Outline
for Model Tribe/Tribal Organization CSBG Application
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I.
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Federal
Fiscal Year or Years Covered by this Tribal Plan and
Application
Please
specify the Federal fiscal year or years covered by this
plan.
FFY ____ only
FFY
____ and FFY ____
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II.
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Letter of
Transmittal
- Cover letter to the Director, Office of Community Services.
Include the Tribal CSBG Program Contact Person, the Tribal CSBG
Official who is to receive the CSBG Grant Award with complete
address, e-mail address, and telephone and fax numbers. If
there is a delegation of authority made by the CEO of the
Tribe/Tribal Organization to certify the plan on their behalf,
this information must be referenced.
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III.
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Executive Summary
A.
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Public
Inspection of Tribal Plan – Describe
how the Tribe/Tribal Organization made available for public
inspection and comment the current Tribal plan or revision to
the Tribal plan. Section 676(a)(2)(B) of the Act requires
that the plan be made available for public inspection by
members of the Tribe in such a manner as will facilitate review
of, and comment on, the plan or revision.
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B.
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Tribal
Resolutions – A
Tribal organization representing more than one Indian Tribe
will be eligible to receive block grant funds on behalf of a
particular Tribe only if the Tribe has by resolution authorized
the organization’s action. Attach copies of
resolutions giving a Tribal organization authority to seek
funding for specific Tribal organizations.
OMB
Approval No. XXXX – XXXX
Expiration
Date: XX/XX/XXXX
THE PAPERWORK
REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting
burden for this collection of information is estimated to
average 10 hours per response, including the time for reviewing
instructions, gathering and maintaining the data needed, and
reviewing the collection of information.
An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of
information unless it displays a currently valid OMB control
number.
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C.
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State or
Federal Recognition – Include
documentation verifying State or Federal recognition of the
Tribe or Tribal organization covered by this plan. The
statement of the State’s chief executive office (Office
of the Governor) verifying that a Tribe is recognized by that
State will also be sufficient to verify State recognition for
the purpose of direct funding.
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IV.
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Statement of CSBG
Assurances (which includes programmatic, administrative, financial
and federal certifications)
As
a part of the annual or biannual application and plan required by
Section 676(b) of the Community Services Block Grant Act, as
amended, (42 U.S.C. 9901 et seq.) (The Act), the CEO of the
Tribe/Tribal Organization shall certify that the Tribe/Tribal
Organization agrees to implement at least one of the programmatic
assurances contained in Sections 676(b)(1)(A)-(C) of the
Act – by signature at the end of this section. Section
V. requires detailed narrative descriptions of how the assurances
will be carried out and how the organization will comply with the
certifications. (Tribes or Tribal Organizations are not
required to comply with other sections or certifications of the
Act other than those outlined here.)
A.
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Programmatic
Assurances
(1)
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Funds made available
through this grant or allotment will be used:
(a)
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to support activities
that are designed to assist low-income families and
individuals, including families and individuals receiving
assistance under part A of title IV of the Social
Security Act (42 U.S.C. 601 et seq.), homeless families
and individuals, migrant or seasonal farmworkers, and
elderly low-income individuals and families, and a
description of how such activities will enable the
families and individuals
(i)
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to remove obstacles
and solve problems that block the achievement of
self-sufficiency (including self-sufficiency for
families and individuals who are attempting to
transition off a State program carried out under part
A of title IV of the Social Security Act);
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(ii)
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to secure and retain
meaningful employment;
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(iii)
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to attain an adequate
education, with particular attention towards improving
literacy skills of the low-income families in the
communities involved, which may include carrying out
family literacy initiatives;
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(iv)
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to make better use of
available income;
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(v)
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to obtain and
maintain adequate housing and a suitable living
environment;
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(vi)
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obtain emergency
assistance through loans, grants, or other means to
meet immediate and urgent family and individual needs;
and
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(vii)
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to achieve greater
participation in the affairs of the communities;
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(3)
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To provide information
containing –
(A)
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a description of the
service delivery system;
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(B)
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a description of how
linkages will be developed to fill identified gaps in the
services, through the provision of information,
referrals, case management, and follow up consultations;
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(C)
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a description of how
funds made available through grants made under section
675C (a) will be coordinated with other public and
private resources;
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(D)
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a
description of how the Tribe will use the funds to
support innovative initiatives, which may include
fatherhood initiatives and other initiatives with the
goal of strengthening families and encouraging effective
parenting.
