Form 1 PA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

ADMINISTRATION FOR CHILDREN AND FAMILIES

Program Office:	Administration on Children, Youth, and Families (ACYF), Family and Youth Services Bureau (FYSB)
Program Announcement Number:	HHS-2008 ACF-ACYF-SDVC-XXXX
Announcement Title:	Family Violence Prevention and Services/Grants to State Domestic Violence Coalitions
CFDA Number:	93.647
Due Date for Applications	(Insert date 30 days from date of publication in the Federal Register)

Executive Summary: This announcement governs the proposed award of formula grants under the Family Violence Prevention and Services Act (FVPSA) to private, non-profit State Domestic Violence Coalitions (Coalitions). The purpose of these grants is to assist in the conduct of activities to promote domestic violence intervention and prevention and to increase public awareness of domestic violence issues (42 U.S.C. 10410(a)).

This notice for family violence prevention and services grants to Coalitions serves four purposes: the first purpose is to confirm a Federal commitment to reducing domestic violence; the second is to urge States, localities, cities, and the private sector to become involved in State and local planning towards an integrated service delivery approach that meets the needs of all victims, including those in marginalized communities; the third is to provide for technical assistance and training relating to domestic violence programs; and the forth is to increase public awareness about and prevention of domestic violence and increase the quality and availability of immediate shelter and related assistance for victims of domestic violence and their dependents (42 U.S.C. 10401). Starting in Fiscal Year (FY) 2009, applications should cover FYs 2009, 2010 and 2011 (see Section II, Funds Available, Length of Project Period).

I. DESCRIPTION

Legislative Authority:  The Family Violence Prevention and Services Act (42 U.S.C. 10401 et. seq.).

Background 

The Family Violence Prevention and Services Act (42 U.S.C. 10410 et seq.) authorizes the Department of Health and Human Services (HHS) Secretary to award grants to statewide, private, non-profit Coalitions to conduct activities to promote domestic violence intervention and prevention and to increase public awareness of domestic violence issues.

Annual State Domestic Violence Coalition Grantee Meeting

Coalitions are expected to send one or more representatives to the annual grantee meeting. Subsequent correspondence will advise Coalition’s of the date, time, and location of their grantee meeting.

Client Confidentiality

FVPSA programs must establish or implement policies and protocols for maintaining the safety and confidentiality of the adult victims of domestic violence and their children whom they serve.  It is essential that the confidentiality of individuals receiving FVPSA services be protected.  Consequently, when providing statistical data on program activities and program services, individual identifiers of client records will not be used by Coalitions, the State, or other FVPSA grantees or subgrantees. The address or location of any FVPSA-supported shelter facility will, except with written authorization of the person or persons responsible for the operation of such shelter, not be made public and the confidentiality of records pertaining to any individual provided domestic violence services by any FVPSA-supported program will be strictly maintained (42 U.S.C. 10402(a)(2)(E)).

Confidentiality requirements have been strengthened and clarified with the passage of the Violence Against Women and Department of Justice Reauthorization Act of 2005 (Public Law 109-162).  In the interest of establishing a consistent Federal standard for domestic violence programs, HHS follows the confidentiality provisions and definition of “personally identifying information” in sections 40002(b)(2) and 40002(a)(18) of the Violence Against Women Act of 1994 (42 U.S.C. 13925(b)(2) and 42 U.S.C. 13925(a)(18)) as a more detailed guidance for grantees about how to comply with the FVPSA confidentiality statute, and requires FVPSA-funded programs to comply with the VAWA confidentiality provisions.  Included in the confidentiality provisions are grant conditions regarding the disclosure of personally identifying information, confidentiality, information sharing, and when release of information is compelled.

In FY 2009 guidance, the FVPSA Program requires that grantees only collect unduplicated data for each program, and that information not be unduplicated across programs or statewide. No client-level data may be shared with a third party, regardless of encryption, hashing or other data security measures, without a written, time-limited release as described in section 40002(b)(2) of the Violence Against Women Act of 1994 (42 U.S.C. 13925(b)(2)).

