Form 1 CSBG State Plan (After September 2021)
Community Services Block Grant (CSBG) Program Model Plan Applications
CSBG State Plan Template 3.0 CLEAN 062821
CSBG State Plan Application for States
OMB: 0970-0382
OMB Control No: 0970-0382
Expiration Date: XX/XX/XXXX
Community Services Block Grant (CSBG)
State Plan
CSBG Cover Page (SF-424M)
SECTION 1: CSBG Administrative Information 2
SECTION 2: State Legislation and Regulation 5
SECTION 3: State Plan Development and Statewide Goals 6
SECTION 4: CSBG Hearing Requirements 8
SECTION 5: CSBG Eligible Entities 9
SECTION 6: Organizational Standards for Eligible Entities 12
SECTION 7: State Use of Funds 14
SECTION 8: State Training and Technical Assistance 19
SECTION 9: State Linkages and Communication 22
SECTION 10: Monitoring, Corrective Action, and Fiscal Controls 26
SECTION 11: Eligible Entity Tripartite Board 30
SECTION 12: Individual and Community Income Eligibility Requirements 31
SECTION 13: Results Oriented Management and Accountability (ROMA) System 32
SECTION 14: CSBG Programmatic Assurance and Information Narrative 34
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Through this information collection, ACF is gathering information about planned activities related to and funded by CSBG for the upcoming fiscal year. Public reporting burden for this collection of information is estimated to average 31 hours per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (Sec. 676, Pub. L. 105-285, 112 Stat. 2735 (42 U.S.C. § 9908)). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0382 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact M. Monique Alcantara at [email protected].
SECTION 1: CSBG Administrative Information
1.1. Identify whether this is a one-year or a two-year plan. One-Year Two-Year
1.1a. Provide the federal fiscal years this plan covers: Year One Year Two
GUIDANCE: If a state indicates “One-Year” under 1.1., they will only have to provide a response for “Year One”.
1.2. Lead Agency and Authorized Official: Update the following information in relation to the lead agency and authorized official designated to administer CSBG in the state, as required by Section 676(a) of the CSBG Act. Information should reflect the responses provided in the Application for Federal Assistance, SF-424M.
Has information regarding the state lead agency and authorized official changed since the last submission of the State Plan? Yes No
If yes, select the fields that have changed. [Check all the apply]
Lead Agency Department Type Department Name
Authorized Official Street Address City
Zip Code Office Number Fax Number
Email Address Website
1.2a. Lead agency [Narrative, 150 Characters]
GUIDANCE: Please only provide the exact name of the CSBG state lead agency as designated within the designation letter and an acronym (as applicable).
EXAMPLE: Office of Community Services (OCS)
1.2b. Cabinet or administrative department of this lead agency [Check one and provide a narrative where applicable]
Community Affairs Department
Community Services Department
Governor’s Office
Health Department
Housing Department
Human Services Department
Social Services Department
Other, describe: [Narrative, 100 characters]
1.2c. Cabinet or Administrative Department Name: Provide the name of the cabinet or administrative department of the CSBG authorized official [Narrative, 100 Characters]
1.2d. Authorized Official of the Lead Agency: The authorized official could be the director, secretary, commissioner etc. as assigned in the designation letter (attached under item 1.3.). The authorized official is the person indicated as the authorized representative on the SF-424M and the official recipient of the Notice of Award per Office of Grant Management requirements. [Narrative, 50 characters each]
Name Title
1.2e. Street Address [Narrative, 200 characters]
1.2f. City [Narrative, 50 characters]
1.2g. State [Dropdown]
1.2h. Zip Code [Numerical Response, 5 digits]
1.2i. Telephone Number [Numerical Response, 10 – 15 digits to include extensions]
1.2j. Fax Number [Numerical Response, 10 digits]
1.2k. Email Address [Narrative, 150 characters]
1.2l. Lead Agency Website [Narrative, 200 characters]
Note: Item 1.2. pre-populates the Annual Report, Module 1, Item A.1.
1.3. Designation Letter: Attach the state’s official CSBG designation letter. A new designation letter is required if the chief executive officer of the state and/or designated agency has changed. [Attach a document.]
GUIDANCE: The designation letter should be updated whenever there is a change to the designee.
INSTRUCTIONAL NOTE: The letter should be from the chief executive officer of the state and include, at minimum, the designated state CSBG lead agency (office, department, or bureau) and title of the authorized official of the lead agency who is to administer the CSBG grant award.
1.4. CSBG Point of Contact: Provide the following information in relation to the designated state CSBG point of contact. The state CSBG point of contact should be the person that will be the main point of contact for CSBG within the state.
Has information regarding the state point of contact changed since the last submission of the State Plan? Yes No
If yes, select the fields that have changed. [Check all the apply]
Agency Name Point of Contact Street Address City
State Zip Code Office Number Fax Number
Email Address Website
1.4a. Agency Name [Narrative, 150 characters]
1.4b. Point of Contact Name [Narrative, 50 characters each]
Name Title
1.4c. Street Address [Narrative, 200 characters]
1.4d. City [Narrative, 50 characters]
1.4e. State [Dropdown]
1.4f. Zip Code [Numerical Response, 5 digits]
1.4g. Telephone Number [Numerical Response, 10 – 15 digits to include extensions]
1.4h. Fax Number [Numerical Response, 10 digits]
1.4i. Email Address [Narrative, 150 characters]
1.4j. Agency Website [Narrative, 200 characters]
1.5. Provide the following information in relation to the State Community Action Association.
There is currently a state Community Action Association within the state. Yes No
Has information regarding the state Community Action Association changed since the last submission of the State Plan? Yes No
If yes, select the fields that have changed. [Check all the apply]
Agency Name Executive Director Street Address City
State Zip Code Office Number Fax Number
Email Address Website RPIC Lead
1.5a. Agency name [Narrative, 150 characters]
1.5b. Executive Director or Point of Contact [Narrative, 50 characters each]
Name Title
1.5c. Street Address [Narrative, 200 characters]
1.5d. City [Narrative, 50 characters]
1.5e. State [Dropdown]
1.5f. Zip Code [Numerical Response, 5 digits]
1.5g. Telephone Number [Numerical Response, 10 – 15 digits to include extensions]
1.5h. Fax Number [Numerical Response, 10 digits]
1.5i. Email Address [Narrative, 150 characters]
1.5j. State Association Website [Narrative, 200 characters]
1.5k. State Association currently serves as the Regional Performance Innovation Consortia (RPIC) lead Yes No
SECTION 2: State Legislation and Regulation
2.1. CSBG State Legislation: State has a statute authorizing CSBG. Yes No
2.2. CSBG State Regulation: State has regulations for CSBG. Yes No
2.3. Legislation/Regulation Document: Attach the legislation and/or regulations or provide a hyperlink(s) to the documents indicated under Items 2.1. and/or Item 2.2. [Attach a document and/or provide a link, 1500 characters]
GUIDANCE: The labeling of all attachments should include the question number for which the document provides supplementary information, the question heading, and the type of document provided. As an example, a state statutory document could be labeled as:
2.3. Legislation/Regulation Document, Washington D.C. Statute
2.4. State Authority: Select a response for each of the following items about the state statute and/or regulations authorizing CSBG:
2.4a. Authorizing Legislation: State legislature enacted authorizing legislation or amendments to an existing authorizing statute last federal fiscal year.
Yes No
2.4b. Regulation Amendments: State established or amended regulations for CSBG last federal fiscal year. Yes No
SECTION 3: State Plan Development and Statewide Goals
3.1. CSBG Lead Agency Mission and Responsibilities: Briefly describe the mission and responsibilities of the state agency that serves as the CSBG lead agency. [Narrative, 2500 characters]
3.2. State Plan Goals: Describe the state’s CSBG-specific goals for state administration of CSBG under this State Plan. [Narrative, 3000 characters]
GUIDANCE: States should consider feedback from OCS, their eligible entities, and the ACSI survey completed by eligible entities when creating their State Plan goals.
Instructional Note: For examples of “goals,” see State Accountability Measure 1Sa(i).
Note: This information is associated with State Accountability Measure 1Sa(i) and pre-populates the state’s Annual Report, Module 1, Item B.1.