676(b)(3)(A)-(D)
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(4)
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To
assure that the Tribe will provide, on an emergency basis,
for the provision of such supplies and services, nutritious
foods, and related services, as may be necessary to
counteract conditions of starvation and malnutrition among
low-income individuals. 676(b)(4)
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(6)
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To
assure that the Tribe will ensure coordination between
antipoverty programs in each community within the Tribe, and
ensure, where appropriate that emergency energy crisis
intervention programs under title XXVI (relating to
low-income home energy assistance) are conducted in such
community. 676(b)(6)
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(7)
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To
assure that the Tribe will permit and cooperate with Federal
investigations undertaken in accordance with section 678D.
676(b)(7)
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(12)
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To
assure that the Tribe will participate in the Results
Oriented Management and Accountability System, another
performance measure system for which the Secretary
facilitated development pursuant to section 678E (b), or an
alternative system for measuring performance and results
that meets the requirements of that section, and a
description of outcome measures to be used to measure
performance in promoting self-sufficiency, family stability,
and community revitalization. 676(b)(12)
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B.
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Administrative and
Financial Assurances
The Chief
Executive Officer certifies that the Tribe/Tribal Organization
further agrees to prohibit any activities to provide voters and
perspective voters with transportation to the polls or provide
similar assistance in connection with an election or any voter
registration activity as required by Section 678F(b)(2)(B)
and (C) of
the Act.
To expend
for administrative expenses an amount not to exceed the greater
of five percent of its allotment or the percentage represented
by the ratio of $55,000 to the smallest State allotment for the
fiscal year as required by Section 675C(b)(2)
of the Act.
At least
annually, each Indian Tribe or Tribal Organization that
receives $500,000 or more (during the fiscal year) in all types
of Federal financial assistance must conduct an audit in
accordance with the Single Audit Act, P.L. 98-502 (31 U.S.C. 75
and OMB Circular A-128) as required by Section 678D(a)(2)(B)
of
the Act.
The Chief
Executive Officer certifies that the Tribe/Tribal Organization
agrees to provide that fiscal control and fund accounting
procedures will be established as may be necessary to assure
the proper disbursal of and accounting for Federal funds paid
to the Tribe or Tribal Organization under this subtitle,
including monitoring the assistance under this subtitle as
required by Section 678D(a)(1)(A)
of the Act.
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C.
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Other
Administrative Certifications
The
Tribe also certifies the following:
(1)
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To
provide assurances that cost and accounting standards of the
Office of Management and Budget shall apply to a recipient
of Community Services Block Grant program funds as required
by Section 678D(a)(1)(B).
(OMB Circulars A-110 and A-122)
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Signature (indicates the sign off
of assurances in previous Section
IV)
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Tribal Chairperson/CEO
Signature
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Print Name
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Date
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V.
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The Narrative Section of the
CSBG Tribal Plan ("How to Develop Plan" Instructions)
Provide the following information describing how the Tribe will
carry out these assurances, as outlined below:
A.
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Tribal
Administrative Structure
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(a)
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Outline the mission and
responsibilities to administer the Tribe’s
Community Services Block Grant program.
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(b)
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Outline the goals and
objectives of the Tribal organization to administer the
Community Services Block Grant program.
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(c)
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Planned distribution of
funds for the current fiscal year(s).
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B.
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Description
of Use of Administrative Funds
Describe
and provide a breakdown of planned administrative expenses for
the fiscal year or years covered by this plan.
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C.