The Importance of Coordinated, Accessible Services

The impacts of domestic violence may include physical injury and death of primary or secondary victims, psychological trauma, isolation from family and friends, harm to children living with a parent or caretaker who is either experiencing or perpetrating domestic violence, increased fear, reduced mobility, damaged credit, employment and financial stability, homelessness, substance abuse, chronic illnesses and a host of other health and related mental health consequences.

Coordination and collaboration among victim services providers, community-based, culturally specific service providers, housing providers and homeless services providers, the police, prosecutors, the courts, child welfare services, employers and businesses, medical and mental health service providers, and Federal, State, and local public officials and agencies is needed to provide more responsive and effective services to victims of domestic violence and their families.  It is essential that community service providers, including those serving or representing marginalized communities, are involved in the design and improvements of intervention and prevention activities.

To help bring about a more effective response to the problem of domestic violence, HHS urges the designated Coalitions receiving funds under this grant announcement to continue to coordinate activities funded under this grant with other new and existing resources for the prevention of domestic violence and related issues.

To serve victims most in need and to comply with Federal law, services must be widely accessible. Services must not discriminate on the basis of age, handicap, sex, race, color, national origin or religion (42 U.S.C. 10406). HHS Services Office for Civil Rights provides guidance to grantees in complying with these requirements. Please see http://www.hhs.gov/ocr/immigration/bifsltr.html for HHS Office of Civil Rights guidance on serving immigrant victims and http://www.hhs.gov/ocr/discrimdisab.html for guidance on the Americans with Disabilities Act and the Rehabilitation Act of 1973. Services must also be provided on a voluntary basis; receipt of shelter or housing must not be conditioned on participation in supportive services.

National Data Collection and Outcomes Measurement

In collaboration with partners at the State FVPSA programs, Coalitions, Tribes and Tribal organizations, the National Resource Center on Domestic Violence, and experts on both data collection and domestic violence issues, the FVPSA Program continues to develop informative, succinct, and non-burdensome reporting formats that safely measure quantifiable outputs and outcomes.  During FY 2007, the FVPSA Program revised and defined the program services reporting components for recipients of FVPSA State Formula Grant funds.  Throughout FY 2008, grantee workshops, teleconferences, and information memoranda provided further guidance on performance reporting requirements for these grantees. In FY 2009, the FVPSA Program is requiring States and their subgrantees, and Tribal grantees to use standardized reporting forms to facilitate the collection of uniform, aggregate data on FVPSA-supported program services and client outcomes, as described in Section V.

II. FUNDS AVAILABLE

In accordance with 42 U.S.C. 10409(d), in FYs 2009 through 2011, HHS will make 10 percent of the amount appropriated under 42 U.S.C. 10409(a)(1), which is not reserved under 42 U.S.C. 10409(a)(2), available for grants to the State-designated, statewide, domestic violence Coalitions. Each year, one grant each will be available for each of the Coalitions in the 50 States, the Commonwealth of Puerto Rico, and the District of Columbia.  The Coalitions of the U.S. Territories (Guam, U.S. Virgin Islands, Northern Mariana Islands, American Samoa, and Trust Territory of the Pacific Islands) are also eligible for grant awards under this announcement.

Length of Project Periods

The project period under this program announcement continues to be 24 months for each FY award. However, applications submitted by Coalitions now cover funding for FY 2009 and FY 2011. In other words, Coalitions apply for three years of grant funds in this one application, but they still have the same amount of time – two years per grant award – to spend the funds. Coalitions will not be required to submit additional applications for the years FY 2010 through FY 2011 unless there are material changes made to the program. Therefore, Coalitions must address their anticipated activities not only for the FY 2009 project period; i.e., October 2009 through September 2011, but also for the project periods covered by FYs 2010 through 2011; i.e., October 2010 through September 2012. Coalitions will have the opportunity to amend their applications for each of the fiscal years FY 2010 and FY 2011 if their anticipated activities materially change. This change does not affect the amount of the grant award or the timing of the grant award, only the application process.

Coalitions will submit a budget narrative with their FY 2009 application, which will show projected budget expenditures for the proposed activities for the two-year project period for the FY 2009 grant, as well as noting any anticipated changes in budget expenditures for the FY 2010 and 2011 project periods. Coalitions will not submit applications in FYs 2010 and FY 2011 unless there are significant changes in their budget narratives. The funds will be awarded annually and only after receipt of the Coalition’s annual report of activities; Coalitions will receive only those funds appropriated for the given fiscal year and must be appropriately accountable to receive funding for the next fiscal year.

