2 2012 Planning Grant Instructions

2012 AmeriCorps

APPLICATION INSTRUCTIONS

State and National Planning

Indian Tribes Planning

Deadline

January 18, 2012

OMB Control #: xxxx-xxxx

Expiration Date: 1/31/2012

IMPORTANT NOTICE

These application instructions conform to the Corporation for National and Community Service’s online grant application system, eGrants. All funding announcements by the Corporation for National and Community Service (CNCS or the Corporation) are posted on www.nationalservice.gov and www.grants.gov.

Public Burden Statement: Public reporting burden for this collection of information is estimated to average 40 hours per submission, including reviewing instructions, gathering and maintaining the data needed, and completing the form. Comments on the burden or content of this instrument may be sent to the Corporation for National and Community Service, Attn: Amy Borgstrom, 1201 New York Avenue, NW, Washington, D.C. 20525. CNCS informs people who may respond to this collection of information that they are not required to respond to the collection of information unless the OMB control number and expiration date displayed on page one are current and valid. (See 5 C.F.R. 1320.5(b)(2)(i).)

Privacy Act Notice: The Privacy Act of 1974 (5 U.S.C § 552a) requires that the following notice be provided to you: The information requested on the AmeriCorps Application Instructions is collected pursuant to 42 U.S.C 12592 and 12615 of the National and Community Service Act of 1990 as amended, and 42 U.S.C. 4953 of the Domestic Volunteer Service Act of 1973 as amended. Purposes and Uses - The information requested is collected for the purposes of reviewing grant applications and granting funding requests. Routine Uses - Routine uses may include disclosure of the information to federal, state, or local agencies pursuant to lawfully authorized requests. In some programs, the information may also be provided to federal, state, and local law enforcement agencies to determine the existence of any prior criminal convictions. The information may also be provided to appropriate federal agencies and Department contractors that have a need to know the information for the purpose of assisting the Department’s efforts to respond to a suspected or confirmed breach of the security or confidentiality or information maintained in this system of records, and the information disclosed is relevant and unnecessary for the assistance. Executive Summaries of all compliant applications received and applications of successful applicants will be published on the CNCS website as part of ongoing efforts to increase transparency in grantmaking. This is described in more detail in the Notice of Federal Funding Opportunity. The information will not otherwise be disclosed to entities outside of AmeriCorps and CNCS without prior written permission. Effects of Nondisclosure - The information requested is mandatory in order to receive benefits.

Federal Funding Accountability and Transparency Act:  Grant recipients will be required to report at www.FSRS.gov on all subawards over $25,000 and may be required to report on executive compensation for recipients and subrecipients. Recipients must have the necessary systems in place to collect and report this information. See 2 C.F.R. Part 170 for more information and to determine how these requirements apply.

Universal Identifier:  Applications must include a Dun and Bradstreet Data Universal Numbering System (DUNS) number and register with the Central Contractor’s Registry (CCR).  All grant recipients are required to maintain a valid registration, which must be renewed annually.

TABLE OF CONTENTS

IMPORTANT NOTICE 2

Submitting Your Application in eGrants 4

I. Applicant Info 5

II. Application Info 5

III. Narratives 6

IV. Performance Measures 9

V. Documents 9

VI. Budget Instructions for Planning Grant Applicants 10

VII. Review, Authorize, and Submit 11

VIII. Survey on Ensuring Equal Opportunity for Applicants 12

ATTACHMENT A: sf-424 Facesheet Instructions 13

ATTACHMENT B: Issue Areas and Service Categories 18

ATTACHMENT C: Performance Measure instructions 20

ATTACHMENT d: Performance Measure Worksheet 22

attachment E: detailed Budget instructions 24

attachment F: Budget worksheet 28

ATTACHMENT G: Budget Checklist 31

ATTACHMENT H: SURVEY ON ENSURING EQUAL OPPORTUNITY 33

attachment I: assurances and certifications 35

Submitting Your Application in eGrants

Dates: Applications are due to CNCS January 18, 2012 at 5:00 p.m. Eastern Time. Successful applicants will be notified by May 31, 2012.

If your proposed planning grant will be used to develop a program that will operate solely within one state, and you are not an Indian Tribe, you must apply through your state service commission for funding. The state service commission (commission) will provide you with the appropriate application materials and inform you of its application deadline.

A list of all State Service Commissions can be found here: http://www.americorps.gov/about/contact/statecommission.asp.

Commissions do not currently exist in American Samoa, the Commonwealth of the Northern Mariana Islands, South Dakota, and the U.S. Virgin Islands. We are not accepting planning grant applications from organizations applying solely within these locales.

Please use these application instructions to apply directly to the Corporation for National and Community Service (CNCS) only if your proposed planning grant will be developing a multi-state AmeriCorps program or if you are an Indian Tribe applying for the Indian Tribe-specific funds.

Indian Tribes have the option of applying through their local state commissions, or directly to CNCS.

Use these instructions in conjunction with the Notice of Funds Available or Notice of Federal Funding Opportunity (Notice) for the year in which you are applying, and the AmeriCorps Regulations, 45 CFR §§ 2520–2550. The Notice includes deadlines, eligibility requirements, submission requirements, and other information that changes year-to-year for all AmeriCorps grant programs.

The Notice can be found at http://www.americorps.org/for_organizations/funding/nofa.asp. The full regulations are available online at www.gpoaccess.gov/ecfr.

If there is any inconsistency between the AmeriCorps regulations, the Notice, and the Application Instructions, the order of precedence is as follows:

1. AmeriCorps regulations 45 CFR §§ 2520–2550 take precedence over the

2. Notice of Federal Funding Opportunity, which takes precedence over the

3. Application Instructions.

Applicants need to establish an eGrants account by accessing this link: https://egrants.cns.gov/espan/main/login.jsp and selecting “Don’t have an eGrants account? Create an account.”

Please note, state commissions submit planning grants as part of their competitive submission, under their competitive state prime.

Your application consists of the following components. Please make sure to complete each section.

I. Applicant Info

II. Application Info

III. Narratives

IV. Performance Measures

V. Documents

VI. Budget

VI. Review, Authorize, and Submit

VIII. Survey on Ensuring Equal Opportunity for Applicants (Optional)

In eGrants, before Starting Section I, you will need to:

• Start a new Grant Application

• Select a Program Area (AmeriCorps)

• Select the appropriate eGrants NOFA:

  • AmeriCorps Indian Tribes Planning Grant FY 2012

  • AmeriCorps National Planning Grant FY 2012

  • AmeriCorps State Competitive Planning Grants FY 2012.

State Commissions must contact their CNCS program officer in order to open a new planning grant program for sub-applicant submission.

I. Applicant Info

In eGrants, complete the Applicant Info Section (Attachment B). This section is particularly important for data collection and evaluation. Please take the time to reflect your proposed program activities accurately in this section.

• In the Program Info Section enter “New.”

• Enter your contact information into the fields that appear.

• Enter or select a Program Director and Program Website URL.

II. Application Info

Information entered in the Applicant Info, Application Info, and Budget sections will populate the SF 424 Facesheet. If you are submitting your application in hard copy, you will find the SF 424 in Attachment A.

In the Application Info Section enter:

• Areas affected by your proposed program. Please include the two-letter abbreviation with both letters capitalized for each state where you plan to operate. Separate each two-letter state abbreviation with a comma. For city or county information, please follow each one with the two-letter capitalized state abbreviation.

• Requested project period start and end dates. You may not request a program start date earlier than June 15. First-time grantees should not expect to start until late summer or early fall. The project period is one year.

• Indicate Yes or No if you are delinquent on any federal debt. If yes, send explanation as described in Section V.D.

• State Application Identifier: Enter N/A.

• State Single Point of Contact: This is pre-filled as “No, this is not applicable.”

• For “Project Director” please enter the project director or other person to contact on matters related to the application.

• Leave the box for “Program Initiative” blank.

• The “Estimated Funds Requested” box will be populated automatically after you complete the budget.

III. Narratives

The narrative section of the application is your opportunity to convince reviewers that your project meets the selection criteria. Below are some general recommendations to help you present your project in a way the reviewers will find compelling and persuasive.

• Lead from your program strengths and be explicit. Do not make the mistake of trying to stretch your proposed program description to fit each funding priority and special consideration articulated in the regulations or the Notice.

• Be clear and succinct. Reviewers are not interested in jargon, boilerplate, rhetoric, or exaggeration. They are interested in learning precisely what you intend to do, and how your project responds to the selection criteria presented below.

• Avoid circular reasoning. The problem you describe should not be defined as the lack of the solution you are proposing.

• Explain how. Avoid simply stating that the criteria will be met. Explicitly describe how the proposed project will meet the criteria.

• Don’t make assumptions. Even if you have received funding from CNCS in the past, do not assume your reviewers know anything about you, your proposed program, your partners, or your beneficiaries. Avoid overuse of acronyms.

• Use an impartial proofreader. Before you submit your application, let someone who is completely unfamiliar with your project read and critique the project narrative.