3.3. State Plan Development: Indicate the information and input the state accessed to develop this State Plan.
3.3a. Analysis of state-level tools [Check all that applies and provide additional information where applicable]
State Performance Indicators and/or National Performance Indicators (NPIs)
U.S. Census data
State Performance Management Data (e.g., accountability measures, ACSI survey information, and/or other information from annual reports)
Monitoring Visits/Assessments
Tools Not Identified Above (specify) [Narrative, 500 characters]
3.3b. Analysis of local-level tools [Check all that applies and provide additional information where applicable]
Eligible Entity Community Needs Assessments
Eligible Entity Community Action Plans
Public Hearings/Workshops
Tools Not Identified Above (e.g., state required reports) [specify] [Narrative, 500 characters]
3.3c. Consultation with [Check all that applies and provide additional information where applicable]
Eligible Entities (e.g., meetings, conferences, webinars; not including the public hearing)
State Association
National Association for State Community Services Programs (NASCSP)
Community Action Partnership (NCAP)
Community Action Program Legal Services (CAPLAW)
CSBG Tribal Training and Technical Assistance (T/TA) provider
Regional Performance Innovation Consortium (RPIC)
Association for Nationally Certified ROMA Trainers (ANCRT)
Federal CSBG Office
Organizations not identified above (specify) [Narrative, 500 characters]
3.4. Eligible Entity Involvement
3.4a. State Plan Development: Describe the specific steps the state took in developing the State Plan to involve the eligible entities. [Narrative, 3000 Characters]
Note: This information is associated with State Accountability Measures 1Sa(ii) and may pre-populate the state’s annual report form.
3.4b. Performance Management Adjustment: Describe how the state has adjusted its State Plan development procedures under this State Plan, as compared to previous State Plans, in order to 1) encourage eligible entity participation and 2) ensure the State Plan reflects input from eligible entities? Any adjustment should be based on the state’s analysis of past performance in these areas, and should consider feedback from eligible entities, OCS, and other sources, such as the public hearing. If the state is not making any adjustments, provide further detail. [Narrative, 3000 Characters]
Note: This information is associated with State Accountability Measures 1Sb(i) and (ii) and pre-populate the Annual Report, Module 1, Item B.1.
3.5. Eligible Entity Overall Satisfaction: Provide the state’s target for eligible entity Overall Satisfaction during the performance period. Year One Year Two
[Numerical, 3 digits]
Instructional Note: The state’s target score will indicate improvement or maintenance of the states’ Overall Satisfaction score from the most recent American Customer Survey Index (ACSI) survey of the state’s eligible entities.
Note: Item 3.5 is associated with State Accountability Measure 8S and may pre-populate the state’s annual report form.
GUIDANCE: The targets reported here should match the future target set in the Annual Report, Section B, Table B.2.
GUIDANCE: Review the ACSI IM about setting targets for your eligible entity overall satisfaction that are realistic, reasonable, attainable, and possible.
SECTION 4: CSBG Hearing Requirements
4.1. Public Inspection: Describe the steps taken by the state to disseminate this State Plan to the public for review and comments prior to the public hearing, as required under Section 676(e)(2) of the Act. [Narrative, 2500 Characters]
GUIDANCE: Under this question, detail how the state provided the State Plan to the public, including providing sufficient time (ideally no fewer than 30 days) for the public to provide feedback prior to the public hearing. Distribution to the public should include distribution directly to the eligible entities (e.g. via email or publication on a public website with specific notification to the eligible entities) in the state as well as any other interested parties.
4.2. Public Notice/Hearing: Describe how the state ensured there was sufficient time and statewide distribution of notice of the public hearing(s) to allow the public to comment on the State Plan, as required under 676(a)(2)(B) of the CSBG Act. [Narrative, 2500 Characters]
4.3. Public and Legislative Hearings: In the table below, specify the date(s) and location(s) of the public and legislative hearing(s) held by the designated lead agency for this State Plan, as required under Section 676(a)(2)(B) and Section 676(a)(3) of the Act.
Instructional Note: A public hearing is required for each new submission of the State Plan. The date(s) for the public hearing(s) must have occurred in the year prior to the first federal fiscal year covered by this plan. Legislative hearings are held at least every three years, and must have occurred within the last three years prior to the first federal fiscal year covered by this plan.
Date |
Location |
Type of Hearing [Select an option] |
If a Combined Hearing was held confirm that the public was invited. |
[Select a Date] |
[Provide the facility and city – Narrative 100 characters] |
Public Legislative Combined |
|
NOTE: ADD-A-ROW function – States can add rows as needed for each hearing as needed
GUIDANCE: A combined hearing refers to having one joint public and legislative hearing.
4.4. Attach supporting documentation or a hyperlink for the public and legislative hearings. [Attach supporting documentation or provide a hyperlink(s), 500 characters]
GUIDANCE: Supporting documentation may include, but is not limited to, agendas, sign-in sheets, transcripts, and notices/advertisements of the hearings. All attachments should include the question number, question heading, type of document and the date of the hearing/meeting (as applicable).
EXAMPLE NAMING CONVENTION: 4.4. Public and Legislative Hearings Agenda 062117
SECTION 5: CSBG Eligible Entities
5.1. CSBG Eligible Entities: In the table below, indicate whether each eligible entity in the state is public or private, the type(s) of entity, and the geographical area served by the entity.
CSBG Eligible Entity |
Geographical Area Served (by county) [Provide all counties] |
Public or Nonprofit |
Type of Entity [Choose all that apply] |
[READ-ONLY] |
[READ-ONLY] |
[READ-ONLY] |
[READ-ONLY]
|
NOTE: THE ADD-A-ROW FUNCTION WILL NOT BE AVAILABLE ON THIS TABLE. ANY ADDITIONS/DELETIONS TO THE ELIGIBLE ENTITY LIST SHOULD BE MADE WITHIN THE MASTER LISTPRIOR TO INITIALIZING A NEW CSBG STATE PLAN.
Note: Table 5.1. pre-populates the Annual Report, Module 1, Table C.1.
GUIDANCE: Under Type of Entity, select more than one type by holding down the CTRL key while making selections.
NOTE: Whether nonprofit or public, entities that receive CSBG funds are generally considered to be Community Action Agencies for the purpose of administering CSBG. The only specific exceptions outlined in the CSBG Act are Limited Purpose Agencies, Migrant and Seasonal Farmworker organizations, and Tribes and Tribal Organizations
INSTRUCTIONAL NOTE: Limited Purpose Agency refers to an eligible entity that was designated as a limited purpose agency under Title II of the Economic Opportunity Act of 1964 for fiscal year 1981, that served the general purposes of a community action agency under Title II of the Economic Opportunity Act, that did not lose its designation as a limited purpose agency under Title II of the Economic Opportunity Act as a result of failure to comply with that Act and that has not lost its designation as an eligible entity under the CSBG Act.
INSTRUCTIONAL NOTE: 90 percent funds are the funds a state provides to eligible entities to carry out the purposes of the CSBG Act. As described under Section 675C of the CSBG Act, a state must provide to the eligible entities “not less than 90 percent” of their CSBG allocation “made available to a state under Section 675A or 675B.
5.2. Total number of CSBG eligible entities: ## [This will automatically update based on Table 5.1.]
5.3. Changes to Eligible Entities List: Within the tables below, describe any changes that have occurred to the eligible entities within the state since the last federal fiscal Year (FFY), as applicable.
One or more of the following changes were made to the eligible entity list: [Check all that apply].
Designation and/or Re-Designation
De-Designations and/or Voluntary Relinquishments
Mergers
No Changes to Eligible Entities List
GUIDANCE: The following three questions will only need to be answered based on your response to 5.3.
5.3a. Designation and Re-Designation: Identify any new entities that have been designated as eligible entities, as defined under Section 676A of the Act, since the last federal fiscal year. Include any eligible entities designated to serve an area previously not served by CSBG as well as any entities designated to replace another eligible entity that was terminated (de-designated) or that voluntarily relinquished its status as a CSBG eligible entity.
CSBG Eligible Entity |
Type |
Start Date |
Geographical Area Served |
[Narrative, 150 characters] |
[Dropdown:
|
[Date Picker] |
[Narrative, 550 characters] |
NOTE: ADD-A-ROW FUNCTION – states can add rows as needed.
GUIDANCE: A designation refers to an entity that was not receiving funding in the previous federal fiscal year(s) and/or was not included in the previous CSBG State Plan. Re-designation refers to an entity that is already designated/receiving funds but is now receiving funds to serve an additional geographic area previously served by another entity. A permanent re-designation must be conducted -in line with procedures outlined in Section 676A of the CSBG Act. An interim re-designation may be noted when an entity has been identified to provide services after a voluntary relinquishment pending official designation of a permanent entity consistent with the requirements of Section 676A. See CSBG Act 676A, Designation and Redesignation…, for more information.
5.3b. De-Designations and Voluntary Relinquishments: Identify any entities that are no longer receiving CSBG funding. Include any eligible entities have been terminated (de-designated) as defined under Section 676(c) and Section 676C of the Act, or voluntarily relinquished their CSBG eligible entity status since the last federal fiscal year.
CSBG Eligible Entity |
Reason |
[Narrative, 150 characters] |
[Dropdown:
|
NOTE: ADD-A-ROW FUNCTION – states can add rows as needed.
5.3c. Mergers: In the table below, provide information about any mergers or other combinations of two or more eligible entities that were individually listed in the prior State Plan.
Original CSBG Eligible Entities |
Surviving CSBG Eligible Entity |
New Name (as applicable) |
DUNS No. |
[Narrative, 500 characters]
List and number all entities involved. |
[Narrative, 150 characters] |
[Narrative, 150 characters] |
[Narrative, 150 characters] |
NOTE: ADD-A-ROW FUNCTION – states can add rows as needed.