Expenditure Period

The FVPSA funds may be used for expenditures on or after October 1 of each fiscal year for which they are granted and will be available for expenditure through September 30 of the following fiscal year; i.e., FY 2009 funds may be used for expenditures from October 1, 2008, through September 30, 2010. 

III. ELIGIBILITY

To be eligible for grants under this program announcement, an organization shall be designated as a statewide, private, non-profit domestic violence coalition meeting the following criteria:

1. The membership of the Coalition includes representatives from a majority of the programs for victims of domestic violence operating within the State (a Coalition may include representatives of Indian Tribes and Tribal organizations as defined in the Indian Self-Determination and Education Assistance Act);

2. The Board membership of the Coalition is representative of such programs; and

3. The purpose of the Coalition is to provide services, community education, and technical assistance to domestic violence programs in order to establish and maintain shelter and related services for victims of domestic violence and their children; and

Additional Information on Eligibility

D-U-N-S Requirement

All applicants must have a D&B Data Universal Numbering System (D-U-N-S) number.  On June 27, 2003, the Office of Management and Budget (OMB) published in the Federal Register a new Federal policy applicable to all Federal grant applicants.  The policy requires Federal grant applicants to provide a D-U-N-S number when applying for Federal grants or cooperative agreements on or after October 1, 2003.  The D-U-N-S number will be required whether an applicant is submitting a paper application or using the government-wide electronic portal, www.Grants.gov.   A D-U-N-S number will be required for every application for a new award or renewal/continuation of an award, including applications or plans under formula, entitlement, and block grant programs, submitted on or after October 1, 2003.

Applicants must ensure that their organization has a D-U-N-S number. Applicants may acquire a D-U-N-S number at no cost by calling the dedicated toll-free D-U-N-S number request line at 1-866-705-5711 or you may request a number on-line at http://www.dnb.com.

Survey for Private Non-Profit Grant Applicants

Private, non-profit organizations are encouraged to submit with their applications the survey located under “Grant Related Documents and Forms,“ “Survey for Private, Non-Profit Grant Applicants,” titled, “Survey on Ensuring Equal Opportunity for Applicants,” at: http://www.acf.hhs.gov/programs/ofs/forms.htm.

IV. APPLICATION REQUIREMENTS FOR STATE DOMESTIC VIOLENCE           COALITION (COALITIONS) APPLICATIONS

This section includes application requirements for FVPSA grants for Coalitions, as follows:

The Paperwork Reduction Act of 1995 (P.L. 104-13)

           

Public reporting burden for this collection of information is estimated to average ten hours per response, including the time for reviewing instructions, gathering and maintaining the data needed and reviewing the collection information.

The project description is approved under the Office of Management and Budget (OMB) control number XXXX-XXXX, which expires October 31, XXXX.  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.

Content of Application Submission

The Coalition application must be signed by the Executive Director of the Coalition or the official designated as responsible for the administration of the grant. The application must contain the following information:

(Each requirement is cited to the specific section of the law.)

(1)   A description of the process and anticipated outcomes of utilizing these Federal funds to work with local domestic violence programs and providers of direct services to victims of domestic violence and their families to encourage appropriate responses to domestic violence within the State, including—

1. Training and technical assistance for local programs and professionals, including those representing marginalized communities, working with victims of domestic violence and their families;

2. Planning and conducting State needs assessments and planning for comprehensive services, including the needs of and services for marginalized communities;

3. Serving as an information clearinghouse and resource center for the State; and

4. Collaborating with other governmental systems that affect victims of domestic violence (42 U.S.C. 10410(a)(1)).

(2)  A description of the public education campaign regarding domestic violence to be conducted by the Coalition through the use of public service announcements and informative materials that are designed for print media; billboards; public transit advertising; electronic broadcast media; and other forms of information dissemination that inform the public about domestic violence, including information aimed at underserved racial, ethnic or language-minority populations (42 U.S.C. 10410(a)(1)).

(3)  The anticipated outcomes and a description of planned grant activities to be conducted in conjunction with judicial and law enforcement agencies concerning appropriate responses to domestic violence cases and an examination of related issues as set forth in (42 U.S.C. 10410(a)(1).