• Follow the instructions and discuss each criterion in the order they are presented in the instructions. Use headings to differentiate narrative sections by criterion.

In eGrants, you will enter text for

• Executive Summary: Maximum one-half page. Executive summaries of all compliant applications will be published on the CNCS website following grant notifications.

• Program Design.

• Organizational Capability.

• Cost Effectiveness and Budget Adequacy.

You may not exceed 15 double spaced pages for the Narratives, including the Executive Summary, as the pages print out from eGrants. Reviewers will not consider material submitted over the page limit, even if eGrants allows you to enter and submit text over the limit. From the Review and Submit page, print out your application prior to final submission to ensure it is not over the 15 page limit. This limit does not include the budget and performance measures.

Please note that the Narratives Section also includes fields for Clarification Information, Amendment Justification, and Continuation Changes. These are not required fields. They will be used to enter information for clarification following review, request amendments once a grant is awarded, and enter changes in the narrative in continuation requests. Please enter N/A in these fields.

1. Executive Summary

Please provide a one-paragraph executive summary of your proposed program. This paragraph must be one-half page or less. The summary should include who, what, where, and why:

• Who will be serving? Who will be served?

• What will the AmeriCorps members do?

• Where will the activity take place?

• What is the expected outcome(s) of the project?

You may fill in the blanks in the following template to complete your executive summary.

This planning grant will be utilized to develop an AmeriCorps program which will engage AmeriCorps members (members) to [AmeriCorps member activities] in [geographic locations where member activities will take place]. Members will address the needs of [beneficiaries to be served] resulting in [anticipated outcome of project]. Program activities will primarily be in the areas of [identify the relevant CNCS focus areas].

CNCS will post these summaries on www.nationalservice.gov in the interest of transparency and Open Government.

2. Rationale and Approach/Program Design

1. Describe why you are applying for a planning grant and what you hope to achieve during the one year planning period, including but not limited to:

• The problem you plan to solve with your AmeriCorps program

• Evidence that the need exists.

• What AmeriCorps members would do to meet the need

• The target communities the program would serve.

2. Provide a) a detailed description of your planning process, b) a timeline for planning activities, and c) how you will use the planning period to develop your capacity to effectively manage an AmeriCorps program including, but not limited to:

• Determining the most appropriate AmeriCorps member activities to address the identified community need.

• Determining the desired characteristics of AmeriCorps members and designing a recruitment strategy.

• Developing a performance measurement system to ensure that reliable data is gathered to demonstrate impact on the communities to be served.

• Creating a process for selecting operating and service sites (if applicable) that will ensure the most appropriate and capable organizations are selected.

• Planning orientation and training for operating and service sites (if applicable).

• Planning orientation and training for AmeriCorps members.

• Ensuring you have the ability to provide or secure effective technical assistance (if applicable).

C. Organizational Capability

Identify the primary and secondary contacts for the grant application. Describe your organization’s ability to successfully plan an AmeriCorps program, including but not limited to:

• Record of accomplishment.

• Prior experience administering federal funds.

• Prior experience in the proposed area of programming.

• The management and staff structure and the role the board of directors, administrators, and staff will play in the planning process.

• Systems and processes for sound programmatic and fiscal oversight or plans to develop this capacity.

 

Special Circumstances

In applying the organizational capability criteria to each proposal, reviewers may also take into account the following circumstances of individual organizations:

• The age of your organization and its rate of growth.

• Whether your organization serves a resource-poor community, such as a rural or remote community, a community with a high poverty rate, or a community with a scarcity of philanthropic and corporate resources.

If you feel that any of the circumstances stated above have an impact on your organizational capability that has not already been discussed, please describe the circumstance and how it affects your organizational capacity.

D. Cost Effectiveness and Budget Adequacy

1. Describe your plans to develop a cost-effective program including how you will develop diverse resources that will support your program implementation and sustainability.

2. Discuss the adequacy of your budget to support the planning process including your match.

3. Describe how you will secure any additional commitments you need for the planning grant.

In applying the cost-effectiveness criteria, CNCS will take into account the following circumstances of individual programs: program age, or the extent to which your program brings on new sites; whether your program or project is located in a resource-poor community, such as a rural or remote community, a community with a high poverty rate, or a community with a scarcity of corporate or philanthropic resources; whether your program or project is located in a high-cost, economically distressed community, measured by applying appropriate Federal and State data; and whether the reasonable and necessary costs of your program or project are higher because they are associated with engaging or serving difficult-to-reach populations, or achieving greater program impact as evidenced through performance measures and program evaluation.

E. Evaluation Summary or Plan

Enter N/A. Evaluations and evaluation plans are not required for planning grants.

F. Amendment Justification

Enter N/A. This field will be used if you are awarded a grant and need to amend it.

G. Clarification Information

Enter N/A. This field will be used to enter information that requires clarification in the post-review period.

H. Continuation Update

Enter N/A for Planning Grants.

IV. Performance Measures

One performance measure is required of Planning Grants, as indicated in the attached Performance Measure worksheet. The Serve America Act Characteristics, Serve America Act Priorities, and Issue Areas and Service categories in the Performance Measures section of the application are required. The performance measure must be entered at the time of application.

Attachment C for instructions for entering the performance measure.

For more information about Performance Measures go to: http://www.nationalserviceresources.org/star/ac

For more information about the National Performance Measures go to:

http://www.nationalserviceresources.org/national-performance-measures/home.

V. Documents

Multi-state applicants and Indian Tribes applying directly to CNCS must provide their federally approved indirect cost rate agreement, if using this agreement to cover administrative costs (see Budget Section III. Administrative/Indirect Costs, below). Please submit Indirect Cost Rates electronically to [email protected]. This information must be received at CNCS by 5 p.m. Eastern Time on the deadline.

Or, you may send hard copy of your federally approved indirect cost rate agreement to:

Corporation for National and Community Service

ATT: Office of Grants Policy and Operations/ASN Application

1201 New York Avenue NW

Washington, DC 20525

Please use an alternative service to the U.S. Postal Service to send hard copy. U.S. Postal Service deliveries to government agencies often are delayed and sometimes damaged due to security measures. Attach a hard copy of the program’s SF424 facesheet to each document so that we know which application corresponds to each document.

VI. Budget Instructions for Planning Grant Applicants

A. Overview of Key Budget Requirements

Program requirements, including requirements on match are located in the AmeriCorps regulations, modified by appropriations language, and summarized below. Administrative costs must not exceed 5% of the total CNCS funds requested.

• You must match with cash or in-kind contributions at least 24% of the project’s total budget.

• The acceptable sources of matching funds are federal, state, local, private sector, and/or other funds in accordance with applicable AmeriCorps requirements.

• Identify the source and total dollar amount of cash match from private, state and local and federal funds, the source type, and total amounts of in-kind support. Define all acronyms the first time they are used.

Note: Legislation permits the use of non-CNCS federal funds as match for the grantee share of the budget. Please discuss your intention of using federal funds to match an AmeriCorps grant with the other agency prior to submitting your application. Section 121(e)(5) of the National Community Service Act requires that grantees that use other federal funds as match for an AmeriCorps grant report the amount and source of these funds to CNCS. The Federal Financial Report (FFR) will be used to collect the federal match data. If a grantee uses federal funds as match, they will be required to report the sources and amounts on the FFR.

B. Preparing Your Budget

Your proposed budget should be sufficient to allow you to perform the tasks described in your narrative. Reviewers will consider the information you provide in this section in their assessment of the Cost-Effectiveness and Budget Adequacy selection criterion.

Follow the detailed budget instructions below to prepare your budget. We recommend that you prepare your budget in the same order as indicated in the Budget Worksheet in Attachment F. The Budget Checklist in Attachment G is a resource for you to ensure your budget is complete.

Please note that Attachments F and G include all budget line items for operating grants. The instructions below include details on which of these line items pertain to Planning Grants.

eGrants will create the budget and the budget narrative automatically from the detailed budget information you enter. Once you have entered your budget information in eGrants you will be asked to validate your budget and eGrants will check your submission for errors.

As you prepare your budget:

• All the amounts you request must be defined for a particular purpose. Do not include miscellaneous, contingency, or other undefined budget amounts.

• Your detailed budget narrative must provide an itemized explanation of proposed costs, including their purpose.

• Present the basis for all calculations in the form of an equation.

• Do not include unallowable expenses, e.g., entertainment costs (which include food and beverage costs) unless they are justified as an essential component of an activity.

• Do not include fractional amounts (cents).

Please refer to the relevant OMB Circulars on allowable costs for further guidance. The OMB circulars are online at www.whitehouse.gov/OMB/circulars.

• A-21 - Cost Principles for Educational Institutions, 2 CFR 220

• A-87 - Cost Principles for State, Local, and Indian Tribal Governments, 2 CFR 225

• A-122 - Cost Principles for Non Profit Organizations, 2 CFR 230

Programs must comply with all applicable federal laws, regulations, and OMB circulars for grant management, allowable costs, and audits, including providing audits to the A-133 clearinghouse if expending over $500,000 in federal funds, as required in OMB Circular A-133.