GUIDANCE: This question refers to the merger or other combinations of two or more existing CSBG eligible entities only.
Under 5.3c, please only include two or more previously designated eligible entities that have merged or combined in order to provide CSBG services.
SECTION 6: Organizational Standards for Eligible Entities
Note: Reference IM 138, State Establishment of Organizational Standards for CSBG Eligible Entities, for more information on Organizational Standards. Click HERE for IM 138.
6.1. Choice of Standards: Confirm whether the state will implement the CSBG Organizational Standards Center of Excellence (COE) organizational standards (as described in IM 138) or an alternative set during the federal fiscal year(s) of this planning period. [Select one]
COE CSBG Organizational Standards
Modified Version of COE CSBG Organizational Standards
Alternative Set of organizational standards
Note: Item 6.1. pre-populates the Annual Report, Module 1, Item D.1.
6.1a. Modified Organizational Standards: In the case that the state is requesting to use modified COE-developed organizational standards, provide the proposed modification for the FFY of this planning period including the rationale. [Narrative, 2500 characters]
6.1b. Alternative Organizational Standards: If using an alternative set of organizational standards, attach the complete list of alternative organizational standards. [Attachment (as applicable)]
6.1c. Alternative Organizational Standards: If using an alternative set of organizational standards: 1) provide any changes from the last set provided during the previous State Plan submission; 2) describe the reasons for using alternative standards; and 3) describe how they are at least as rigorous as the COE- developed standards.
There were no changes from the previous State Plan submission [If not selected, provide a narrative, 2500 characters]
Provide reason for using alternative standards [Narrative, 2500 characters]
Describe rigor compared to COE-developed Standards [Narrative, 2500 characters]
6.2. Implementation: Check the box that best describes how the state officially adopted organizational standards for eligible entities in a manner consistent with the state’s administrative procedures act. If “Other” is selected, provide a timeline and additional information, as necessary. [Check all that applies and provide a narrative (as applicable)]
Regulation
Policy
Contracts with Eligible Entities
Other, describe: [Narrative, 4000 characters]
6.3. Organizational Standards Assessment: Describe how the state will assess eligible entities against organizational standards this federal fiscal year(s). [Check all that applies]
Peer-to-Peer Review (with validation by the state or state-authorized third party)
Self-Assessment (with validation by the state or state-authorized third party)
Self-Assessment/Peer Review with State Risk Analysis
State-Authorized Third-Party Validation
Regular On-Site CSBG monitoring
Other
6.3a. Assessment Process: Describe the planned assessment process. [Narrative, 4000 characters]
GUIDANCE: Descriptions should also include improvements to the process made since the previous year including any new processes to increase efficiency or consistency of assessments.
6.4. Eligible Entity Exemptions: Will the state make exceptions in applying the organizational standards for certain eligible entities due to special circumstances or organizational characteristics (as described in IM 138)? Yes No
GUIDANCE: You will only need to respond to the following question if you responded “yes” to 6.4.
6.4a. Provide the specific eligible entities the state will exempt from meeting organizational standards and provide a description and a justification for each exemption. Total Number of Exempt Entities: [Auto – calculated]
CSBG Eligible Entity |
Description/Justification |
[Narrative, 150 characters] |
[If Yes is selected, provide a narrative, 2500 characters] |
NOTE: ADD-A-ROW FUNCTION – states can add rows for each additional exception.
6.5. Performance Target: Provide the percentage of eligible entities that the state expects to meet all the state-adopted organizational standards for the FFY(s) of this planning period. [Insert a percentage] Year One Year Two
Note: Item 6.5. is associated with State Accountability Measures 6Sa and pre-populates the Annual Report, Module 1, Table D.2.
GUIDANCE: Prior to setting the target, states should review IM 138, review previous performance, and collaborate with the eligible entities and the state association to identify targets
SECTION 7: State Use of Funds
Eligible Entity Allocation (90 Percent Funds) [Section 675C(a) of the CSBG Act]
7.1. Formula: Select the method (formula) that best describes the current practice for allocating CSBG funds to eligible entities. [Check one]
Historic
Base + Formula
Formula Alone
Formula with Variables
Hold Harmless + Formula
Other
7.1a. Formula Description: Describe the current practice for allocating CSBG funds to eligible entities. [Narrative, 4000 characters]
7.1b. Statute: Does a state statutory or regulatory authority specify the formula for allocating “not less than 90 percent” funds among eligible entities? Yes No
7.2. Planned Allocation: Specify the percentage of your CSBG planned allocation that will be funded to eligible entities and in accordance to the “not less than 90 percent funds” requirement as described under Section 675C(a) of the CSBG Act. In the table, provide the planned allocation for each eligible entity receiving funds for the fiscal year(s) covered by this plan. Year One % Year Two %
Planned CSBG 90 Percent Funds – Year One
CSBG Eligible Entity |
Funding Amount ($) |
[READ-ONLY] Pre-populates from the CSBG Eligible Entity Master List |
Enter the dollar amount for each eligible entity for the first FFY covered by this CSBG State Plan. |
Total |
[Auto-calculated] |
Planned CSBG 90 Percent Funds – Year Two
CSBG Eligible Entity |
Funding Amount ($) |
[READ-ONLY] Pre-populates from the CSBG Eligible Entity Master List |
Enter the dollar amount for each eligible entity for the second FFY covered by this CSBG State Plan. |
Total |
[Auto-calculated] |
Note: This information pre-populates the state’s Annual Report, Module 1, Table E.2.
7.3. Distribution Process: Describe the specific steps in the state’s process for distributing 90 percent funds to the eligible entities and include the number of days each step is expected to take. Please include information about state legislative approval or other types of administrative approval (such as approval by a board or commission). [Narrative, 4000 characters]
7.3a. Distribution Method: Select the option below that best describes the distribution method the state uses to issue CSBG funds to eligible entities:
Reimbursement
Advance
Hybrid
Other [Narrative, 4000 characters]
7.4. Distribution Timeframe: Does the state intend to make funds available to eligible entities no later than 30 calendar days after OCS distributes the federal award?
Yes No
7.4a. Distribution Consistency: If no, describe state procedures to ensure funds are made available to eligible entities consistently and without interruption. [Narrative, 4000 characters]
Note: Item 7.4 is associated with State Accountability Measure 2Sa and may pre-populate the state’s annual report form.
7.5. Distribution of Funds Performance Management Adjustment: Describe the state’s strategy for improving grant and/or contract administration procedures under this State Plan as compared to past plans. Any improvements should be based on analysis of past performance and should consider feedback from eligible entities, OCS, and other sources, such as the public hearing. If the state is not making any improvements, provide further detail. [Narrative, 4000 characters]
Note: This information is associated with State Accountability Measure 2Sb and may pre-populate the state’s annual report form.
Administrative Funds [Section 675C(b)(2) of the CSBG Act]
7.6. Allocated Funds: Specify the percentage of your CSBG planned allocation for administrative activities for the FFY(s) covered by this State Plan.
Year One % Year Two % [Numeric response, specify %]
Note: This information pre-populates the state’s Annual Report, Module 1, Table E.4.
7.7. State Staff: Provide the number of state staff positions to be funded in whole or in part with CSBG funds for the FFY(s) covered by this State Plan.
Year One Year Two [Numeric response, 0.00 – 99.99]
7.8. State FTEs: Provide the number of state Full Time Equivalents (FTEs) to be funded with CSBG funds for the FFY(s) covered by this State Plan?
Year One Year Two [Numeric response, 0.00 – 99.99]
Use of Remainder/Discretionary Funds [Section 675C(b) of the CSBG Act]
7.9. Remainder/Discretionary Funds Use: Does the state have remainder/discretionary funds as described in Section 675C(b) of the CSBG Act? Yes No
GUIDANCE: “No” should only be selected if the percentages provided under 7.2. and 7.6. equal 100%.
If yes, provide the allocated percentage and describe the use of the remainder/discretionary funds in the table below. Year One % Year Two %
Note: This response will link to the corresponding assurance, Item 14.2.
INSTRUCTIONAL NOTE: The assurance under 676(b)(2) of the Act (Item 14.2 of this State Plan) specifically requires a description of how the state intends to use remainder/discretionary funds to “support innovative community and neighborhood-based initiatives related to the purposes of [the CSBG Act].” Include this description in Item 7.9f of the table below and/or attach the information.
If a funded activity fits under more than one category in the table, allocate the funds among the categories. For example, if the state provides funds under a contract with the State Community Action association to provide training and technical assistance to eligible entities and to create a statewide data system, the funds for that contract should be allocated appropriately between Items 7.9a. – 7.9c. If allocation is not possible, the state may allocate the funds to the primary category with which the activity is associated.
Note: This information is associated with State Accountability Measures 3Sa and pre-populates the Annual Report, Module 1, Table E.7.