4. The anticipated outcomes and a description of planned grant activities to be conducted in conjunction with Family Law Judges, Criminal Court Judges, Child Protective Services agencies, Child Welfare agencies, Family Preservation and Support Service agencies, and children’s advocates to develop appropriate responses to child custody and visitation issues in domestic violence cases and in cases where domestic violence and child abuse are both present (42 U.S.C. 10410(a)(1)).

5. The anticipated outcomes and a description of other activities in support of the general purpose of furthering domestic violence intervention and prevention(42 U.S.C. 10410(a)).

6. Documentation in the form of support letters, memoranda of agreement, or jointly signed statements, that the Coalition has actively sought and encouraged the participation of law enforcement agencies and other legal or judicial organizations in the preparation of the grant application (42 U.S.C. 10410(b)(4)(A)), and will actively seek and encourage the participation of such organizations in grant funded activities (42 U.S.C. 10410(b)(4)(B).

6. The following documentation that certifies the status of the Coalition and must be included in the grant application:

1. A description of the procedures developed between the State domestic violence agency and the Coalition that provide for the required implementation of the following cooperative activities:

1. The participation of the Coalition in the planning and monitoring of the distribution of grants and grant funds provided in the State (42 U.S.C. 10410(a)(5)); and

2. The participation of the Coalition in compliance activities regarding the State’s family violence prevention and services program grantees (42 U.S.C. 10402(a)(2)(C) and (a)(3)).

 

2. Unless already on file at HHS, a copy of a currently valid 501(c)(3) certification letter from the IRS stating private, non-profit status; or a copy of the applicant’s listing in the IRS’ most recent list of tax-exempt organizations described in section 501(c)(3) of the IRS code (See Section III, Additional Information on Eligibility); or a copy of the articles of incorporation bearing the seal of the State in which the corporation or association is domiciled (See Section III, Additional Information on Eligibility);

(c)  A current list of the organizations operating programs for victims of domestic violence in the State and the applicant Coalition’s current membership list by organization;            

                       

(d) A list of the applicant Coalition’s current Board of Directors, with each individual’s organizational affiliation and the Chairperson identified;

(e) A list of any Coalition or contractual positions to be supported by funds from this grant; and

(f) A budget narrative that clearly describes the planned expenditure of funds under this grant.

(8) Required Assurances (included in the application as Appendix A):

1. The applicant Coalition will not use grant funds, directly or indirectly, to influence the issuance, amendment, or revocation of any Executive Order or similar legal document by any Federal, State or local agency, or to undertake to influence the passage or defeat of any legislation by the Congress, or any State, or local legislative body, or State proposals by initiative petition, except where representatives of the Coalition  are testifying, or making other appropriate communications, or when formally requested to do so by a legislative body, a committee, or a member of such organization (42 U.S.C. 10410(d)(1)); or in connection with legislation or appropriations directly affecting the activities of the Coalition or any member of the Coalition (42 U.S.C. 10410(d)(2)).

2. The applicant Coalition will prohibit discrimination on the basis of age, handicap, sex, race, color, national origin or religion, as described in 42 U.S.C. 10406.

3. The applicant will comply with FVPSA confidentiality requirements and must provide assurances that individual identifiers of client records will not be used when providing statistical data on program activities and program services, that the confidentiality of records pertaining to any individual provided domestic violence prevention or treatment services by any FVPSA-supported program will be strictly maintained, and the address or location of any FVPSA-supported shelter will not be made public without the written authorization of the person or persons responsible for the operation of such shelter (42 U.S.C. 10402(a)(2)(E)).

Certifications

All applicants must submit or comply with the required certifications found in the Appendices, as follows:

Anti-Lobbying Certification and Disclosure Form must be signed and submitted with the application (See Appendix B):  Applicants must furnish prior to award an executed copy of the Standard Form (SF) LLL, Certification Regarding Lobbying, when applying for an award in excess of $100,000.  Applicants who have used non-Federal funds for lobbying activities in connection with receiving assistance under this announcement shall complete a disclosure form, if applicable, with their applications (approved by OMB under control number 0348-0046).  Applicants should sign and return the certification with their application.