VII. Review, Authorize, and Submit

eGrants requires that you review and verify your entire application before submitting, by completing the following sections in eGrants:

• Review

• Authorize

• Assurances

• Certifications

• Verify

• Submit

Authorization, Assurances and Certifications

Read the Authorization, Assurances, and Certifications carefully (Attachment I). The person who authorizes the application must be the applicant’s Authorized Representative or his/her designee and must have an active eGrants account to sign these documents electronically. An Authorized Representative is the person in your organization authorized to accept and commit funds on behalf of the organization. A copy of the governing body’s authorization for this official representative to sign must be on file in the applicant’s office.

Be sure to check your entire application to ensure that there are no errors before submitting it. eGrants will also generate a list of errors if there are sections that need to be corrected prior to submission when you verify the application. If someone else is acting in the role of the applicant’s authorized representative, that person must log into his/her eGrants account and proceed with Authorize and Submit. After signing off on the Authorization, Assurances, and Certifications, his/her name will override any previous signatory that may appear and show on the application as the Authorized Representative.

Note: Anyone within your organization who will be entering information in the application at any point during application preparation and submission in the eGrants system must have their own eGrants account. Individuals may establish an eGrants account by accessing this link: https://egrants.cns.gov/espan/main/login.jsp and selecting “Don’t have an eGrants account? Create an account.”

VIII. Survey on Ensuring Equal Opportunity for Applicants (Optional)

CNCS and other federal agencies are collaborating with the White House Office of Faith-Based and Community Initiatives to conduct a survey of organizations that apply for federal funding. The purpose of this voluntary information collection is to compile statistics on the types of organizations that apply to CNCS for funds, such as number of employees, budget size, and self-identification as a faith-based/religious organization or a non-religious community-based organization.

This form is for applicants that are nonprofit private organizations, not including private universities. All information from the attached survey will be confidential and the responses will be aggregated in a summary report. Information provided on your form will not be released and will not be considered in any way in making funding decisions. If you are submitting a hard copy application, the form can be found in Attachment H.

You may complete the survey while preparing your application or after submitting your application.

1. To complete the survey while preparing your application, go to the Main Menu, select Enter Survey on Ensuring Equal Opportunity, provide requested information and submit.

2. If you submit your grant application without completing the survey, a pop-up box will appear and ask you if you would like to complete the survey. You may select Yes, No, or Remind Me Later. If you select Remind Me Later, you will be asked to fill in the survey next time you attempt to submit an application to CNCS.

ATTACHMENT A: Facesheet Instructions
(eGrants Applicant Info and Application Info Sections)

Modified Standard Form 424 (Rev. 11/02 to conform to the eGrants system)

This form is required for applications submitted for federal assistance.

Item #

1. Filled in for your convenience.

2. Self-explanatory.

3. 3. a. and 3. b. are for state use only (if applicable).

4. Item 4. a: Leave blank.

Item 4. b: If you are a recipient in year 2 or 3 of an already-awarded grant, enter the grant number, otherwise, leave blank.

5. Enter the following information:

a. The complete name of the organization that will be legally responsible for the grant, not the name of the organizational unit within the legally responsible organization. (For example, indicate “National University” instead of “Liberal Arts Department.”)

b. Your organization’s DUNS number (received from Dun and Bradstreet). This is a required field. Please see the Notice for instructions on how to obtain a DUNS number.

c. The name of the primary organizational unit that will undertake the assistance activity, if different from 5. a.

d. Your organization’s complete address with the 9 digit ZIP+ 4 code.

e. The name and contact information of the project director or other person to contact on matters related to this application.

6. Enter your Employer Identification Number (EIN) as assigned by the Internal Revenue Service.

7. Item 7. a.: Enter the appropriate letter in the box.

Item 7. b.: Please enter the characteristic(s) that best describe your organization.

	K-12 Education		Non-Profit Organizations
1	School (K-12)	11	Community-Based Organization
2	Local Education Agency	12	Faith-Based Organization
3	State Education Agency	13	Chamber of Commerce/ Business Association
		14	Community Action Agency/ Program
	Higher Education	15	Service/Civic Organization
4	Vocational/Technical College	16	Volunteer Management Organization
5	Community College	17	Self-Incorporated Senior Corps Project
6	2-year College	18	Statewide Association
7	4-year College	19	National Non-Profit (Multistate)
8	Hispanic Serving College or University	20	Local Affiliate of National Organization
9	Historically Black College or University	21	Tribal Organization (Non-government)
10	Tribally Controlled College or University	22	Other Native American Organization
	Government
23	Local Government-Municipal	28	Other State Government
24	Health Department	29	Tribal Government Entity
25	Law Enforcement Agency	30	Area Agency on Aging
26	Governor’s Office	31	U.S. Territory
27	State Commission/Alternative Administrative Entity

8. Check the appropriate box for type of application and enter the appropriate letter(s) in the lower boxes:

• Check “New” if your organization has never held an AmeriCorps State or National grant before.

• Check “New Application/Previous Grantee” if your organization has held an AmeriCorps State or National grant in the past and this application is for a new grant.

• Check “Continuation” if you are a grantee applying for an additional year of funding within an existing multi-year grant project period. AmeriCorps State and National grants are typically awarded for three-year periods.

9. Filled in for your convenience.

10. Use the following list of CFDA (Catalog of Federal Domestic Assistance) numbers for the applicable program listing, or other source if so instructed in the Notice: 94.006 AmeriCorps State and National.

11. Enter the project title.

a. When applying for a “Continuation” or “Amendment” applicants should use the same title as used for their existing grant program. When applying as a “New Applicant/Previous Grantee” if the application is for re-funding of a previous grant program, use the same title as was used in the prior grant program if appropriate (i.e., if the program is unchanged).

b. Enter the name of the CNCS program initiative, if any, as provided in the instructions corresponding to the Notice for which you are applying; otherwise, leave blank.

12. List only the largest political entities affected (e.g., counties, and cities). Please include the two-letter abbreviation with both letters capitalized for each state where you plan to operate. Separate each two-letter state abbreviation with a comma. For city or county information, please follow each with the two-letter capitalized state abbreviation.

13. (See item 8) “New” application or “New application/previous grantee:” Enter the dates for the proposed three-year project period. “Continuation” or “Amendment” application: Enter the dates of the approved three-year project period.

Performance Period: this appears only in eGrants, and is for the use of staff only.

14. Leave blank, staff use only.

15. Estimated Funding. Check the appropriate box to indicate the grant year for which funding is being requested. Enter the amount requested or to be contributed during this budget period on each appropriate line, as shown below. The value of in-kind contributions should be included in these amounts, as applicable. For revisions (See item 8), if the action will result in a dollar change to an existing award, include only the amount of the change. For decreases, enclose the amounts in parentheses.

a. Federal	The total amount of federal funds being requested in the budget.
b. Applicant	The total amount of the applicant share as entered in the budget.
c. State	The amount of the applicant share that is coming from state sources.
d. Local	The amount of the applicant share that is coming from local governmental sources (e.g., city, county and other municipal sources).
e. Other	The amount of the applicant share that is coming from non-governmental sources.
f. Program Income	The amount of the applicant share that is coming from income generated by programmatic activities (i.e., use of the additive option where program income is used to increase the size of the program).
g. Total	The applicant's estimate of the total funding amount for the agreement.

16. Pre-filled for your convenience. This program is excluded from coverage by State Executive Order 12372.

17. Check the appropriate box. This question applies to the applicant organization, not the person who signs as the authorized representative. Categories of debt include delinquent audit allowances, loans, and taxes. If Yes, attach an explanation.

18. The person who signs this form must be the applicant’s authorized representative. A copy of the governing body’s authorization for this official representative to sign must be on file in the applicant’s office.