Use of Remainder/Discretionary Funds – Year One
Remainder/Discretionary Fund Uses (See 675C(b)(1) of the CSBG Act) |
Planned $ |
Brief Description of Services and/or Activities |
7.9a. Training/Technical Assistance to eligible entities |
Enter the planned amount as applicable for the first FFY that this CSBG State Plan covers. |
These planned services/activities will be described in State Plan Item 8.1 [Read-Only] |
7.9b. Coordination of state-operated programs and/or local programs |
Enter the planned amount as applicable for the first FFY that this CSBG State Plan covers. |
These planned services/activities will be described in State Plan Section 9, State Linkages and Communication [Read-Only] |
7.9c. Statewide coordination and communication among eligible entities |
Enter the planned amount as applicable for the first FFY that this CSBG State Plan covers. |
These planned services/activities will be described in State Plan Section 9, State Linkages and Communication [Read-Only] |
7.9d. Analysis of distribution of CSBG funds to determine if targeting greatest need (Briefly describe under Column 4) |
Enter the planned amount as applicable for the first FFY that this CSBG State Plan covers. |
[Narrative, 4000 characters] |
7.9e. Asset-building programs (Briefly describe under Column 4) |
Enter the planned amount as applicable for the first FFY that this CSBG State Plan covers. |
[Narrative, 4000 characters] |
7.9f. Innovation programs/activities by eligible entities or other neighborhood groups (Briefly describe under Column 4) |
Enter the planned amount as applicable for the first FFY that this CSBG State Plan covers. |
[Narrative, 4000 characters] |
7.9g. State Charity tax credits (Briefly describe under Column 4) |
Enter the planned amount as applicable for the first FFY that this CSBG State Plan covers. |
[Narrative, 4000 characters] |
7.9h. Other activities (Specify these other activities under Column 4) |
Enter the planned amount as applicable for the first FFY that this CSBG State Plan covers. |
[Narrative, 4000 characters] |
Totals |
Auto-calculated |
|
Use of Remainder/Discretionary Funds – Year Two
Remainder/Discretionary Fund Uses (See 675C(b)(1) of the CSBG Act) |
Planned $ |
Brief Description of Services and/or Activities |
7.9a. Training/Technical Assistance to eligible entities |
Enter the planned amount as applicable for the second FFY that this CSBG State Plan covers. |
These planned services/activities will be described in State Plan Item 8.1 [Read-Only] |
7.9b. Coordination of state-operated programs and/or local programs |
Enter the planned amount as applicable for the second FFY that this CSBG State Plan covers. |
These planned services/activities will be described in State Plan Section 9, State Linkages and Communication [Read-Only] |
7.9c. Statewide coordination and communication among eligible entities |
Enter the planned amount as applicable for the second FFY that this CSBG State Plan covers. |
These planned services/activities will be described in State Plan Section 9, State Linkages and Communication [Read-Only] |
7.9d. Analysis of distribution of CSBG funds to determine if targeting greatest need (Briefly describe under Column 4) |
Enter the planned amount as applicable for the second FFY that this CSBG State Plan covers. |
[Narrative, 4000 characters] |
7.9e. Asset-building programs (Briefly describe under Column 4) |
Enter the planned amount as applicable for the second FFY that this CSBG State Plan covers. |
[Narrative, 4000 characters] |
7.9f. Innovation programs/activities by eligible entities or other neighborhood groups (Briefly describe under Column 4) |
Enter the planned amount as applicable for the second FFY that this CSBG State Plan covers. |
[Narrative, 4000 characters] |
7.9g. State Charity tax credits (Briefly describe under Column 4) |
Enter the planned amount as applicable for the second FFY that this CSBG State Plan covers. |
[Narrative, 4000 characters] |
7.9h. Other activities (Specify these other activities under Column 4) |
Enter the planned amount as applicable for the second FFY that this CSBG State Plan covers. |
[Narrative, 4000 characters] |
Totals |
Auto-calculated |
|
GUIDANCE: If the percentages provided under 7.2. and 7.6. do not equal 100%, the remaining percentage should be reported under 7.9. If the state does not have any remainder/ discretionary fund activities (as listed in 7.9a. – 7.9g.), the remainder should be described in 7.9h.
7.10. Remainder/Discretionary Funds Partnerships: Select the types of organizations, if any, the state intends to work with (by grant or contract using remainder/discretionary funds) to carry out some or all the activities in Table 7.9. [Check all that applies and narrative where applicable]
The State Directly Carries Out All Activities (No Partnerships)
The State Partially Carries Out Some Activities
CSBG Eligible Entities (if checked, include the expected number of CSBG eligible entities to receive funds) [Numeric response, 0 – 100]
Other Community-based Organizations
State Community Action Association
Regional CSBG Technical Assistance Provider(s)
National Technical Assistance Provider(s)
Individual Consultant(s)
Tribes and Tribal Organizations
Other [Narrative, 2500 characters]
Note: This response will link to the corresponding CSBG assurance in Item 14.2.
7.11. Use of Remainder/Discretionary Funds Performance Management Adjustment: Describe any adjustments the state will make to the use of remainder/discretionary funds under this State Plan as compared to past State Plans? Any adjustment should be based on the state’s analysis of past performance, and should consider feedback from eligible entities, OCS, and other sources, such as the public hearing. If the state is not making any adjustments, provide further detail. [Narrative, 4000 characters]
Note: This information is associated with State Accountability Measures 3Sb and may pre-populate the state’s annual report form.
SECTION 8: State Training and Technical Assistance
8.1. Training and Technical Assistance Plan: Describe the state’s plan for delivering CSBG-funded training and technical assistance to eligible entities under this State Plan by completing the table below. The T/TA plan should include all planned CSBG T/TA activities funded through the administrative or remainder/discretionary funds of this CSBG award (as reported in Section 7). The CSBG T/TA plan should include training and technical assistance conducted directly by the state or through partnerships (as specified in 8.3). Add a row for each activity: indicate the timeframe; whether it is training, technical assistance, or both; and the topic.
Note: This information is associated with State Accountability Measure 3Sc and pre-populates the Annual Report, Module 1, Table F.1.
Training and Technical Assistance – Year One
Planned Timeframe |
Training, Technical Assistance, or Both |
Topic |
Brief Description of “Other” |
Dropdown Options:
[Select one dropdown per row] |
Dropdown Options:
[Select one dropdown per row] |
Dropdown Options:
[Select one dropdown per row] |
If other is selected in Column 3, describe in this column
[Narrative, 500 characters] |
NOTE: ADD-A-ROW FUNCTION – States can add rows for each additional training
Training and Technical Assistance – Year Two
Planned Timeframe |
Training, Technical Assistance, or Both |
Topic |
Brief Description of “Other” |
Dropdown Options:
[Select one dropdown per row] |
Dropdown Options:
[Select one dropdown per row] |
Dropdown Options:
[Select one dropdown per row] |
If other is selected in Column 3, describe in this column
[Narrative, 500 characters] |
NOTE: ADD-A-ROW FUNCTION – States can add rows for each additional training
8.1a. Training and Technical Assistance Budget: The planned budget for all training and technical assistance:
Year One Year Two
8.1b. Training and Technical Assistance Collaboration: Describe how the state will collaborate with the State Association and other stakeholders in the planning and delivery of training and technical assistance. [Narrative, 2500 characters]
8.2. Organizational Standards Technical Assistance: Does the state have Technical Assistance Plans (TAPs) in place for all eligible entities with unmet organizational standards, if appropriate? Yes No
Note: 8.2 is associated with State Accountability Measure 6Sb. The state should put a TAP in place to support eligible entities with one or more unmet organizational standards.
8.2a. Address Unmet Organizational Standards: Describe the state’s plan to provide T/TA to eligible entities to ensure they address unmet Organizational Standards. [Narrative, 2500 characters]
8.3. Training and Technical Assistance Organizations: Indicate the types of organizations through which the state intends to provide training and/or technical assistance as described in Item 8.1, and briefly describe their involvement. (Check all that apply.) [Check all that applies and narrative where applicable]
All T/TA is conducted by the state
CSBG eligible entities (if checked, provide the expected number of CSBG eligible entities to receive funds) [Numeric response, 0 – 100]
Other community-based organizations
State Community Action Association
Regional CSBG technical assistance provider(s)
National technical assistance provider(s)
Individual consultant(s)
Tribes and Tribal Organizations
Other [Narrative, 1000 characters]
8.4. CSBG-Funded T/TA Performance Management Adjustment: Describe adjustments the state made to the training and technical assistance plan under this State Plan as compared to past plans. Any adjustment should be based on the state’s analysis of past performance, and should consider feedback from eligible entities, OCS, and other sources, such as the public hearing. If the state is not making any adjustments, provide further detail. [Narrative, 2500 Characters]
Note: This information is associated with State Accountability Measures 3Sd and may pre- populate the state’s annual report form.
SECTION 9: State Linkages and Communication
Note: This section describes activities that the state may support with CSBG remainder/discretionary funds, described under Section 675C(b)(1) of the CSBG Act. The state may indicate planned use of remainder/discretionary funds for linkage/communication activities in Section 7, State Use of Funds, items 7.9(b) and (c).
