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. 0970-0382
Expiration
Date: 08/31/2013
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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