Note: Falsification or concealment of a material fact, or submission of false, fictitious or fraudulent statements or representations to any department or agency of the United States Government may result in a fine of not more than $10,000 or imprisonment for not more than five (5) years, or both. (18 U.S. Code Section 1001

APPLICATION FOR FEDERAL ASSISTANCE Standard Form 424 (Rev. 2-2007) Prescribed by OMB Circular A-102						1. TYPE OF SUBMISSION: Application Non-Construction
2. a. DATE SUBMITTED:		3. a. DATE RECEIVED BY STATE:      				3. b. STATE APPLICATION IDENTIFIER:      
      2. b. APPLICATION IDENTIFIER:      		4. a. DATE RECEIVED BY FEDERAL AGENCY:      				4. b. FEDERAL IDENTIFIER: (Staff Only)      
5. APPLICANT INFORMATION
5. a. LEGAL NAME:       5. b. ORGANIZATIONAL DUNS:       5. c. ORGANIZATIONAL UNIT (DEPARTMENT/DIVISION):      				5. e. NAME AND TELEPHONE NUMBER OF PERSON TO BE CONTACTED ON MATTERS INVOLVING THIS APPLICATION (give area code):
5. d. ADDRESS (give street address, city, county, state and zip code): STREET:       CITY:       COUNTY:       STATE:       COUNTRY:      				NAME:       TELEPHONE NUMBER: (     )       -       FAX NUMBER: (     )       -       EMAIL:       INTERNET E-MAIL ADDRESS:       WEBSITE:      
6. EMPLOYER IDENTIFICATION NUMBER (EIN):                  				7. a. TYPE OF APPLICANT: (enter appropriate letter in box) A. State H. Independent School District B. County I. State Controlled Institution of Higher Learning C. Municipal J. Private University D. Township K. Indian Tribe E. Interstate L. Individual F. Intermunicipal M. Profit Organization G. Special District N. Private Non-Profit Organization O. Federal Government P. HQ Internal Organizations Q. State Education Agency R. Territory S. Other (specify) 7. b. CNCS APPLICANT CHARACTERISTICS Enter appropriate codes:
8. TYPE OF APPLICATION NEW NEW/PREVIOUS GRANTEE CONTINUATION REVISION If Revision, enter appropriate letter(s) in box(es):       A. AUGMENTATION B. BUDGET REVISION: C. NO COST EXTENSION to       (enter date) E. OTHER (specify below)      
				9. NAME OF FEDERAL AGENCY: Corporation for National and Community Service
10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:          				11. a. DESCRIPTIVE TITLE OF APPLICANT’S PROJECT:      
12. AREAS AFFECTED BY PROJECT (List Cities, Counties, States, etc.):				11.b. CNCS PROGRAM INITIATIVE (IF ANY):
13. PROPOSED PROJECT: START DATE:       ENDING DATE:       14. Performance Period (Staff Use Only_            
15. ESTIMATED FUNDING: Check applicable box: Yr 1: Yr.2: Yr. 3:					16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS? a. YES. THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 PROCESSS FOR REVIEW ON: DATE ___________________________________ b. NO. PROGRAM IS NOT COVERED BY E.O. 12372 17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT? YES If “Yes,” attach an explanation. NO
a. FEDERAL	$      
b. APPLICANT	$      
c. STATE	$      
d. LOCAL	$      
e. OTHER	$      
f. PROGRAM INCOME	$      
g. TOTAL	$      
18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT, THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.
a. TYPED NAME OF AUTHORIZED REPRESENTATIVE:      			b. TITLE:      				c. TELEPHONE NUMBER:      
d. SIGNATURE OF AUTHORIZED REPRESENTATIVE:      							e. DATE SIGNED:      

ATTACHMENT B: Issue Areas and Service Categories (eGrants Performance Measures Section)

In this section you will select service categories that describe your program activities. First select an issue area, and then choose one or more service categories. When you have selected all applicable service categories, indicate which service category is the primary one by entering a 1 next to the check box, and which is the secondary by entering a 2 next to the checkbox. Only one service category can be indicated as the primary, and one as the secondary.

Issue Areas and Service Categories (Issue Areas in Bold)

Community and Economic Development

Community-based Volunteer Programs

Community Revitalization/Improvement

Consumer Education

Cooperatives/Credit Unions

Food Production/Community Gardens/Farming

Job Development/Placement

Management Consulting

Micro Enterprise

Other Economic and Community Development

Public Safety

Regional/State/City Planning

Small/Minority Business Development

Social Services Planning & Delivery Systems/Community Organization

Tax Counseling/Counseling

Technology Access

Thrift Store

Transportation Services

Welfare to Work

Disaster Recovery/Relief

Disaster Mitigation

Disaster Preparedness

Disaster Recovery

Disaster Response

Other Disaster

Education

Adult Education and Literacy

After School Programs

America Reads

Computer Literacy

Cultural Heritage

ESL

Elementary Education

GED/Dropouts

Head Start/School Preparedness

Job Preparedness/School to Work

Library Services

Other Education

Pre-Elementary Day Care

Secondary Education

Service-Learning

Special Education

Tutoring & Child Literacy—Elementary

Tutoring & Child Literacy—High School

Tutoring & Child Literacy—Middle School

Vocational Education

Youth Leadership/Development

Environment

Clean Air

Clean and Safe Water

Community Restoration/Clean Up

Energy Conservation

Environmental Awareness

Indoor Environment

Other Environment

Toxic Waste Management

Waste Reduction, Management, and Recycling

Wildlife, Land & Vegetation Protection or Restoration

Health/Nutrition

Boarder Babies

CHIOS/SCHIPS

Congregate Meals

Delivery of Health Services

Food Distribution/Collection

HIV/AIDS

Health Education

Health Screening

Hospice/Terminally Ill

Immunization

In-Home Care

Maternal/Child Health Services

Mental Health

Mental Retardation

Other Health/Nutrition

Physical Disabilities Programs

Substance Abuse

Homeland Security

Disaster Preparedness/Relief

Public Health

Other Homeland Security

Public Safety

Human Needs

Adoption

Adult Day Care/Senior Center

Companionship/Outreach

Crisis Intervention

Intensive Mentoring (at least 1 hour weekly for at least 9 months)

Mentoring

Other Human Needs

Respite

Senior Center Program (Non Residential)

Senior Citizen Assistance

Teen Pregnancy/Abstinence/Parent Support

Housing

Home Management Support/Education

Homeless

Housing Referrals/Relocation/Other

Housing Rehabilitation/Construction

Independent Living—Disabled

Independent Living—Seniors

Other Housing

Tenant Organizing

Transitional Housing

Public Safety

Adult Offender/Ex-Offender Services/Rehabilitation

Child Abuse/Neglect

Children & Youth Safety Programs

Community Policing/Community Patrol

Conflict Resolution/Mediation

Crime Awareness/Crime Avoidance

Elder Abuse/Neglect

Family Violence

Improvement of Household Security

Juvenile Justice, Delinquency, Gangs

Legal Assistance

Neighborhood Watch/Block Watch

Other Public Safety

Safe Havens

Safety/Fire Prevention/Accident Prevention

Sexual Abuse/Rape

Victim/Witness Assistance

ATTACHMENT C: Performance Measure Instructions (eGrants Performance Measures Section)

Step 1: Select Serve America Act (SAA) Characteristics.

To begin, click one or more boxes in the “SAA Characteristics.”

Step 2: Select Serve America Act Priorities

Select the Focus Area in which your primary service activity fits. If your primary service activity does not fit into a Focus Area, select “Other” and skip to Step 5. You should only select multiple Focus Areas if each to represents a significant area of planned AmeriCorps member activity. Do not include multiple Focus Areas to describe the same activity. Select the Focus Area that best describes the activity.

Step 3: Indicate that you will not opt-in to National Performance Measures:

Although eGrants will allow you to select all of your Focus Areas at once, we suggest starting with one Focus Area that represents your primary activity and then repeating Step 2 – Step 6 for additional Focus Areas if applicable.

When you select a Focus Area, eGrants automatically pre-populates “No, I will not be using a national performance measure related to this Priority.”

• Leave this selection as “No.”

Step 4: Complete the MSY Chart(s)

For each Focus Area selected, complete a Member Service Years (MSY) Chart. Although planning grants do not include MSYs, please enter 1 minimum-time MSY at 3% in order to submit in eGrants. This is a system requirement and has no bearing on your grant requirements. Repeat for any Focus Areas you have entered other than “Other.”

Step 4: Select Issue Areas and Service Categories

In eGrants, the service categories are located in the Performance Measures Section. In this section you will select issue areas and service categories that describe your program activities. First select an issue area, and then choose service categories from the pull down menu. When you have selected all applicable service categories, indicate which service category is the primary and which is the secondary in importance to your program. Only one service category can be indicated as the primary, and one as the secondary. See Attachment C for the list of Issue Areas and Service Categories.

Step 4: Add a Performance Measure

Begin by creating the Performance Measure Output.

Step 5: Add Performance Measurement Title

Give this performance measure the title “Planning Grant Measure” and enter it in the text box.

Step 6: Select a Service Category

Service Category is a drop-down menu of choices based on your earlier identification of Service

Categories; select one and continue.

Step 7: Describe Strategies to Achieve Result

Enter “Plan an AmeriCorps program and gain capacity to apply successfully for an AmeriCorps operational grant.”

Step 8: Select a Result Type

Select Output.

Step 9: Write a Result Statement

Enter “Planning process completed.”

Step 10: Select an Indicator

Select any indicator. This will not be reviewed for planning grants.

Step 11: Write a Target Description

Enter N/A.

Step 12: Select a Target Number or Percent

Enter any number in this field. This will not be reviewed for planning grants.

Step 13: Identify your Instruments

Enter N/A.

Step 14: Write a Performance Measure Statement

Enter N/A.

ATTACHMENT D: Performance Measure Worksheet (eGrants Performance Measures Section)

Please fill in the performance measure information for each section as specified below.