9.1. State Linkages and Coordination at the State Level: Describe the linkages and coordination at the state level that the state intends to create or maintain to ensure increased access to CSBG services to low-income people and communities under this State Plan and avoid duplication of services (as required by the assurance under Section 676(b)(5)). Describe additional information as needed. [Check all that apply from the list below and provide a Narrative, 4000 characters]
Note: This response will link to the corresponding CSBG assurance, Item 14.5. In addition, this information is associated with State Accountability Measure 7Sa and pre-populates the Annual Report, Module 1, Item G.1.
State Low Income Home Energy Assistance Program (LIHEAP) office
State Weatherization office
State Temporary Assistance for Needy Families (TANF) office
Head Start State Collaboration offices
State public health office
State education department
State Workforce Innovation and Opportunity Act (WIOA) agency
State budget office
Supplemental Nutrition Assistance Program (SNAP)
State child welfare office
State housing office
Other
9.2. State Linkages and Coordination at the Local Level: Describe how the state is encouraging partnerships and collaborations at the state level with public and private sector organizations, to assure the effective delivery and coordination of CSBG services to transform low-income communities and avoid duplication of services (as required by assurances under Section 676(b)(5) – (6)). [Narrative, 4000 characters]
Note: This response will link to the corresponding CSBG assurances, Items 14.5 and 14.6, and pre-populates the Annual Report, Module 1, Item G.2.
9.3. Eligible Entity Linkages and Coordination
9.3a. State Assurance of Eligible Entity Linkages and Coordination: Describe how the state will assure that eligible entities will partner and collaborate with public and private sector organizations to assure the effective delivery and coordination of CSBG services to low-income people and communities and avoid duplication of services (as required by the assurance under Section 676(b)(5)). [Narrative, 4000 characters]
Note: This response will link to the corresponding CSBG assurance, Item 14.5. and pre-populates the Annual Report, Module 1, Item G.3a.
9.3b. State Assurance of Eligible Entity Linkages to Fill Service Gaps: Describe how the eligible entities will develop linkages to fill identified gaps in the services, through the provision of information, referrals, case management, and follow-up consultations, according to the assurance under Section 676(b)(3)(B) of the CSBG Act. [Narrative, 4000 characters]
Note: This response will link to the corresponding CSBG assurance, Item 14.3b. and pre-populates the Annual Report, Module 1, Item G.3b.
9.4. Workforce Innovation and Opportunity Act (WIOA) Employment and Training Activities: Does the state intend to include CSBG employment and training activities as part of a WIOA Combined State Plan, as allowed under the Workforce Innovation and Opportunity Act (as required by the assurance under Section 676(b)(5) of the CSBG Act)? Yes No
Note: This response will link to the corresponding CSBG assurance, Item 14.5.
9.4a. WIOA Combined Plan: If the state selected yes under Item 9.4, provide the CSBG-specific information included in the state’s WIOA Combined Plan. This information includes a description of how the state and the eligible entities will coordinate the provision of employment and training activities through statewide and local WIOA workforce development systems. This information may also include examples of innovative employment and training programs and activities conducted by community action agencies or other neighborhood-based organizations as part of a community antipoverty strategy. [Narrative, 4000 characters]
9.4b. Employment and Training Activities: If the state selected no under Item 9.4, describe the coordination of employment and training activities, as defined in Section 3 of WIOA, by the state and by eligible entities providing activities through the WIOA system. [Narrative, 4000 characters]
9.5. Emergency Energy Crisis Intervention: Describe how the State will assure, where appropriate, that emergency energy crisis intervention programs under title XXVI (relating to Low-Income Home Energy Assistance) are conducted in each community in the State, as required by the assurance under Section 676(b)(6) of the CSBG Act). [Narrative, 4000 characters]
Note: This response will link to the corresponding CSBG assurance, Item 14.6.
9.6. Faith-based Organizations, Charitable Groups, and Community Organizations: Describe how the state will assure local eligible entities will coordinate and form partnerships with other organizations, including faith-based organizations, charitable groups, and community organizations, according to the state’s assurance under Section 676(b)(9) of the CSBG Act. [Narrative, 4000 characters]
Note: this response will link to the corresponding assurance, Item 14.9
9.7. Coordination of Eligible Entity 90 Percent Funds with Public/Private Resources: Describe how the eligible entities will coordinate CSBG 90 percent funds with other public and private resources, according to the assurance under Section 676(b)(3)(C) of the CSBG Act. [Narrative, 4000 characters]
Note: This response will link to the corresponding assurance, Item 14.3c.
9.8. Coordination among Eligible Entities and State Community Action Association: Describe state activities for supporting coordination among the eligible entities and the State Community Action Association. [Narrative, 4000 characters]
Note: This information will pre-populate the Annual Report, Module 1, Item G.5.
9.9. Communication with Eligible Entities and the State Community Action Association: In the table below, detail how the state intends to communicate with eligible entities, the State Community Action Association, and other partners identified under this State Plan on the topics listed below.
For any topic that is not applicable, select Not Applicable under Expected Frequency.
Communication Plan
Subject Matter |
Expected Frequency |
Format |
Brief Description of “Other” |
Upcoming Public and/or Legislative Hearings |
[Dropdown Options:
|
[Select All that Apply:
|
If “Other” is selected in Column 3, describe in this column.
[Narrative, 250 characters] |
State Plan Development |
|||
Organizational Standards Progress |
|||
State Accountability Measures Progress |
|||
Community Needs Assessments/Community Action Plans |
|||
State Monitoring Plans and Policies |
|||
Training and Technical Assistance (T/TA) Plans |
|||
ROMA and Performance Management |
|||
State Interagency Coordination |
|||
CSBG Legislative/Programmatic Updates |
|||
Tripartite Board Requirements |
NOTE: THE ADD-A-ROW FUNCTION WILL NOT BE AVAILABLE ON THIS TABLE. ANY ADDITIONS/DELETIONS TO THE ELIGIBLE ENTITY LIST SHOULD BE MADE WITHIN THE MASTER LISTPRIOR TO INITIALIZING A NEW CSBG STATE PLAN.
9.10. Feedback to Eligible Entities and State Community Action Association: Describe how the state will provide information to local entities and State Community Action Associations regarding performance on State Accountability Measures. [Narrative, 4000 characters]
Note: This information is associated with State Accountability Measure 5S(iii) and will pre-populate the Annual Report, Module 1, Item G.6.
GUIDANCE: Under this question, include how the state will provide information to local entities and state associations within 60 days of receiving feedback from OCS.
9.11. Communication Plan Performance Management Adjustment: Describe any adjustments the state made to the Communication Plan in this State Plan as compared to past plans. Any adjustment should be based on the state’s analysis of past performance, and should consider feedback from eligible entities, OCS, and other sources, such as the public hearing. If the state is not making any adjustments, provide further detail. [Narrative, 4000 characters]
Note: This information is associated with State Accountability Measures 7Sb; this response may pre-populate the state’s annual report form.
SECTION 10: Monitoring, Corrective Action, and Fiscal Controls
Monitoring of Eligible Entities (Section 678B(a) of the CSBG Act)
10.1. Specify the proposed schedule for planned monitoring visits including: full on-site reviews; on- site reviews of newly designated entities; follow-up reviews – including return visits to entities that failed to meet state goals, standards, and requirements; and other reviews as appropriate.
This is an estimated schedule to assist states in planning. States may indicate “no review” for entities the state does not plan to monitor in the performance period.
Note: This information is associated with State Accountability Measure 4Sa(i); this response pre-populates the Annual Report, Module 1, Table H.1.
GUIDANCE: Monitoring that is specific to organizational standards should be referenced within Section 6, Item 6.3a.
Monitoring Schedule – Year One
CSBG Eligible Entity |
Monitoring Type |
Review Type |
Target Quarter |
Start Date of Last Full Onsite Review |
End Date of Last Full Onsite Review |
Brief Description of “Other” |
[READ ONLY]
|
[Dropdown Options: Full On-Site Newly Designated Follow-up Other No Review |
[Dropdown Options: Onsite Review Desk Review] |
[Dropdown Options: FY1 Q1 FY1 Q2 FY1 Q3 FY1 Q4] |
Select a Date |
Select a Date |
If “Other” is selected in Column 2, describe in this column
[Narrative, 500 characters] |
Monitoring Schedule – Year Two
CSBG Eligible Entity |
Monitoring Type |
Review Type |
Target Quarter |
Start Date of Last Full Onsite Review |
End Date of Last Full Onsite Review |
Brief Description of “Other” |
[READ ONLY]
|
[Dropdown Options: Full On-Site Newly Designated Follow-up Other No Review |
[Dropdown Options: Onsite Review Desk Review] |
[Dropdown Options: FY2 Q1 FY2 Q2 FY2 Q3 FY2 Q4] |
Select a Date |
Select a Date |
If “Other” is selected in Column 2, describe in this column
[Narrative, 500 characters] |
GUIDANCE: Comprehensive monitoring includes a review of program, administrative, fiscal and organizational standards.