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Program
Implementation - Describe
the following:
(a)
The Service Delivery System –
a description of the service delivery system for services
provided or coordinated with funds targeted to low-income
individuals and families. Include a description of the
service areas, if applicable.
(b)
Linkages – a
description of how linkages will be developed to fill
identified gaps in services, through the provision of
information, referrals, case management, and follow up
consultations.
(c)
Coordination with Other Public and Private Resources – a
description of how funds made available will be coordinated
with other public and private resources.
(d)
Innovative Community and Neighborhood-based Initiatives –
a
description of how funds will be used to support innovative
community and neighborhood-based initiatives related to the
purposes of the CSBG, which may include fatherhood initiatives
and other initiatives with the goal of strengthening families
and encouraging effective parenting.
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D.
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Programmatic Assurances
Information
describing how each of the implemented assurances from Section
676(b)(1)(A) – (C) will be carried out by the Tribe or
Tribal organization.
Include a description of how these activities will enable
families and individuals to achieve the objectives of the CSBG
program. If funds are used to address more than one
programmatic assurance, do include a description of the
activities.
Information
describing how the Tribe or Tribal organization will carry out
this assurance: To
assure that the Tribe will provide, on an emergency basis, for
the provision of such supplies and services, nutritious foods,
and related services, as may be necessary to counteract
conditions of starvation and malnutrition among low-income
individuals. Assurance 676(b)(4)
Information
describing how the Tribe or Tribal organization will carry out
this assurance: To
assure that the Tribe will ensure coordination between
antipoverty programs in each community within the Tribe, and
ensure, where appropriate that emergency energy crisis
intervention programs under title XXVI (relating to low-income
home energy assistance) are conducted in such community.
Assurance 676(b)(6)
Information
describing how the Tribe or Tribal organization will carry out
this assurance. Include a description of outcome
measures to be used to measure performance in promoting
self-sufficiency, family stability and community
revitalization: To
assure that the Tribe will participate in the Results Oriented
Management and Accountability System, another performance
measure system for which the Secretary facilitated development
pursuant to section 678E(b), or an alternative system for
measuring performance and results that meets the requirements
of that section, and a description of outcome measures to be
used to measure performance in promoting self-sufficiency,
family stability, and community revitalization. Assurance
676(b)(12)
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E.
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Fiscal Controls,
Administrative, Financial Assurances and Certifications
Describe
the Tribe or Tribal Organization’s plan for complying
with the requirement to prohibit any activities to provide
voters and perspective voters with transportation to the
polls or provide similar assistance in connection with
an election or any voter registration activity;
Describe the Tribe or Tribal
Organization’s systems of fiscal controls, procedures,
and plans for audits and inspections. Specify the date
of the last audit conducted and the period covered by the
audit.
Sign and include the
required certifications regarding Anti-Lobbying, Drug Abuse,
Debarment and Suspension and the Environmental Tobacco Smoke,
also known as the Pro-Children Act of 1994, P.L. 103-227
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F.
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Annual
Report
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Provide a narrative
description of how the Tribe met its CSBG goals and
objectives and information on the types of projects
supported with CSBG funds for the prior year. Include
information on accomplishments of projects and activities
relating to the required assurances supported with CSBG
funds received for the prior year. Include outcome
data that addresses the implementation of the stated
national goals of the CSBG for the prior year’s
funding. Provide a description of information on the
use and distribution of the prior year’s CSBG funding.
The
stated national goals are:
Goal 1 – Low-income
people become more self-sufficient (self-sufficiency).
Goal
2 - The conditions in which low-income people live are
improved (community revitalization).
Goal 3 –
Low-income people own a stake in their community.
Goal
4 – Partnerships among supporters and providers of
services to low-income people are achieved.
Goal 5 –
Agencies increase their capacity to achieve results.
Goal
6 – Low-income people, especially vulnerable
populations, achieve their potential by strengthening family
and other supportive systems. (family stability)
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VI.
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Appendices
A.
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Additional Data or
Information (as needed)
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