General Info

Performance Measurement Title:

Planning Grant

Service Category (see Attachment B, Service Categories):

Enter Service Category

Needs and Activities

Enter: Plan an AmeriCorps program and develop capacity to apply successfully for an AmeriCorps operational grant.

Enter: Work with grantor staff to design and conduct planning process as outlined in planning grant application.

Result Type

Outputs are counts of the amount of service members or volunteers have completed, but do not provide information on benefits to or other changes in the lives of members and/or beneficiaries.

Intermediate-outcomes specify changes that have occurred in the lives of members and/or beneficiaries, but are short of a significant benefit for them.

Result: Output

Result Statement:

Enter: Planning process completed.

Indicator: A specific, measurable item of information that specifies progress toward achieving a result.

Indicator: NA

Other Indicator: NA

Targets

Target Description: NA

# (number) or % (percent): NA

Instruments: Specific tool to collect information (e.g. behavior checklist, tally sheet, attitude questionnaire, interview protocol). NA

Result: Intermediate Outcome

Result Statement: NA

1-2 sentences stating the expected result.

Indicator: A specific, measurable item of information that specifies progress toward achieving a result.

Indicator: NA

Other Indicator: NA

Targets

Target Description: NA

# (number) or % (percent): NA

Instruments: Specific tool to collect information (e.g. behavior checklist, tally sheet, attitude questionnaire, interview protocol). NA

ATTACHMENT E: Detailed Budget Instructions

(eGrants Budget Section)

Section I. Program Operating Costs

Complete Section I, Program Operating Costs, of the Budget Worksheet by entering the “Total Amount,” “CNCS Share,” and “Grantee Share” for Parts A-I, as follows:

A. Personnel Expenses

Under “Position/Title Description,” list each staff position separately and provide salary and percentage of effort devoted to this award. Each staff person’s role listed in the budget must be described in the application narrative and each staff person mentioned in the narrative must be listed in the budget. Because the purpose of this grant is to enable and stimulate volunteer community service, do not include the value of direct community service performed by volunteers. However, you may include the value of volunteer services contributed to the organization for organizational functions such as accounting, audit work, or training of staff.

B. Personnel Fringe Benefits

Under “Purpose/Description,” identify the types of fringe benefits to be covered and the costs of benefit(s) for each staff position. Allowable fringe benefits typically include FICA, Worker’s Compensation, Retirement, SUTA, Health and Life Insurance, IRA, and 401K. You may provide a calculation for total benefits as a percentage of the salaries to which they apply or list each benefit as a separate item. If a fringe benefit amount is over 30%, please list separately. Holidays, leave, and other similar vacation benefits are not included in the fringe benefit rates but are absorbed into the personnel expenses (salary) budget line item. Uncommon or exceptionally high-cost benefits should be itemized and justified.

C. 1. Staff Travel

Describe the purpose for which program staff members will travel. Provide a calculation that includes itemized costs for airfare, transportation, lodging, per diem, and other travel-related expenses multiplied by the number of trips/staff. Where applicable, identify the current standard reimbursement rate(s) of the organization for mileage, daily per diem, and similar supporting information. The standard mileage reimbursement should not exceed the federal mileage rate unless a result of applicant policy and justified in budget narrative. Only domestic travel is allowable.

We expect applicants to include funds in this line item for travel for staff and site staff to attend CNCS-sponsored technical assistance meetings. There are two to three such opportunities per year, including opportunities for new grantee orientation, the Annual Grantee Meeting, financial training, and the National Conference on Service and Volunteering.

For example: two staff members will attend the National Conference on Service and Volunteering.

2 staff X $750 airfare + $50 ground transportation + $400 lodging + $35 per diem = $2,470 for national conference.

C. 2. Member Travel

N/A.

D. Equipment

N/A.

E. Supplies

Include the amount of funds to purchase consumable supplies and materials that cost under $5,000 per unit. Items over $5,000 are considered equipment and are not allowed as a budget cost for planning grants. You must individually list any single item costing $1,000 or more.

F. Contractual and Consultant Services

Include costs for consultants related to the project’s operations, except training consultants, who will be listed in Sections G., below. Payments to individuals for consultant services under this grant may not exceed $750 per day (excluding costs for indirect expenses, travel, supplies, etc.). The $750 daily rate is a ceiling, and we anticipate budgeted daily rates at considerably lower levels. Indicate the daily rate, number of days, and total cost for consultants you are proposing to use and their contractual services.

G. 1. Staff Training

Include the costs associated with training staff on project requirements and training to enhance the skills needed for effective project implementation, i.e., project or financial management, team building, etc. If using a consultant(s) for training, indicate the estimated daily rate, not to exceed the maximum daily rate limit of $750.

G. 2. Member Training

N/A.

H. Evaluation

N/A.

I. Other Program Operating Costs

Allowable costs in this budget category should include when applicable:

• Criminal history background checks for any employees or other individuals who receive a salary, education award, living allowance, or stipend or similar payment from the grant (federal or non-federal share).

• Office space rental for projects operating without an approved indirect cost rate agreement that covers office space. If space is budgeted and it is shared with other projects or activities, the costs must be equitably pro-rated and allocated between the activities or projects.

• Utilities, telephone, Internet and similar expenses that are specifically used for AmeriCorps project staff, and are not part of the organizations indirect cost/admin cost allocation pool. If such expenses are budgeted and shared with other projects or activities, the costs must be equitably pro-rated and allocated between the activities or projects.

Section II. Member Costs

All Member Costs are N/A.

Section III. Administrative/Indirect Costs

Definitions

Administrative costs are general or centralized expenses of the overall administration of an organization that receives CNCS funds and do not include particular project costs. These costs may include administrative staff positions. For organizations that have an established indirect cost rate for federal awards, administrative costs mean those costs that are included in the organization’s indirect cost rate agreement. Such costs are generally identified with the organization’s overall operation and are further described in Office of Management and Budget Circulars A-21, A-87, and A-122.

Options for Calculating Administrative/Indirect Costs (choose either A. OR B.)

Applicants choose one of two methods to calculate allowable administrative costs – a CNCS-fixed percentage rate method or a federally approved indirect cost rate method. Regardless of the option chosen, the CNCS share of administrative costs is limited to 5% of the total CNCS funds actually expended under this grant.

A. CNCS Fixed Percentage Method

Five Percent Fixed Administrative Costs Option

The CNCS-fixed percentage rate method allows you to charge administrative costs up to a cap without a federally approved indirect cost rate and without documentation supporting the allocation. If you choose the CNCS-fixed percentage rate method (Section IIIA in eGrants), you may charge, for administrative costs, a fixed 5% of the total of CNCS funds expended. In order to charge this fixed 5%, the grantee match for administrative costs may not exceed 10% of all direct cost expenditures.

1. To determine the CNCS share for Section III:  Multiply the sum of the CNCS funding shares of Sections I and II by 0.0526. This is the maximum amount you can request as CNCS share. The 5% maximum is calculated by multiplying the sum of the CNCS share of Section I and Section II by the factor 0.0526. The factor 0.0526 is used to calculate the maximum amount of federal funds that may be budgeted for administrative (indirect) costs, rather than 0.0500, as a way to mathematically compensate for determining Section III costs when the total budget (Sections I + II + III) is not yet established. Enter this amount as the CNCS share for Section III A.

2. To determine the Grantee share for Section III:  Then multiply the total (both CNCS and grantee share) of Sections I and II by 10% (0.10) and enter this amount as the grantee share for Section III A.

3. Enter the sum of the CNCS and grantee shares under Total Amount.

If a commission elects to retain a share of the 5% of federal funds available to programs for administrative costs, that decision is identified within each subgrant’s budget. To calculate these fractional shares, within Section III of the subgrant budget, one-fifth (20%) of the federal dollars budgeted for administrative costs is allocated to the commission’s share and four-fifths (80%) of the federal dollars budgeted for administrative costs are allocated to the program’s share. The allocation between commission and program shares would be calculated as follows:

([Section I] + [Section II] x 0.0526) x (0.20) = Commission Share

([Section I] + [Section II] x 0.0526) x (0.80) = Subgrantee Share

If a commission elects to retain a share that is less than 1% budgeted for administrative costs, adjust the calculation above, as appropriate.

B.  Federally approved Indirect Cost Rate

If you have a federally approved indirect cost rate and choose to use it, the rate will constitute documentation of your administrative costs, including the 5% maximum payable by CNCS. Specify the Cost Type for which your organization has current documentation on file, i.e., Provisional, Predetermined, Fixed, or Final indirect cost rate. Supply your approved IDC rate (percentage) and the base upon which this rate is calculated (direct salaries, salaries and fringe benefits, etc.). It is at your discretion whether or not to claim your entire IDC rate to calculate administrative costs. If you choose to claim a lower rate, please include this rate in the Rate Claimed field.