If you are monitoring an entity as a follow up to an issue with another program, this can be listed under “Other.”
When providing the date of your last full onsite review – this could be for any type of review that took place onsite. No dates for desk reviews should be provided here.
10.2. Monitoring Policies: Provide a copy of state monitoring policies and procedures by attaching and/or providing a hyperlink. [Attach a document or add a link]
10.3. Initial Monitoring Reports: According to the state’s procedures, by how many calendar days must the state disseminate initial monitoring reports to local entities? [Insert a number from 1 – 100]
Note: This item is associated with State Accountability Measure 4Sa(ii) and may pre-populate the state’s annual report form.
Corrective Action, Termination and Reduction of Funding and Assurance Requirements (Section 678C of the Act)
10.4. Closing Findings: Are state procedures for addressing eligible entity findings/deficiencies and the documenting closure of findings included in the state monitoring policies attached under 10.2? Yes No
10.4a. Closing Findings Procedures: If no, describe state procedures for addressing eligible entity findings/deficiencies and the documenting closure of findings. [Narrative, 2500 characters]
10.5. Quality Improvement Plans (QIPs): Provide the number of eligible entities currently on QIPs, if applicable. [Numeric Response, 0 – 100]
Note: The QIP information is associated with State Accountability Measures 4Sc.
10.6. Reporting of QIPs: Describe the state’s process for reporting eligible entities on QIPs to the Office of Community Services within 30 calendar days of the state approving a QIP? [Narrative, 4000 characters]
Note: This item is associated with State Accountability Measure 4Sa(iii)).
10.7. Assurance on Funding Reduction or Termination: The state assures that “any eligible entity that received CSBG funding the previous fiscal year will not have its funding terminated or reduced below the proportional share of funding the entity received in the previous fiscal year unless, after providing notice and an opportunity for a hearing on the record, the state determines that cause exists for such termination or such reduction, subject to review by the Secretary as provided in Section 678C(b)” per Section 676(b)(8) of the CSBG Act. Yes No
Note: This response will link with the corresponding assurance under item 14.8.
Policies on Eligible Entity Designation, De-designation, and Re-designation
10.8. Eligible Entity Designation: Does the state CSBG statute and/or regulations provide for the designation of new eligible entities? Yes No
10.8a. New Designation Citation: If yes, provide the citation(s) of the law and/or regulation. [Narrative, 2500 Characters]
10.8b. New Designation Procedures: If no, describe state procedures for the designation of new eligible entities and how the procedures were made available to eligible entities and the public. [Narrative, 4000 characters]
10.9. Eligible Entity Termination: Does the state CSBG statute and/or regulations provide for termination of eligible entities? Yes No
10.9a. Termination Citation: If yes, provide the citation(s) of the law and/or regulation. [Narrative, 2500 characters]
10.9b. Termination Procedures: If no, describe state procedures for termination of new eligible entities and how the procedures were made available to eligible entities and the public. [Narrative, 4000 characters]
10.10. Eligible Entity Re-Designation: Do the state CSBG statute and/or regulations provide for re-designation of an existing eligible entity? Yes No
10.10a. Re-Designation Citation: If yes, provide the citation(s) of the law and/or regulation. [Narrative, 2500 Characters]
10.10b. Re-Designation Procedures: If no, describe state procedures for re-designation of existing eligible entities and how the procedures were made available to eligible entities and the public. [Narrative, 4000 characters]
GUIDANCE: Re-designation implies that an entity that is already designated/receiving funds is now performing the duties and receiving funds that were previously designated to another entity, in addition to the funding that they are already receiving. This is different from a merger as an entity is not absorbing another entity. This re-designation may be permanent (requires a formula redistribution) or temporary while the state has officially designated a new entity and has completed a formula redistribution. See CSBG Act 676A, Designation and Redesignation…, for more information.
Fiscal Controls and Audits and Cooperation Assurance
10.11. Fiscal Controls and Accounting: Describe how the state’s fiscal controls and accounting procedures will a) permit preparation of the SF-425 Federal fiscal reports (FFR) and b) permit the tracing of expenditures adequate to ensure funds have been used appropriately under the block grant, as required by Block Grant regulations applicable to CSBG at 45 CFR 96.30(a). [Narrative, 4000 characters]
10.12. Single Audit Management Decisions: Describe state procedures for issuing management decisions for eligible entity single audits, as required by Block Grant regulations applicable to CSBG at 45 CFR 75.521. [Narrative, 4000 characters]
Note: This information is associated with State Accountability Measure 4Sd.
10.13. Assurance on Federal Investigations: The state will “permit and cooperate with Federal investigations undertaken in accordance with Section 678D” of the CSBG Act, as required by the assurance under Section 676(b)(7) of the CSBG Act. Yes No
Note: This response will link with the corresponding assurance, Item 14.7
10.13a. Federal Investigations Policies: Are state procedures for permitting and cooperating with federal investigations included in the state monitoring policies attached under 10.2? Yes No
10.14. Monitoring Procedures Performance Management Adjustment: Describe any adjustments the state made to monitoring procedures in this State Plan as compared to past plans? Any adjustment should be based on the state’s analysis of past performance, and should consider feedback from eligible entities, OCS, and other sources, such as the public hearing. If the state is not making any adjustments, provide further detail. [Narrative, 2500 Characters]
Note: This item is associated with State Accountability Measure 4Sb and may pre-populate the state’s annual report form.
SECTION 11: Eligible Entity Tripartite Board
11.1. Tripartite Board Verification: Verify which of the following measures are taken to ensure that the state verifies CSBG eligible entities are meeting Tripartite Board requirements under Section 676B(a)(2) of the CSBG Act. [Check all that applies and narrative where applicable]
Attend Board meetings
Organizational Standards Assessment
Monitoring
Review copies of Board meeting minutes
Track Board vacancies/composition
Other [Narrative, 2500 characters]
11.2. Tripartite Board Updates: Provide how often the state requires eligible entities (which are not on TAPs or QIPs) to provide updates regarding their Tripartite Boards. This includes but is not limited to copies of meeting minutes, vacancy alerts, changes to bylaws, low-income member selection process, etc. [Select one and provide a narrative where applicable]
Annually
Semiannually
Quarterly
Monthly
As It Occurs
Other [Narrative, 2500 characters]
11.3. Tripartite Board Representation Assurance: Describe how the states will verify that eligible entities have policies and procedures by which individuals or organizations can petition for adequate representation on an eligible entity’s Tripartite Board as required by the assurance under Section 676(b)(10) of the CSBG Act. [Narrative, 2500 Characters]
Note: This response will link with the corresponding assurance, Item 14.10.
11.4. Tripartite Board Alternative Representation: Does the state permit public eligible entities to use, as an alternative to a Tripartite Board, “another mechanism specified by the state to assure decision-making and participation by low-income individuals in the development, planning, implementation, and evaluation of programs” as allowed under Section 676B(b)(2) of the CSBG Act? Yes No
11.4a. If yes, describe the mechanism used by public eligible entities as an alternative to a Tripartite Board. [Narrative, 2500 Characters]
SECTION 12: Individual and Community Income Eligibility Requirements
12.1. Required Income Eligibility: Provide the income eligibility threshold for services in the state. [Select one item below and numeric response where applicable.]
125% of the HHS poverty line
X % of the HHS poverty line (fill in the threshold): % [Numeric response]
Varies by eligible entity [Narrative, 4000 characters]
GUIDANCE: Under Varies by eligible entity, provide the threshold and the reason that it varies by entity.
12.1a. Describe any state policy and/or procedures for income eligibility, such as treatment of income and family/household composition. [Narrative, 4000 characters]
12.2. Income Eligibility for General/Short Term Services: Describe how the state ensures eligible entities generally verify income eligibility for those services with limited intake procedures (where individual income verification is not possible or practical). An example of these services is emergency food assistance. [Narrative, 4000 characters]
12.3. Community-targeted Services: Describe how the state ensures eligible entities’ services target and benefit low-income communities for those services that provide a community-wide benefit (e.g., development of community assets/facilities, building partnerships with other organizations). [Narrative, 4000 characters]
SECTION 13: Results Oriented Management and Accountability (ROMA) System
13.1. Performance Measurement System: Identify the performance measurement system that the state and all eligible entities use, as required by Section 678E(a) of the CSBG Act and the assurance under Section 676(b)(12) of the CSBG Act. [Select one]
Note: This response will also link to the corresponding assurance, Item 14.12. and will pre-populate the Annual Report, Module 1, Item I.1.
