MHBG_Funding_Agreements 4-29-13

I.

State Information

Chief Executive Officer’s Funding Agreements, Assurances Non-Construction Programs and
Certifications (Form 03)
Fiscal Year 2014
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administrations
Funding Agreements
as required by
Community Mental Health Services Block Grant Program
as authorized by
Title XIX, Part B, Subpart I and Subpart III of the Public Health Service Act
and
Tile 42, Chapter 6A, Subchapter XVII of the United States Code

Section
Section 1911
Section 1912
Section 1913
Section 1914
Section 1915
Section 1916
Section 1917
Section 1941
Section 1942
Section 1943
Section 1946
Section 1947
Section 1953
Section 1955
Section 1956

Title XIX, Part B, Subpart I of the Public Health Service Act
Title
Formula Grants to States
State Plan for Comprehensive Community Mental Health Services for Certain
Individuals
Certain Agreements
State Mental Health Planning Council
Additional Provisions
Restrictions on Use of Payments
Application for Grant
Title XIX, Part B, Subpart III of the Public Health Service Act
Opportunity for Public Comment on State Plans
Requirement of Reports and Audits by States
Additional Requirements
Prohibition Regarding Receipt of Funds
Nondiscrimination
Continuation of Certain Programs
Services Provided by Nongovernmental Organizations
Services for Individuals with Co-Occurring Disorders

Chapter
42 USC § 300x
42 USC § 300x-1
42 USC § 300x-2
42 USC § 300x-3
42 USC § 300x-4
42 USC § 300x-5
42 USC § 300x-6
42 USC § 300x-51
42 USC § 300x-52
42 USC § 300x-53
42 USC § 300x-56
42 USC § 300x-57
42 USC § 300x-63
42 USC § 300x-65
42 USC § 300x-66

I hereby certify that the state or territory will comply with Title XIX, Part B, Subpart I and Subpart III of
the Public Health Service (PHS) Act, as amended, and summarized above, except for those sections in
the PHS Act that do not apply or for which a which a waiver has been granted or may be granted by the
Secretary for the period covered by this agreement.
State: Insert name
Name of Chief Executive Officer (CEO) or Designee: Insert name
Signature of CEO or Designee 1: Inset name
Title:
Date Signed: mm/dd/yyyy

1

If the agreement is signed by an authorized designee, a copy of the designation must be attached.