1. Determine the base amount of direct costs to which you will apply the IDC rate, including both the CNCS and Grantee shares, as prescribed by your established rate agreement (i.e., based on salaries and benefits, total direct costs, or other). Then multiply the appropriate direct costs by the rate being claimed. This will determine the total amount of indirect costs allowable under the grant.

2. To determine the CNCS share:  Multiply the sum of the CNCS funding share in Sections I and II by 0.0526. This is the maximum amount you can claim as the CNCS share of indirect costs.

3. To determine the Grantee share:  Subtract the amount calculated in step b (the CNCS administrative share) from the amount calculated in step a (the Indirect Cost total). This is the amount the applicant can claim as grantee share for administrative costs.

Section IV. Match

Source of Match

In the “Source of Match” field that appears at the end of the Budget Sections, enter a brief description of the Source of Match, the amount, the match classification (Cash, In-kind, or Not Available) and Match Source (State/Local, Federal, Private, Other or Not Available) for your entire match. Define any acronyms the first time they are used.

ATTACHMENT F: Budget Worksheet (eGrants Budget Section)

Section I. Program Operating Costs

A. Personnel Expenses

Position/Title/Description	Qty	Annual Salary	% Time	Total Amount	CNCS Share	Grantee Share
Totals

B. Personnel Fringe Benefits

Purpose/Description	Calculation	Total Amount	CNCS Share	Grantee Share
Totals

C.1. Staff Travel

Purpose	Calculation	Total Amount	CNCS Share	Grantee Share
Totals

C. 2. Member Travel

Purpose	Calculation	Total Amount	CNCS Share	Grantee Share
Totals

Item/ Purpose/Justification	Qty	Unit Cost	Total Amount	CNCS Share	Grantee Share
Totals

D. Equipment

E. Supplies

Item/ Purpose/Justification	Qty	Unit Cost	Total Amount	CNCS Share	Grantee Share
Totals

Purpose	Calculation	Daily Rate	Total Amount	CNCS Share	Grantee Share
Totals

F. Contractual and Consultant Services

G.1. Staff Training

Purpose	Calculation	Daily Rate	Total Amount	CNCS Share	Grantee Share
Totals

G.2. Member Training

Purpose	Calculation	Daily Rate	Total Amount	CNCS Share	Grantee Share
Totals

H. Evaluation

Purpose	Calculation	Daily Rate	Total Amount	CNCS Share	Grantee Share
Totals

I. Other Program Operating Costs

Purpose	Calculation	Daily Rate	Total Amount	CNCS Share	Grantee Share
Totals

Subtotal Section I:	Total Amount	CNCS Share	Grantee Share

Section II. Member Costs—N/A

Source of Match

Source(s), Type, Amount, Intended Purpose

	Private	State and/or Local	Federal	Sources
In-kind	$	$	$	.
Cash	$	$	$
Total	$	$	$

Section III. Administrative/Indirect Costs

A. CNCS-fixed Percentage Rate

Purpose	Calculation	Total Amount	CNCS Share	Grantee Share
Totals

B. Federally Approved Indirect Cost Rate

Cost Type	CostBasis	Calculation	Rate	Rate Claimed	Total Amount	CNCS Share	Grantee Share

Total Sections I + II + III:	Total Amount	CNCS Share	Grantee Share

Budget Total: Validate this budget Required Match Percentages:	Total Amount	CNCS Share	Grantee Share

ATTACHMENT G: Budget Checklist

Below is a checklist to help you make certain that you submit an accurate budget narrative that meets AmeriCorps requirements.

In Compliance?	Section I. Program Operating Costs
Yes __ No __	Costs charged under the Personnel line item directly relate to the operation of the AmeriCorps project? Examples include costs for staff that recruit, train, place, or supervise members as well as manage the project.
Yes __ No __	Staff indirectly involved in the management or operation of the applicant organization is funded through the administrative cost section (Section III.) of the budget? Examples of administrative costs include central management and support functions.
Yes __ No __	Staff fundraising expenses are not charged to the grant? You may not charge AmeriCorps staff members’ time and related expenses for fundraising to the federal or grantee share of the grant. Expenses incurred to raise funds must be paid out of the funds raised. Development officers and fundraising staff are not allowable expenses.
Yes __ No __	All positions in the budget are fully described in the narrative?
Yes __ No __	The types of fringe benefits to be covered and the costs of benefit(s) for each staff position are described? Allowable fringe benefits typically include FICA, Worker’s Compensation, Retirement, SUTA, Health and Life Insurance, IRA, and 401K. You may provide a calculation for total benefits as a percentage of the salaries to which they apply or list each benefit as a separate item. If the fringe amount is over 30%, please list separately. Holidays, leave, and other similar vacation benefits are not included in the fringe benefit rates but are absorbed into the personnel expenses (salary) budget line item?
Yes __ No __	Holidays, leave, and other similar vacation benefits are not included in the fringe benefit rates but are absorbed into the personnel expenses (salary) budget line item?
Yes __ No __	The purpose for all staff and member travel is clearly identified?
Yes __ No __	You have budgeted funds for staff travel to CNCS sponsored meetings in the budget narrative under Staff Travel?
Yes __ No __	Funds to pay relocation expenses of AmeriCorps members are not in the federal share of the budget?
Yes __ No __	Funds for the purchase of equipment (does not include general use office equipment) are limited to 10% of the total grant amount?
Yes __ No __	All single equipment items over $5000 per unit are specifically listed?
Yes __ No __	Justification/explanation of equipment items is included in the budget narrative?
Yes __ No __	All single supply items over $1000 per unit are specifically listed?
Yes __ No __	You only charged to the federal share of the budget member service gear, with the exception of safety equipment, that includes the AmeriCorps logo?
Yes __ No __	Are all consultant services budgeted below the maximum federal daily rate of $750/day? Is the daily rate noted in all sections of the budget narrative where consultants are proposed?
Yes __ No __	Does the budget reflect adequate budgeted costs for project evaluation?
Yes __ No __	Have you provided budgeted costs for background checks of members and grant-funded staff that are in covered positions per 45 CFR 2522.205?
Yes __ No __	Are all items in the budget narrative itemized and the purpose of the funds justified?

In Compliance?	Section II. Member Costs
Yes __ No __	Are the living allowance amounts correct? Full-time AmeriCorps members must receive at least the minimum living allowance as indicated in the chart in the budget instructions. Note: Programs in existence prior to September 21, 1993 may offer a lower living allowance than the minimum. If such a program chooses to offer a living allowance, it is exempt from the minimum requirement, but not from the maximum requirement.
Yes __ No __	Living allowances are not paid on an hourly basis? They may be calculated using service hours and program length to derive a weekly or biweekly distribution amount. Divide the distribution in equal increments that are not based on the specified number of hours served.
Yes __ No __	Is FICA calculated correctly? You must pay FICA for any member receiving a living allowance. Unless exempted by the IRS, calculate FICA at 7.65% of the total amount of the living allowance.
Yes __ No __	Is the Worker’s Compensation calculation correct? Some states require worker’s compensation for AmeriCorps members. Check with your local State Department of Labor or State Commission to determine whether or not you are required to pay worker’s compensation and at what level (i.e., rate). If you are not required to pay worker’s compensation, you need to provide similar coverage for members’ on-the-job injuries through their own existing coverage or a new policy purchased in accordance with normal procedures (i.e., Death and Dismemberment coverage).
Yes __ No __	Health care is provided for full-time AmeriCorps members only (unless part-time serving in a full-time capacity)? If your project chooses to provide health care to other half-time members, you may not use federal funds to help pay for any portion of the cost. Projects must provide health care coverage to all full-time members who do not have adequate health care coverage at the time of enrollment or who lose coverage due to participation in the project. In addition, projects must provide coverage if a full-time member loses coverage during the term of service through no deliberate act of his/her own.

In Compliance?	Section III. Administrative/Indirect Costs
Yes __ No __	Applicant has chosen Option A – CNCS-fixed percentage method and the maximum federal share of administrative costs does not exceed 5% of the total federal funds budgeted? To determine the federal administrative share, multiply all other budgeted federal funds by .0526.
Yes __ No __	Applicant has chosen Option A – CNCS-fixed percentage method and the maximum grantee share is at 10% or less of total budgeted funds?
Yes __ No __	Applicant has chosen Option B – federally approved indirect cost rate method and documentation submitted to CNCS if multi-state, state or territory without commission or Indian Tribe applicant? Administrative costs budgeted include the following: (1) indirect costs such as legal staff, central management and support functions; (2) costs for financial, accounting, audit, internal evaluations, and contracting functions; (3) costs for insurance that protects the entity that operates the project; and (4) the portion of the salaries and benefits of the director and any other project administrative staff not attributable to the time spent in direct support of a specific project.
Yes __ No __	Applicant has chosen Option B – The maximum grantee share does not exceed the federally approved rate, less the 5% CNCS share?