The Results Oriented Management and Accountability (ROMA) System
Another performance management system that meets the requirements of Section 678E(b) of the CSBG Act
An alternative system for measuring performance and results
13.1a. ROMA Description: If ROMA was chosen in Item 13.1, describe the state’s written policies, procedures, or guidance documents on ROMA. [Narrative, 4000 characters]
13.1b. Alternative System Description: If an alternative system was chosen in Item 13.1, describe the system the state will use for performance measurement. [Narrative, 4000 characters]
13.2. Outcome Measures: Indicate and describe the outcome measures the state will use to measure eligible entity performance in promoting self-sufficiency, family stability, and community revitalization, as required under Section 676(b)(12) of the CSBG Act. [Select one and provide a narrative, 4000 characters]
Note: This response will also link to the corresponding assurance, Item 14.12.
CSBG National Performance Indicators (NPIs)
NPIs and others
Others
13.3. Eligible Entity Support: Describe how the state supports the eligible entities in using ROMA or an alternative performance management system. [Narrative, 4000 characters]
Note: The activities described under Item 13.3 may include activities listed in “Section 8: Training and Technical Assistance.” If so, mention briefly, and/or cross-reference as needed. This response will also link to the corresponding assurance, Item 14.12.
13.4. Eligible Entity Use of Data: Describe how the state intends to validate that the eligible entities are using data to improve service delivery. [Narrative, 4000 characters]
Note: This response will also link to the corresponding assurance, Item 14.12.
Community Action Plans and Needs Assessments
13.5. Community Action Plan: Describe how the state will secure a Community Action Plan from each eligible entity, as a condition of receipt of CSBG funding by each entity, as required by Section 676(b)(11) of the CSBG Act. [Narrative, 4000 characters]
Note: This response will link to the corresponding assurance, Item 14.11.
13.6. Community Needs Assessment: Describe how the state will assure that each eligible entity includes a community needs assessment for the community served (which may be coordinated with community needs assessments conducted by other programs) in each entity’s Community Action Plan, as required by Section 676(b)(11) of the CSBG Act. [Narrative, 4000 characters]
Note: This response will link to the corresponding assurance, Item 14.11.
SECTION 14: CSBG Programmatic Assurance and Information Narrative
(Section 676(b) of the CSBG Act)
14.1. Use of Funds Supporting Local Activities
CSBG Services
14.1a. 676(b)(1)(A) Describe how the state will assure “that funds made available through grant or allotment will be used –
(A) to support activities that are designed to assist low-income families and individuals, including families and individuals receiving assistance under title IV of the Social Security Act, homeless families and individuals, migrant or seasonal farmworkers, and elderly low-income individuals and families, and a description of how such activities will enable the families and individuals--
(i) to remove obstacles and solve problems that block the achievement of self- sufficiency (particularly for families and individuals who are attempting to transition off a State program carried out under part A of title IV of the Social Security Act);
(ii) to secure and retain meaningful employment;
(iii) to attain an adequate education with particular attention toward improving literacy skills of the low-income families in the community, which may include family literacy initiatives;
(iv) to make better use of available income;
(v) to obtain and maintain adequate housing and a suitable living environment;
(vi) to obtain emergency assistance through loans, grants, or other means to meet immediate and urgent individual and family needs;
(vii) to achieve greater participation in the affairs of the communities involved, including the development of public and private grassroots partnerships with local law enforcement agencies, local housing authorities, private foundations, and other public and private partners to –
(I) document best practices based on successful grassroots intervention in urban areas, to develop methodologies for widespread replication; and
(II) strengthen and improve relationships with local law enforcement agencies, which may include participation in activities such as neighborhood or community policing efforts;
[Narrative, 4000 characters]
Needs of Youth
14.1b. 676(b)(1)(B) Describe how the state will assure “that funds made available through grant or allotment will be used –
(B) to address the needs of youth in low-income communities through youth development programs that support the primary role of the family, give priority to the prevention of youth problems and crime, and promote increased community coordination and collaboration in meeting the needs of youth, and support development and expansion of innovative community-based youth development programs that have demonstrated success in preventing or reducing youth crime, such as--
(i) programs for the establishment of violence-free zones that would involve youth development and intervention models (such as models involving youth mediation, youth mentoring, life skills training, job creation, and entrepreneurship programs); and
(ii) after-school child care programs;
[Narrative, 4000 characters]
Coordination of Other Programs
14.1c. 676(b)(1)(C) Describe how the state will assure “that funds made available through grant or allotment will be used –
(C) to make more effective use of, and to coordinate with, other programs related to the purposes of this subtitle (including State welfare reform efforts)
[Narrative, 4000 characters]
State Use of Discretionary Funds
14.2. 676(b)(2) Describe “how the State intends to use discretionary funds made available from the remainder of the grant or allotment described in section 675C(b) in accordance with this subtitle, including a description of how the State will support innovative community and neighborhood-based initiatives related to the purposes of this subtitle.”
Note: The State describes this assurance under “State Use of Funds: Remainder/Discretionary,” items 7.9 and 7.10
[No response as the state describes this assurance under 7.9 and 7.10.]
Eligible Entity Service Delivery, Coordination, and Innovation
14.3. 676(b)(3) “Based on information provided by eligible entities in the State, a description of…”
Eligible Entity Service Delivery System
14.3a. 676(b)(3)(A) Describe “the service delivery system, for services provided or coordinated with funds made available through grants made under 675C(a), targeted to low-income individuals and families in communities within the State;”
[Narrative, 4000 characters]
Eligible Entity Linkages – Approach to Filling Service Gaps
14.3b. 676(b)(3)(B) Describe “how linkages will be developed to fill identified gaps in the services, through the provision of information, referrals, case management, and followup consultations.”
Note: The state describes this assurance in the State Linkages and Communication section, item 9.3b.
[No response as the state describes this assurance under 9.3b.]
Coordination of Eligible Entity Allocation 90 Percent Funds with Public/Private Resources
14.3c. 676(b)(3)(C) Describe how funds made available through grants made under 675C(a)will be coordinated with other public and private resources.”
Note: The state describes this assurance in the State Linkages and Communication section, item 9.7.
[No response as the state describes this assurance under 9.7]
Eligible Entity Innovative Community and Neighborhood Initiatives, Including Fatherhood/Parental Responsibility
14.3d. 676(b)(3)(D) Describe “how the local entity will use the funds [made available under 675C(a)] to support innovative community and neighborhood-based initiatives related to the purposes of this subtitle, which may include fatherhood initiatives and other initiatives with the goal of strengthening families and encouraging parenting.”
Note: The description above is about eligible entity use of 90 percent funds to support these initiatives. States may also support these types of activities at the local level using state remainder/discretionary funds, allowable under Section 675C(b)(1)(F). In this State Plan, the state indicates funds allocated for these activities under item 7.9(f).
[Narrative, 4000 characters]
Eligible Entity Emergency Food and Nutrition Services
14.4. 676(b)(4) Describe how the state will assure “that eligible entities in the State will provide, on an emergency basis, for the provision of such supplies and services, nutritious foods, and related services, as may be necessary to counteract conditions of starvation and malnutrition among low-income individuals.”
[Narrative, 4000 characters]
State and Eligible Entity Coordination/linkages and Workforce Innovation and Opportunity Act Employment and Training Activities
14.5. 676(b)(5) Describe how the state will assure “that the State and eligible entities in the State will coordinate, and establish linkages between, governmental and other social services programs to assure the effective delivery of such services, and [describe] how the State and the eligible entities will coordinate the provision of employment and training activities, as defined in section 3 of the Workforce Innovation and Opportunity Act, in the State and in communities with entities providing activities through statewide and local workforce development systems under such Act.”
Note: The state describes this assurance in Section 9, State Linkages and Communication, specifically under 9.1 – 9.4b.
[No response as the state describes this assurance under Section 9.1 – 9.4b]
State Coordination/Linkages and Low-income Home Energy Assistance
14.6. 676(b)(6) Provide “an assurance that the State will ensure coordination between antipoverty programs in each community in the State, and ensure, where appropriate, that emergency energy crisis intervention programs under title XXVI (relating to low- income home energy assistance) are conducted in such community.”
Note: The state describes this assurance in Section 9, State Linkages and Communication section, items 9.2 and 9.5.
[No response as the state describes this assurance under 9.2 and 9.5]
Federal Investigations
14.7. 676(b)(7) Provide “an assurance that the State will permit and cooperate with Federal investigations undertaken in accordance with section 678D.”
Note: The state addresses this assurance in Section 10, Fiscal Controls and Monitoring under 10.13.
[No response as the state describes this assurance under 10.13]
Funding Reduction or Termination
14.8. 676(b)(8) Provide “an assurance that any eligible entity in the State that received funding in the previous fiscal year through a community services block grant made under this subtitle will not have its funding terminated under this subtitle, or reduced below the proportional share of funding the entity received in the previous fiscal year unless, after providing notice and an opportunity for a hearing on the record, the State determines that cause exists for such termination or such reduction, subject to review by the Secretary as provided in section 678C(b).”
Note: The state addresses this assurance in Section 10 Fiscal Controls and Monitoring under 10.7.