Certification Regarding Environmental Tobacco Smoke (See Appendix C):  Applicants must also understand they will be held accountable for the smoking prohibition included within P. L. 103-227, Title XII Environmental Tobacco Smoke (also known as the PRO-Children Act of 1994).  A copy of the Federal Register notice that implements the smoking prohibition is included with forms.  By signing and submitting the application, applicants are accepting and agreeing to all terms and conditions of the certification.

Certification Regarding Drug-Free Workplace Requirements (See Appendix D):  The signature on the application by the program official attests to the applicants’ intent to comply with the Drug-Free Workplace requirements and compliance with the Debarment Certification.  By signing and submitting the application, applicants are accepting and agreeing to all terms and conditions of the certification.

These certifications can be found at www.acf.hhs.gov/programs/ofs/forms.htm.

Notification Under Executive Order 12372

This program is covered under Executive Order 12372, “Intergovernmental Review of Federal Programs” for State plan consolidation and simplification only – 45 CFR 100.12.  The review and comment provisions of the Executive Order and Part 100 do not apply.

Applications should be sent to:

Family Violence Prevention and Services Program

Family and Youth Services Bureau

Administration on Children, Youth and Families

Administration for Children and Families

Attention: Allison Randall

1250 Maryland Avenue, SW.

Room 8220

Washington, DC  20024

V. REPORTING REQUIREMENTS

Performance Reports

The Coalition grantee must submit an annual report of activities describing the coordination, training and technical assistance, needs assessment, and comprehensive planning activities carried out.  Additionally, the Coalition must report on the public information and education services provided; the activities conducted in conjunction with judicial and law enforcement agencies; the actions conducted in conjunction with other agencies such as the State child welfare agency; activities conducted in conjunction with community-based, culturally specific service providers or organizations serving or representing marginalized communities; and any other activities undertaken under this grant award.  The annual report also must provide an assessment of the effectiveness of the grant-supported activities.

The annual report is due 90 days after the end of the fiscal year in which the grant is awarded; i.e., December 29. Annual reports should be sent to:

Family Violence Prevention and Services Program

Family and Youth Services Bureau

Administration on Children, Youth and Families

Administration for Children and Families

Attention: Allison Randall

1250 Maryland Avenue, SW.

Room 8220

Washington, DC  20024  

Please note that HHS may suspend funding for an approved application if any applicant fails to submit an annual performance report or if the funds are expended for purposes other than those set forth under this announcement.

Financial Status Reports

Grantees must submit annual Financial Status Reports. The first SF-269A is due December 29, 2009.  The final SF-269A is due December 29, 2010.  SF-269A can be found at the following URL:  http://www.whitehouse.gov/omb/grants/grants_forms.html. 

Completed reports should be sent to:

Frederick Griefer

Division of Mandatory Grants

Office of Grants Management

Office of Administration

Administration for Children and Families

370 L’Enfant Promenade, S.W.

6^th Floor

Washington, DC  20447    

Grantees have the option to submit their reports online through the Online Data Collection (OLDC) system at the following address: https://extranet.acf.hhs.gov/ssi.

Failure to submit reports on time may be a basis for withholding grant funds, suspension or termination of the grant.  In addition, all funds reported after the obligation period will be recouped.

 

VI. ADMINISTRATIVE AND NATIONAL POLICY REQUIREMENTS

Grantees are subject to the requirements in 45 CFR Part 74 (non-governmental) or 45 CFR Part 92 (governmental).

Direct Federal grants, sub-award funds, or contracts under this ACF program shall not be used to support inherently religious activities such as religious instruction, worship, or proselytization. Therefore, organizations must take steps to separate, in time or location, their inherently religious activities from the services funded under this program. Regulations pertaining to the Equal Treatment for Faith-Based Organizations, which includes the prohibition against Federal funding of inherently religious activities, can be found at the HHS web site at http://www.hhs.gov/fbci/waisgate21.pdf.

A faith-based organization receiving HHS funds retains its independence from Federal, State, and local governments and may continue to carry out its mission, including the definition, practice, and expression of its religious beliefs. For example, a faith-based organization may use space in its facilities to provide secular programs or services funded with Federal funds without removing religious art, icons, scriptures, or other religious symbols. In addition, a faith-based organization that receives Federal funds retains its authority over its internal governance, and it may retain religious terms in its organization’s name, select its board members on a religious basis, and include religious references in its organization’s mission statements and other governing documents in accordance with program requirements, statutes, and other applicable requirements governing the conduct of HHS funded activities.