In Compliance?	Match
Yes __ No __	Is the overall match being met at the required level, based on the year of funding?
Yes __ No __	For all matching funds, the source(s) [private, state and local, and federal], the type of contribution (cash or in-kind), and the amount (or an estimate) of match, are clearly identified in the narrative and in the Source of Match fields in eGrants?

ATTACHMENT H: Survey on Ensuring

Equal Opportunity for Applicants

OMB NO. 1894-0010 EXP 5/31/2012

MB No. 1890-0014 Exp. 1/131/2006

Purpose: The Federal government is committed to ensuring that all qualified applicants, small or large, non-religious or faith-based, have an equal opportunity to compete for Federal funding. In order for us to better understand the population of applicants for Federal funds, we are asking nonprofit private organizations (not including private universities) to fill out this survey.

Upon receipt, the survey will be separated from the application. Information provided on the survey will not be considered in any way in making funding decisions and will not be included in the Federal grants database. While your help in this data collection process is greatly appreciated, completion of this survey is voluntary.

Instructions for Submitting the Survey: If you are applying using a hard copy application, please place the completed survey in an envelope labeled “Applicant Survey.” Seal the envelope and include it along with your application package. If you are applying electronically, please submit this survey along with your application.

Applicant’s (Organization) Name:

Applicant’s DUNS Number:

Federal Program: CFDA Number:

1. Has the applicant ever received a grant or contract from the Federal government?

Yes No

2. Is the applicant a faith-based organization?

Yes No

3. Is the applicant secular organization?

Yes No

4. Does the applicant have 501(c) (3) status?

Yes No

5. Is the applicant a local affiliate of a national organization?

Yes No

6. How many full-time equivalent employees does the applicant have? (Check only one box).

3 or Fewer 15-50

4-5 51-100

6-14 over 100

7. What is the size of the applicant’s annual budget? (Check only one box.)

Less Than $150,000

$150,000 - $299,999

$300,000 - $499,999

$500,000 - $999,999

$1,000,000 - $4,999,999

$5,000,000 or more

Survey Instructions on Ensuring Equal Opportunity for Applicant

Provide the applicant’s (organization) name and DUNS number and the grant name and CFDA number.

1. Self-explanatory.

2. Self-identify.

3. Self-identify.

4. 501(c) (3) status is a legal designation provided on application to the Internal Revenue Service by eligible organizations. Some grant programs may require nonprofit applicants to have 501(c)(3) status. Other grant programs do not.

5. Self-explanatory.

6. For example, two part-time employees who each work half-time equal one full-time equivalent employee. If the applicant is a local affiliate of a national organization, the responses to survey questions 2 and 3 should reflect the staff and budget size of the local affiliate.

7. Annual budget means the amount of money your organization spends each year on all of its activities.

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1894-0010. The time required to complete this information collection is estimated to average five (5) minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Amy Borgstrom, Corporation for National and Community Service, 1201 New York Avenue, NW, Washington, D.C. 20525.

ATTACHMENT I: Assurances and Certifications (eGrants Review, Authorize and Submit Section)

Instructions

By signing and submitting this application, as the duly authorized representative of the applicant, you certify that the applicant will comply with the Assurances and Certifications described below.

a) Inability to certify

Your inability to provide the assurances and certifications listed below will not necessarily result in denial of a grant. You must submit an explanation of why you cannot do so. We will consider your explanation in determining whether to enter into this transaction. However, your failure to furnish an explanation will disqualify your application.

b) Erroneous certification or assurance

The assurances and certifications are material representations of fact upon which we rely in determining whether to enter into this transaction. If we later determine that you knowingly submitted an erroneous certification or assurance, in addition to other remedies available to the federal government, we may terminate this transaction for cause or default.

c) Notice of error in certification or assurance

You must provide immediate written notice to us if at any time you learn that a certification or assurance was erroneous when submitted or has become erroneous because of changed circumstances.

d) Definitions

The terms “covered transaction”, “debarred”, “suspended”, “ineligible”, “lower tier covered transaction”, “participant”, “person”, “primary covered transaction”, “principal”, “proposal”, and “voluntarily excluded” as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. An applicant shall be considered a “prospective primary participant in a covered transaction” as defined in the rules implementing Executive Order 12549. You may contact us for assistance in obtaining a copy of those regulations.

e) Assurance requirement for subgrant agreements

You agree by submitting this proposal that if we approve your application you shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by us.

f) Assurance inclusion in subgrant agreements

You agree by submitting this proposal that you will obtain an assurance from prospective participants in all lower tier covered transactions and in all solicitations for lower tier covered transactions that the participants are not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction.

g) Assurance of subgrant principals

You may rely upon an assurance of a prospective participant in a lower-tier covered transaction that is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless you know that the assurance is erroneous. You may decide the method and frequency by which you determine the eligibility of your principals. You may, but are not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs.

h) Non-assurance in subgrant agreements

If you knowingly enter into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the federal government, we may terminate this transaction for cause or default.

i) Prudent person standard

Nothing contained in the aforementioned may be construed to require establishment of a system of records in order to render in good faith the assurances and certifications required. Your knowledge and information is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

ASSURANCES

 

As the duly authorized representative of the applicant, I certify, to the best of my knowledge and belief, that the applicant:

 

• Has the legal authority to apply for federal assistance, and the institutional, managerial, and financial capability (including funds sufficient to pay the non-federal share of project costs) to ensure proper planning, management, and completion of the project described in this application.

• Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the state, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives.

• Will establish safeguards to prohibit employees from using their position for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain.

• Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.

• Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728-4763) relating to prescribed standards for merit systems for programs funded under one of the nineteen statutes or regulations specified in Appendix A of OPM’s Standards for a Merit System of Personnel Administration (5 CFR 900, Subpart F).

• Will comply with all federal statutes relating to nondiscrimination. These include but are not limited to: Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color, or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. 1681-1683, and 1685-1686). which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), which prohibits discrimination on the basis of disability (d) The Age Discrimination Act of 1975, as amended (42 U.S.C. 6101-6107), which prohibits discrimination on the basis of age; (e) The Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) sections 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. 290dd-3 and 290ee-3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in the National and Community Service Act of 1990, as amended; and (j) the requirements of any other nondiscrimination statute(s) which may apply to the application.

• Will comply, or has already complied, with the requirements of Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of federal or federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of federal participation in purchases.

• Will comply with the provisions of the Hatch Act (5 U.S.C. 1501-1508 and 7324-7328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds.

• Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C 276a and 276a-77), the Copeland Act (40 U.S.C 276c and 18 U.S.C. 874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. 327-333), regarding labor standards for Federally assisted construction sub-agreements.

• Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires the recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more.

• Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved state management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C 1451 et seq.); (f) conformity of federal actions to State (Clean Air) Implementation Plans under Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. 7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended (P.L. 93-205).

• Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C 1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system.

• Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. 470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16U.S.C. 469a-l et seq.).

• Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and related activities supported by this award of assistance.

• Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. 2131 et seq.) pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities supported by this award of assistance.

• Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§ 4801 et seq.) which prohibits the use of lead based paint in construction or rehabilitation of residence structures.

• Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act of 1984, as amended, and OMB Circular A-133, Audits of States, Local Governments, and Non-Profit Organizations.

• Will comply with all applicable requirements of all other Federal laws, executive orders, regulations, application guidelines, and policies governing this program.

• Will comply with all rules regarding prohibited activities, including those stated in applicable Notice, grant provisions, and program regulations, and will ensure that no assistance made available by the Corporation will be used to support any such prohibited activities.

• Will comply with the nondiscrimination provisions in the national service laws, which provide that an individual with responsibility for the operation of a project or program that receives assistance under the national service laws shall not discriminate against a participant in, or member of the staff of, such project or program on the basis of race, color, national origin, sex, age, political affiliation, disability, or on the basis of religion. (NOTE: the prohibition on religious discrimination does not apply to the employment of any staff member paid with non-Corporation funds or paid with Corporation funds but employed with the organization operating the project prior to or on the date the grant was awarded. If your organization is a faith-based organization that makes hiring decisions on the basis of religious belief, your organization may be entitled, under the Religious Freedom Restoration Act, 42 U.S.C. § 2000bb, to receive federal funds and yet maintain that hiring practice, even though the national service legislation includes a restriction on religious discrimination in employment of staff hired to work on a Corporation-funded project and paid with Corporation grant funds. (42 U.S.C. §§ 5057(c) and 12635(c)). For the circumstances under which this may occur, please see the document “Effect of the Religious Freedom Restoration Act on Faith-Based Applicants for Grants” on the Corporation’s website at: http://www.usdoj.gov/archive/fbci/effect-rfra.pdf.

• Will comply with all other federal statutes relating to nondiscrimination, including any self-evaluation requirements. These include but are not limited to: (a)Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color, or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. 1681-1683, and 1685-1686). which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), which prohibits discrimination on the basis of handicaps (d) The Age Discrimination Act of 1975, as amended (42 U.S.C. 6101-6107), which prohibits discrimination on the basis of age; (e) The Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) sections 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. 290 dd-3 and 290 ee-3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; and (i) the requirements of any other nondiscrimination statute(s) which may apply to the application.