[No response as the state describes this assurance under 10.7]
Coordination with Faith-based Organizations, Charitable Groups, Community Organizations
14.9. 676(b)(9) Describe how the state will assure “that the State and eligible entities in the State will, to the maximum extent possible, coordinate programs with and form partnerships with other organizations serving low-income residents of the communities and members of the groups served by the State, including religious organizations, charitable groups, and community organizations.”
Note: The state describes this assurance in Section 9 State Linkages and Communication, under 9.6.
[No response as the state describes this assurance under 9.6]
Eligible Entity Tripartite Board Representation
14.10. 676(b)(10) Describe how “the State will require each eligible entity in the State to establish procedures under which a low-income individual, community organization, or religious organization, or representative of low-income individuals that considers its organization, or low-income individuals, to be inadequately represented on the board (or other mechanism) of the eligible entity to petition for adequate representation.”
Note: The state describes this assurance in Section 11 Eligible Entity Tripartite Boards, under 11.3.
[No response as the state describes this assurance under 11.3]
Eligible Entity Community Action Plans and Community Needs Assessments
14.11. 676(b)(11) Provide “an assurance that the State will secure from each eligible entity in the State, as a condition to receipt of funding by the entity through a community services block grant made under this subtitle for a program, a community action plan (which shall be submitted to the Secretary, at the request of the Secretary, with the State plan) that includes a community-needs assessment for the community served, which may be coordinated with community-needs assessments conducted for other programs.”
Note: The state describes this assurance in Section 13 ROMA, under 13.5 and 13.6.
[No response as the state describes this assurance under 13.5 and 13.6]
State and Eligible Entity Performance Measurement: ROMA or Alternate system
14.12. 676(b)(12) Provide “an assurance that the State and all eligible entities in the State will, not later than fiscal year 2001, participate in the Results Oriented Management and Accountability System, another performance measure system for which the Secretary facilitated development pursuant to section 678E(b), or an alternative system for measuring performance and results that meets the requirements of that section, and [describe] outcome measures to be used to measure eligible entity performance in promoting self-sufficiency, family stability, and community revitalization.”
Note: The state describes this assurance in Section 13 ROMA under 13.1 – 13.4.
[No response as the state describes this assurance under 13.1 – 13.4]
Validation for CSBG Eligible Entity Programmatic Narrative Sections
14.13. 676(b)(13) Provide “information describing how the State will carry out the assurances described in this section.”
Note: The state provides information for each of the assurances directly in section 14 or in corresponding items throughout the State Plan, which are included as hyperlinks in section 14.
[No response for this item]
By checking this box, the state CSBG authorized official is certifying the assurances set out above.
SECTION 15: Federal Certifications
The box after each certification must be checked by the State CSBG authorized official.
15.1. Lobbying
Certification for Contracts, Grants, Loans, and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that:
If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions. Submission of this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
By checking this box, the state CSBG authorized official is providing the certification set out above.
15.2. Drug-Free Workplace Requirements
This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988: 45 CFR Part 76, Subpart, F. Sections 76.630(c) and (d)(2) and 76.645 (a)(1) and (b) provide that a Federal agency may designate a central receipt point for STATE-WIDE AND STATE AGENCY-WIDE certifications, and for notification of criminal drug convictions. For the Department of Health and Human Services, the central point is: Division of Grants Management and Oversight, Office of Management and Acquisition, Department of Health and Human Services, Room 517-D, 200 Independence Avenue, SW Washington, DC 20201.
Certification Regarding Drug-Free Workplace Requirements (Instructions for Certification)
(1) By signing and/or submitting this application or grant agreement, the grantee is providing the certification set out below.
(2) The certification set out below is a material representation of fact upon which reliance is placed when the agency awards the grant. If it is later determined that the grantee knowingly rendered a false certification, or otherwise violates the requirements of the Drug-Free Workplace Act, the agency, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act.
(3) For grantees other than individuals, Alternate I applies.
(4) For grantees who are individuals, Alternate II applies.
(5) Workplaces under grants, for grantees other than individuals, need to be identified on the certification. If known, they may be identified in the grant application. If the grantee does not identify the workplaces at the time of application, or upon award, if there is no application, the grantee must keep the identity of the workplace(s) on file in its office and make the information available for Federal inspection. Failure to identify all known workplaces constitutes a violation of the grantee’s drug-free workplace requirements.
(6) Workplace identifications must include the actual address of buildings (or parts of buildings) or other sites where work under the grant takes place. Categorical descriptions may be used (e.g., all vehicles of a mass transit authority or State highway department while in operation, State employees in each local unemployment office, performers in concert halls or radio studios).
(7) If the workplace identified to the agency changes during the performance of the grant, the grantee shall inform the agency of the change(s), if it previously identified the workplaces in question (see paragraph five).
(8) Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common rule apply to this certification. Grantees’ attention is called, in particular, to the following definitions from these rules:
Controlled substance means a controlled substance in Schedules I through V of the Controlled Substances Act (21 U.S.C. 812) and as further defined by regulation (21 CFR 1308.11 through 1308.15);
Conviction means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or both, by any judicial body charged with the responsibility to determine violations of the Federal or State criminal drug statutes;
Criminal drug statute means a Federal or non-Federal criminal statute involving the manufacture, distribution, dispensing, use, or possession of any controlled substance;
Employee means the employee of a grantee directly engaged in the performance of work under a grant, including: (i) All direct charge employees; (ii) All indirect charge employees unless their impact or involvement is insignificant to the performance of the grant; and, (iii) Temporary personnel and consultants who are directly engaged in the performance of work under the grant and who are on the grantee’s payroll. This definition does not include workers not on the payroll of the grantee (e.g., volunteers, even if used to meet a matching requirement; consultants or independent contractors not on the grantee’s payroll; or employees of subrecipients or subcontractors in covered workplaces).
Certification Regarding Drug-Free Workplace Requirements
Alternate I. (Grantees Other Than Individuals)
The grantee certifies that it will or will continue to provide a drug-free workplace by:
(a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the grantee’s workplace and specifying the actions that will be taken against employees for violation of such prohibition;
(b) Establishing an ongoing 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 may be imposed upon employees for drug abuse violations occurring in the workplace;
(c) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph (a);
(d) Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant, the employee will - -
(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction;
(e) Notifying the agency in writing, within 10 calendar days after receiving notice under paragraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant activity the convicted employee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant;
(f) Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d)(2), with respect to any employee who is so convicted - -
(1) Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency;
(g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e) and (f).
The grantee may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant:
Place of Performance (Street address, city, county, state, zip code) [Narrative, 2500 characters]
Check if there are workplaces on file that are not identified here. Alternate II. (Grantees Who Are Individuals)
(a) The grantee certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant;
(b) If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant activity, he or she will report the conviction, in writing, within 10 calendar days of the conviction, to every grant officer or other designee, unless the Federal agency designates a central point for the receipt of such notices. When notice is made to such a central point, it shall include the identification number(s) of each affected grant.
[55 FR 21690, 21702, May 25, 1990]
By checking this box, the state CSBG authorized official is providing the certification set out above.
15.3. Debarment
CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS
Certification Regarding Debarment, Suspension, and Other Responsibility Matters — Primary Covered Transactions
Instructions for Certification
(1) By signing and submitting this proposal, the prospective primary participant is providing the certification set out below.
(2) The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency’s determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction.
(3) The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.
(4) The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
(5) 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. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations.
(6) The prospective primary participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency entering into this transaction.
(7) The prospective primary participant further agrees by submitting this proposal that it will include the clause titled “Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusive-Lower Tier Covered Transaction,” provided by the department or agency entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
(8) A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs.
(9) Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.
(10) Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.
************
Certification Regarding Debarment, Suspension, and Other Responsibility Matters — Primary Covered Transactions
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and
(d) Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion — Lower Tier Covered Transactions
Instructions for Certification
(1) By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below.
(2) The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.
(3) The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or had become erroneous by reason of changed circumstances.
(4) 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 meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations.
(5) The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated.
(6) The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled “Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,” without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
(7) A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transactions, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs.
(8) Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.
(9) Except for transactions authorized under paragraph five of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.
************
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion — Lower Tier Covered Transactions
(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.
(2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.
By checking this box, the state CSBG authorized official is providing the certification set out above.
15.4. Environmental Tobacco Smoke
Public Law 103227, Part C Environmental Tobacco Smoke, also known as the Pro Children Act of 1994, requires that smoking not be permitted in any portion of any indoor routinely owned or leased or contracted for by an entity and used routinely or regularly for provision of health, day care, education, or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law does not apply to children’s services provided in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1000 per day and/or the imposition of an administrative compliance order on the responsible entity by signing and submitting this application the applicant/grantee certifies that it will comply with the requirements of the Act.
The applicant/grantee further agrees that it will require the language of this certification be included in any subawards which contain provisions for the children’s services and that all subgrantees shall certify accordingly.
By checking this box, the state CSBG authorized official is providing the certification set out above.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Alcantara, Monique (ACF) |
| File Modified | 0000-00-00 |
| File Created | 2023-08-27 |
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