Faith-based and community organizations may reference the “Guidance to Faith-Based and Community Organizations on Partnering with the Federal Government” at http://www.whitehouse.gov/government/fbci/guidance/index.html.

HHS Grants Policy Statement

The HHS Grants Policy Statement (GPS) is the Department of Human Services new single policy guide for discretionary grants and cooperative agreements. Unlike previous HHS policy documents, the GPS is intended to be shared with and used by grantees. It became effective October 1, 2006 and is applicable to all Operating Divisions (OPDIVS), such as ACF, except the National Institutes of Health (NIH). The GPS covers basic grant processes, standard terms and conditions and points of contact as well as important OPDIV-specific requirements. Appendices include a glossary of terms and a list of standard abbreviations for ease of reference. The GPS may be accessed as http:///www.acf.hhs.gov/grants/grants_resources.html.

VII. OTHER INFORMATION

For Further Information Contact:  Allison Randall at (202) 205-7889 or e-mail at [email protected].

Date: ______________________                   ________________________________

                                                                        Joan E. Ohl

                                                                       Commissioner

                                                                        Administration on Children, Youth

and Families

Appendices:     Required Assurances and Certifications:

                        A. Assurances

B. Anti-Lobbying and Disclosure

                        C. Environmental Tobacco Smoke

                        D. Drug-Free Workplace Requirements                       

Appendix A

ASSURANCES OF COMPLIANCE WITH GRANT REQUIREMENTS

The undersigned certifies that:

1. The applicant Coalition will not use grant funds, directly or indirectly, to influence the issuance, amendment, or revocation of any Executive Order or similar legal document by any Federal, State or local agency, or to undertake to influence the passage or defeat of any legislation by the Congress, or any State, or local legislative body, or State proposals by initiative petition, except where representatives of the Coalition  are testifying, or making other appropriate communications, or when formally requested to do so by a legislative body, a committee, or a member of such organization (42 U.S.C. 10410(d)(1)); or in connection with legislation or appropriations directly affecting the activities of the Coalition or any member of the Coalition (42 U.S.C. 10410(d)(2)).

2. The applicant Coalition will prohibit discrimination on the basis of age, handicap, sex, race, color, national origin or religion, as described in 42 U.S.C. 10406.

3. The applicant will comply with FVPSA confidentiality requirements and must provide assurances that individual identifiers of client records will not be used when providing statistical data on program activities and program services, that the confidentiality of records pertaining to any individual provided domestic violence prevention or treatment services by any FVPSA-supported program will be strictly maintained, and the address or location of any FVPSA-supported shelter will not be made public without the written authorization of the person or persons responsible for the operation of such shelter (42 U.S.C. 10402(a)(2)(E)).

____________________________________________

Signature

____________________________________________
Title

____________________________________________
Organization

Appendix B

CERTIFICATION REGARDING LOBBYING

Certification for Contracts, Grants, Loans, and Cooperative Agreements

The undersigned certifies, to the best of his or her knowledge and belief, that:

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.

 

3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Statement for Loan Guarantees and Loan Insurance

 

The undersigned states, to the best of his or her knowledge and belief, that:

If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions. Submission of this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

____________________________________________

Signature

____________________________________________
Title

____________________________________________
Organization

                                                                                                           

Appendix C

CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE

Public Law 103227, Part C Environmental Tobacco Smoke, also known as the Pro Children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor routinely owned or leased or contracted for by an entity and used routinely or regularly for provision of health, day care, education, or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law does not apply to children’s services provided in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1000 per day and/or the imposition of an administrative compliance order on the responsible entity. By signing and submitting this application the applicant/grantee certifies that it will comply with the requirements of the Act.

The applicant/grantee further agrees that it will require the language of this certification be included in any subawards which contain provisions for the children’s services and that all subgrantees shall certify accordingly.

Appendix D

CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS

This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988: 45 CFR Part 76, Subpart, F. Sections 76.630(c) and (d)(2) and 76.645(a)(1) and (b) provide that a Federal agency may designate a central receipt point for STATE-WIDE AND STATE AGENCY-WIDE certifications, and for notification of criminal drug convictions. For the Department of Health and Human Services, the central point is: Division of Grants Management and Oversight, Office of Management and Acquisition, Department of Health and Human Services, Room 517-D, 200 Independence Avenue, SW Washington, DC 20201.

Certification Regarding Drug-Free Workplace Requirements

(Instructions for Certification)

1. By signing and/or submitting this application or grant agreement, the grantee is providing the certification set out below.

2. The certification set out below is a material representation of fact upon which reliance is placed when the agency awards the grant. If it is later determined that the grantee knowingly rendered a false certification, or otherwise violates the requirements of the Drug-Free Workplace Act, the agency, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act.

3. For grantees other than individuals, Alternate I applies.

4. For grantees who are individuals, Alternate II applies.

5. Workplaces under grants, for grantees other than individuals, need not be identified on the certification. If known, they may be identified in the grant application. If the grantee does not identify the workplaces at the time of application, or upon award, if there is no application, the grantee must keep the identity of the workplace(s) on file in its office and make the information available for Federal inspection. Failure to identify all known workplaces constitutes a violation of the grantee’s drug-free workplace requirements.

6. Workplace identifications must include the actual address of buildings (or parts of buildings) or other sites where work under the grant takes place. Categorical descriptions may be used (e.g., all vehicles of a mass transit authority or State highway department while in operation, State employees in each local unemployment office, performers in concert halls or radio studios).

7. If the workplace identified to the agency changes during the performance of the grant, the grantee shall inform the agency of the change(s), if it previously identified the workplaces in question (see paragraph five).

8. Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common rule apply to this certification. Grantees’ attention is called, in particular, to the following definitions from these rules:
   
   Controlled substance means a controlled substance in Schedules I through V of the Controlled Substances Act (21 U.S.C. 812) and as further defined by regulation (21 CFR 1308.11 through 1308.15);
   
   Conviction means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or both, by any judicial body charged with the responsibility to determine violations of the Federal or State criminal drug statutes;
   
   Criminal drug statute means a Federal or non-Federal criminal statute involving the manufacture, distribution, dispensing, use, or possession of any controlled substance;
   
   Employee means the employee of a grantee directly engaged in the performance of work under a grant, including: (i) All direct charge employees; (ii) All indirect charge employees unless their impact or involvement is insignificant to the performance of the grant; and, (iii) Temporary personnel and consultants who are directly engaged in the performance of work under the grant and who are on the grantee’s payroll. This definition does not include workers not on the payroll of the grantee (e.g., volunteers, even if used to meet a matching requirement; consultants or independent contractors not on the grantee’s payroll; or employees of subrecipients or subcontractors in covered workplaces).
   
   

Certification Regarding Drug-Free Workplace Requirements

Alternate I. (Grantees Other Than Individuals)

The grantee certifies that it will or will continue to provide a drug-free workplace by:

(1) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the grantee’s workplace and specifying the actions that will be taken against employees for violation of such prohibition;

(2) Establishing an ongoing drug-free awareness program to inform employees about –

(a) The dangers of drug abuse in the workplace;

(b) The grantee’s policy of maintaining a drug-free workplace;

(c) Any available drug counseling, rehabilitation, and employee assistance programs; and

(d) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;

(3) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph (a);

(4) Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant, the employee will –

(a) Abide by the terms of the statement; and

(b) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction;

(5) Notifying the agency in writing, within 10 calendar days after receiving notice under paragraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant activity the convicted employee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant;

(6) Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d)(2), with respect to any employee who is so convicted –

(a) Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or

(b) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency;

(7) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e) and (f).

The grantee may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant:

Place of Performance (Street address, city, county, state, zip code)

                                                                                                                                

                                                                                                                                

Check if there are workplaces on file that are not identified here.

Alternate II. (Grantees Who Are Individuals)

1. The grantee certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant;

2. If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant activity, he or she will report the conviction, in writing, within 10 calendar days of the conviction, to every grant officer or other designee, unless the Federal agency designates a central point for the receipt of such notices. When notice is made to such a central point, it shall include the identification number(s) of each affected grant.

   
   

 

                                                                                                           

 

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