• Will provide, in the design, recruitment, and operation of any AmeriCorps program, for broad-based input from – (1) the community served, the municipality and government of the county (if appropriate) in which the community is located, and potential participants in the program; and (2) community-based agencies with a demonstrated record of experience in providing services and local labor organizations representing employees of service sponsors, if these entities exist in the area to be served by the program;

• Will, prior to the placement of participants, consult with the appropriate local labor organization, if any, representing employees in the area who are engaged in the same or similar work as that proposed to be carried out by an AmeriCorps program, to ensure compliance with the nondisplacement requirements specified in section 177 of the NCSA;

• Will, in the case of an AmeriCorps program that includes or serves children, consult with the parents or legal guardians of children in developing and operating the program;

• Will, before transporting minor children, provide the children’s parents or legal guardians with the reason for the transportation and obtain the parent’s or legal guardian’s permission for such transportation, consistent with state law;

• Will, in the case of an AmeriCorps program that is not funded through a State, consult with and coordinate activities with the State Commission for the state in which the program operates.

• Will ensure that any national service program carried out by the applicant using assistance provided under section 121 of the National and Community Service Act of 1990 and any national service program supported by a grant made by the applicant using such assistance will address unmet human, educational, environmental, or public safety needs through services that provide a direct benefit to the community in which the service is performed;

• Will comply with the nonduplication and nondisplacement requirements set out in section 177 of the National and Community Service Act of 1990, and in the Corporation’s regulations at § 2540.100;

• Will comply with the grievance procedure requirements as set out in section 176(f) of the National and Community Service Act of 1990 and in the Corporation’s regulations at 45 CFR § 2540.230;

• Will provide participants in the national service program with the training, skills, and knowledge necessary for the projects that participants are called upon to perform, including training on prohibited activities;

• Will provide support services to participants, such as information regarding G.E.D. attainment and post-service employment, and, if appropriate, opportunities for participants to reflect on their service experiences;

• Will arrange for an independent evaluation of any national service program carried out using assistance provided to the applicant under section 121 of the National and Community Service Act of 1990 or, with the approval of the Corporation, conduct an internal evaluation of the program;

• Will apply measurable performance goals and evaluation methods, which are to be used as part of such evaluation to determine the program’s impact on communities and persons served by the program, on participants who take part in the projects, and in other such areas as required by the Corporation;

• Will ensure the provision of a living allowance and other benefits to participants as required by the Corporation;

• Has not violated a Federal criminal statute;

• If a state applicant, will ensure that the State subgrants will be used to support national service programs selected by the State on a competitive basis;

• If a state applicant, will seek to ensure an equitable allocation within the State of assistance and approved national service positions, taking into consideration such factors as the locations of the programs, population density, and economic distress;

• If a state applicant, will ensure that not less than 60% of the assistance will be used to make grants to support national service programs other than those carried out by a State agency, unless the Corporation approves otherwise.

CERTIFICATIONS

 

Certification – Debarment, Suspension, and Other Responsibility Matters

This certification is required by the government-wide regulations implementing Executive Order 12549, Debarment and Suspension, 2 CFR Part 180, Section 180.335, What information must I provide before entering into a covered transaction with a Federal agency?

As the duly authorized representative of the applicant, I certify, to the best of my knowledge and belief, that neither the applicant nor its principals:

• Is presently excluded or disqualified;

• Has been convicted within the preceding three years of any of the offenses listed in § 180.800(a) or had a civil judgment rendered against it for one of those offenses within that time period;

• Is presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission or any of the offenses listed in § 180.800(a); or

• Has had one or more public transactions (Federal, State, or local) terminated within the preceding three years for cause or default.

Certification – Drug Free Workplace

This certification is required by the Corporation’s regulations implementing sections 5150-5160 of the Drug-Free Workplace Act of 1988 (P.L. 100-690), 45 CFR Part 2545, Subpart B. The regulations require certification by grantees, prior to award, that they will make a good faith effort, on a continuing basis, to maintain a drug-free workplace. The certification set out below is a material representation of fact upon which reliance will be placed when the agency determines to award the grant. False certification or violation of the certification may be grounds for suspension of payments, suspension or termination of grants, or government-wide suspension or debarment (see 45 CFR Part 2542, Subparts G and H).

As the duly authorized representative of the grantee, I certify, to the best of my knowledge and belief, that the grantee will provide a drug-free workplace by:

1. Publishing a drug-free workplace statement that:

   1. Notifies employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the grantee’s workplace;

   2. Specifies the actions that the grantee will take against employees for violating that prohibition; and

   3. Informs employees that, as a condition of employment under any award, each employee will abide by the terms of the statement and notify the grantee in writing if the employee is convicted for a violation of a criminal drug statute occurring in the workplace within five days of the conviction;

2. Requiring that a copy of the statement described in paragraph (A) be given to each employee who will be engaged in the performance of any Federal award;

3. Establishing a drug-free awareness program to inform employees about:

   1. The dangers of drug abuse in the workplace;

   2. The grantee’s policy of maintaining a drug-free workplace;

   3. Any available drug counseling, rehabilitation, and employee assistance programs; and

   4. The penalties that the grantee may impose upon them for drug abuse violations occurring in the workplace;

4. Providing us, as well as any other Federal agency on whose award the convicted employee was working, with written notification within 10 calendar days of learning that an employee has been convicted of a drug violation in the workplace;

5. Taking one of the following actions within 30 calendar days of learning that an employee has been convicted of a drug violation in the workplace:

   1. Taking appropriate personnel action against the employee, up to and including termination; or

   2. Requiring that the employee participate satisfactorily in a drug abuse assistance or rehabilitation program approved for these purposes by a Federal, State, or local health, law enforcement, or other appropriate agency;

6. Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (A) through (E).

 

Certification - Lobbying Activities

As required by Section 1352, Title 31 of the U.S. Code, as the duly authorized representative of the applicant, I certify, to the best of my knowledge and belief, that:

• No federal appropriated funds have been paid or will be paid, by or on behalf of the applicant, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer of Congress in connection with the awarding of any federal contract, the making of any federal loan, the entering into of any cooperative agreement, or modification of any federal contract, grant, loan, or cooperative agreement;

• 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 applicant will submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions;

• The applicant will require that the language of this certification be included in the award documents for all subcontracts at all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients will certify and disclose accordingly.

Erroneous certification or assurance

The assurances and certifications are material representations of fact upon which we rely in determining whether to enter into this transaction. If we later determine that you knowingly submitted an erroneous certification or assurance, in addition to other remedies available to the federal government, we may terminate this transaction for cause or default.

Notice of error in certification or assurance

You must provide immediate written notice to us if at any time you learn that a certification or assurance was erroneous when submitted or has become erroneous because of changed circumstances.

Definitions

The terms “debarment”, “suspension”, “excluded”, “disqualified”, “ineligible”, “participant”, “person”, “principal”, “proposal”, and “voluntarily excluded” as used in this document have the meanings set out in 2 CFR Part 180, subpart I, “Definitions.” A transaction shall be considered a “covered transaction” if it meets the definition in 2 CFR part 180 subpart B, “Covered Transactions.”

Assurance requirement for subgrant agreements

You agree by submitting this proposal that if we approve your application you shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by us.

Assurance inclusion in subgrant agreements

You agree by submitting this proposal that you will obtain an assurance from prospective participants in all lower tier covered transactions and in all solicitations for lower tier covered transactions that the participants are not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction.

Assurance of subgrant principals

You may rely upon an assurance of a prospective participant in a lower-tier covered transaction that is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless you know that the assurance is erroneous. You may decide the method and frequency by which you determine the eligibility of your principals. You may, but are not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs.

Non-assurance in subgrant agreements

If you knowingly enter into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the federal government, we may terminate this transaction for cause or default.

Prudent person standard

Nothing contained in the aforementioned may be construed to require establishment of a system of records in order to render in good faith the assurances and certifications required. Your knowledge and information is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

Certification - Grant Review Process (State Commissions Only)

I certify that in conducting our review process, we have ensured compliance with the National and Community Service Act of 1990, the Corporation's peer review requirements, and all state laws and conflict of interest rules.

Assurances and Certifications

assurance signature: NOTE: Sign this form and include in the application.

SIGNATURE:

By signing this assurances page, you certify that you agree to perform all actions and support all intentions in the Assurances section.

Organization Name:

Program Name:

Name and Title of Authorized Representative:

Signature:

Date:

cERTIFICATION signature: NOTE: Sign this form and include in the application.

SIGNATURE:

By signing this certification page, you certify that you agree to perform all actions and support all intentions in the Certification sections of this application. The three Certifications are:

• Certification: Debarment, Suspension and Other Responsibility Matters

• Certification: Drug-Free Workplace

• Certification: Lobbying Activities

Organization Name:

Program Name:

Name and Title of Authorized Representative:

Signature:

Date: