Section 1923(b)

IV. Requirements Regarding Tuberculosis and Human Immunodeficiency Virus, Section 1924

V. Group Homes for Recovering Substance Abusers, Section 1925

Optional beginning FY 2001 and subsequent fiscal years. Territories as described in Section 1925(c) are exempt.

The State “has established, and is providing for the ongoing operation of a revolving fund” in accordance with Section 1925 of the PHS Act, as amended. This requirement is now optional.

VI. State Law Regarding Sale of Tobacco Products to Individuals Under Age of 18, Section 1926:

• The State has a law in effect making it illegal to sell or distribute tobacco products to minors as provided in Section 1926 (a)(1).

• The State will enforce such law in a manner that can reasonably be expected to reduce the extent to which tobacco products are available to individuals under the age of 18 as provided in Section 1926 (b)(1).

• The State will conduct annual, random unannounced inspections as prescribed in Section 1926 (b)(2).

VII. Treatment Services for Pregnant Women, Section 1927

The State “…will ensure that each pregnant woman in the State who seeks or is referred for and would benefit from such services is given preference in admission to treatment facilities receiving funds pursuant to the grant.”

VIII. Additional Agreements, Section 1928

• Improvement of Process for Appropriate Referrals for Treatment, Section 1928(a)

• Continuing Education, Section 1928(b)

• Coordination of Various Activities and Services, Section 1928(c)

• Waiver of Requirement, Section 1928(d)

IX. Submission to Secretary of Statewide Assessment of Needs, Section 1929

X. Maintenance of Effort Regarding State Expenditures, Section 1930

With respect to the principal agency of a State, the State “will maintain aggregate State expenditures for authorized activities at a level that is not less than the average level of such expenditures maintained by the State for the 2-year period preceding the fiscal year for which the State is applying for the grant.”

XI. Restrictions on Expenditure of Grant, Section 1931

XII. Application for Grant; Approval of State Plan, Section 1932

XIII. Opportunity for Public Comment on State Plans, Section 1941

The plan required under Section 1932 will be made “public in such a manner as to facilitate comment from any person (including any Federal person or any other public agency) during the development of the plan (including any revisions) and after the submission of the plan to the Secretary.

XIV. Requirement of Reports and Audits by States, Section 1942

XV. Additional Requirements, Section 1943

XVI. Prohibitions Regarding Receipt of Funds, Section 1946

XVII. Nondiscrimination, Section 1947

XVIII. Services Provided By Nongovernmental Organizations, Section 1955

I hereby certify that the State or Territory will comply with Title XIX, Part B, Subpart II and Subpart III of the Public Health Service Act, as amended, as summarized above, except for those Sections in the Act that do not apply or for which a waiver has been granted or may be granted by the Secretary for the period covered by this agreement.

State:

Name of Chief Executive Officer or Designee:

Signature of CEO or Designee:

Title: Date Signed:

If signed by a designee, a copy of the designation must be attached

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Form Approved: 08/26/2004 Approval Expires: 08/31/2007