Form 0 HS Grant Application

OMB No: 0970-0207

Expires 4/30/2003

Grant Application to Continue a Head Start or Early Head Start Program

Administration for Children and Families

Department of Health and Human Services

1. General Instructions

1. Introduction

The Administration for Children and Families (ACF) will make annual grant awards for 12-month periods to Head Start and Early Head Start grantees on a three-year grant application cycle. Applicants must submit a full project description, a budget, and a budget narrative in the first year of each three-year grant cycle. Applicants shall submit an abbreviated project description, a budget and budget narrative in each of the subsequent two years. Separate budgets must be completed for Early Head Start grants and Head Start grants even if funds are to be awarded in a single grant document.

2. Due Dates for the Submission of Applications

Applications should be submitted to ACF no later than 90 days prior to the end of the grant period. An original application and two copies should be submitted to the responsible ACF Grants Officer.

3. Content of Applications

Applicants must submit the following seven items in continuation applications for each year of the grant cycle. The Project Description and the Budget and Budget Justification must be submitted in full in the first year and the Project Description may be abbreviated in subsequent years, in accordance with the attached instructions in Part II, below.

Computer-generated facsimiles may be substituted for any of the forms in this packet. To facilitate review and processing of the application, all pages should be numbered.

1. Standard Form (SF) 424: Application for Federal Assistance

A copy of this form is attached.

Regarding the box in the upper right corner, “Applicant Identifier,” insert the applicant’s grant number.

Regarding Item 9, insert “Administration for Children and Families/DHHS.”

Regarding Item 10, the Federal Domestic Assistance Number for the Head Start and Early Head Start Programs is 93.600.

Regarding Item 11, in addition to the title of the project, applicants should specify whether the submission is for a first-, second-, or third-year continuation or an application for supplemental funds or a request for a grant amendment.

Regarding Item 16, this program is covered under Executive Order 12372, Intergovernmental Review of Federal Programs, and 45 CFR Part 100, Intergovernmental Review of Department of Health and Human Services Programs and Activities. Applicants in States and jurisdictions participating in the Executive Order process should contact their State Single Points of Contact (SPOC) as soon as possible to alert them to the prospective application and to receive any necessary instructions.

2. SF 424A, Budget Information — Non-Construction Programs

The SF 424A must be submitted for all funding requests.

In programs where there are delegate agencies, a separate budget must be submitted for each delegate agency and a combined form should be submitted for the grantee with the total costs associated with delegate agencies included in the Contractual Object Class Category, Section B., line 6f.

In Section B, Budget Categories, applicants should enter proposed budget amounts for Training and Technical Assistance funds in a column separate from the column for funds for program operations.

Federal program costs should be placed in the Object Class Categories in Section B, in accordance with Part III, Instructions for the Program Approach Form and the Line-item Budget.

In Section C, Non-Federal Resources, applicants should enter the amount of non-Federal Resources, including cash and in-kind contributions, that will be used to support the project.

Section D, Forecasted Cash Needs, and Section E, Budget Estimates of Federal Funds Needed for Balance of the Project, should be left blank.

Explanations and justifications of the amounts proposed in the SF 424A must be provided in Section A.3 of the Project Description, Budget and Budge Narrative Statement.

3. Program Approach Form and Line Item Budget Form for Head Start and Early Head Start

These forms are provided to help standardize the presentation of this information and to provide ease in presenting it. Applicants must complete these forms in accordance with Part III., Instructions for the Program Approach Form and Line-Item Budget for Head Start and Early Head Start.

In programs where there are delegate agencies, a separate Approach to Child Care Services form must be submitted for the grantee and for each delegate agency. A separate form must be submitted for Early Head Start and Head Start.

Applicants also must fill out the Program Approach and Line-Item Budget Forms for Head Start and Early Head Start as part of their grant applications. Separate forms must be submitted for Early Head Start and Head Start. Where programs are delegate, separate Program Approach Forms and Line Item Budget Forms must be completed for each delegate agency.

3. Project Description and Budget Justification

Applicants must submit a Project Description based upon Part II, Instructions for Completion of a Full and Abbreviated Project Description, Budget and Budget Justification for all Head Start or Early Head Start Grant Applications.

3. Policy Council Approval

Applicants must attach documentation of Policy Council approval of the application.

3. Indirect Cost Negotiated Agreement

Applicants must submit a copy of the most recent indirect cost agreement, if applicable, negotiated between the grantee or delegate agencies and the Department of Health and Human Services, Division of Cost Allocation, or other cognizant Federal agency.

3. Certifications, Disclosures, and Assurances

Applicants must sign and submit the attached Compendium of Required Certifications and Assurances, which includes: SF 424B Assurances — Non-Construction Programs; Drug-Free Workplace Requirements — Grantees Other than Individuals; Certification Regarding Environmental Tobacco Smoke; Certification Regarding Debarment, Suspension, and Other Responsibility Matters; Certification Regarding Lobbying, Certification For Contracts, Grants, Loans, and Cooperative Agreements. The compendium must be signed by a designated official of the governing body of the grantee agency.

2. General Instructions for Completion of a Full and Abbreviated Project Description, Budget and Budget Justification

All applicants must submit a Project Description, Budget, and Budget Justification based upon the following instructions:

Section A: All continuing applications. Applicants submitting applications for the first year of a three-year cycle should respond to the “Full Project Description” instructions, Applicants submitting applications for the second and third year of a three-year cycle should respond to the “Abbreviated Project Description” instructions.

Section B: Applicants requesting supplemental funds.

Section C: Applicants requesting grant amendments.

Project Descriptions should be concise and complete, but not unnecessarily lengthy.

1. Continuation Application

1. Objectives, Need for Assistance, and Geographic Area

Full Project Description

Objectives and Need for Assistance: Applicants must submit a summary of significant findings from the most recent Community Assessment. Included should be a summary of each of the six categories of information required by the Head Start regulation on Eligibility, Recruitment, Selection, Enrollment and Attendance in Head Start, 45 CFR 1305.3(b):

• The demographic make-up of Head Start eligible children, including number, location, and ethnic and racial composition.

• Other child development programs serving Head Start eligible children.

• The estimated number of children with disabilities.

• Data regarding the education, health, nutrition and social service needs of Head Start eligible children.

• The education, health, nutrition and social services needs of Head Start eligible children, as defined by their families and community institutions.

• Resources available in the community.

Applicants should explain how the findings of the Community Assessment were used to help reach decisions in the six areas listed in 45 CFR 1305.3(c):

• Determine the program’s philosophy and long-range and short-range program objective.

• Determine the type of services and program option or options to be provided.

• Determine the recruitment area of the program.

• If applicable, determine the recruitment areas of delegate agencies.

• Determine the locations of centers and home-based programs.

• Set the criteria that define the types of children and families that will be given priority for recruitment and selection.

Geographic Area: Applicants must identify their proposed service area and define it by county or sub‑county areas, such as a municipality, town or census tract, or a Federally recognized Indian reservation. Maps or other graphic aids may be attached.

Abbreviated Project Description

Objectives, Need for Assistance and Geographic Area: Applicants must provide a summary of any significant changes in the information in the Community Assessment determined during the annual review of the Community Assessment including changes in the service area. The applicant must describe any proposed changes in the program that have resulted from a reconsideration of the decisions described in the six areas listed in 45 CFR 1305.3(c).

If there are no major changes, this should be stated in the application. No additional information is necessary.

2. Program Approach and Results or Benefits Expected

Full Project Description

Program Approach: Applicants must provide information regarding both their program’s long‑range goals and the objectives to be accomplished during the three‑year period. Goals and objectives must relate to the findings of the Community Assessment, be consistent with the philosophy of Head Start, and reflect the findings of the program’s annual self‑assessment.

Applicants must fill out the Program Approach Form, explained below in Section II, which specifies the kinds of Head Start services which will be provided.

Applicants must describe how they are going to deliver high quality services to children and families in all areas of service and program management defined by the Head Start Program Performance Standards (45 CFR Part 1304) and the Head Start Program Performance Standards on Services to Children with Disabilities (45 CFR Part 1308). Applicants must discuss how they plan to provide Early Childhood Development and Health Services, build Family and Community Partnerships and ensure effective Program Design and Management. Applicants must explain how their approach is linked to findings of the Community Assessment and the program’s long-term and short‑term goals. Full written plans for implementing services should not be submitted.

Applicants must provide information on progress made in meeting program requirements and plans for improving the management and delivery of services. Specific needs for improvement identified through self-assessments, monitoring reports, cost analysis data, Program Information Report data, audits, fiscal reports and correspondence from the Regional Office should be discussed.

Results or Benefit Expected: Applicants must provide a brief summary of the results and benefits which are expected in meeting the goals and objectives of the program during the following three-year period.

Abbreviated Project Description

Program Approach: Applicants must provide information regarding changes to the local long‑range goals and shorter‑term program objectives to be accomplished during the three‑year cycle. If there are no changes to the program goals and objectives, this should be stated in the application. No additional information is required.

If major changes from the previous year’s program are proposed, applicants must submit information to explain and justify the proposed changes. Major changes are the addition or discontinuance of a program option, addition or discontinuance of a delegate agency, reductions in total funded enrollment, and changes in the structure of Head Start/Early Head Start coordinating/management staff positions.

If no major changes are being proposed, this should be stated in the application. No additional information is required.

Results or Benefit Expected: Applicants must provide a summary of results and benefits which have been realized in meeting the goals and objectives of their program in implementing major activities established for the previous program year.

3. Budget and Budget Justification

Full Project Description

Applicants should complete the Line-Item Budget for Head Start and Early Head Start which provides detail for each object class on the SF 424A. Applicants also must provide a narrative budget justification which that explains the necessity, reasonableness, and allocability of proposed costs. The budget justification should relate the proposed budget to the activities indicated in the Program Narrative.

Applicants must provide itemized lists of equipment purchases and contracts and a brief explanation of travel costs and of non-Federal resources used to meet the non-Federal match requirement. The budget narrative discussion should make reference to these lists, and should provide narrative discussion of any items that merit further explanation.

Applicants also should explain and justify any proposed renovations or construction, and any “other” direct costs (in object class (h) of the Line-Item Budget). The budget narrative should explain any situation or special programming that makes the data on the Program Approach Form and Line-Item Budget unusual.

Information must be provided regarding the source and amount of cash and other resources that will be used to support the project in addition to the Federal funds requested and the required non-Federal match. In instances where the Head Start program delivers services in cooperation with other child development and child care programs, such as State-funded preschool or child care, applicants should describe how coordination will be managed from a budgetary perspective, addressing such areas as shared staff, facilities, and equipment.

Abbreviated Project Description

Applicants must submit the Line-Item Budget for Head Start and Early Head Start and a budget justification annually.

2. APPLICATION FOR SUPPLEMENTAL FUNDS

For supplemental assistance requests, applicants must explain the reason for the request and justify the need for additional funding. Applicants must indicate whether the request is for a permanent funding increase or if the request is for one-time funds. An SF 424 and 424A form, including evidence of Policy Council approval of the request, also must be submitted. The budget and budget justification should include only those items for which additional funds are requested.

3. APPLICATION FOR GRANT AMENDMENT

Applicants wanting to make a major program change within the course of a grant year with no significant increase or decrease in funding must make a request for a grant amendment and secure written approval from the appropriate ACF grant office prior to making the change. Major changes include but are not limited to discontinuance of a delegate agency, reductions in total funded enrollment, and changes in the structure of Head Start/Early Head Start management staff positions.

Except for changes requiring prior approval, grantees do not need to submit grant amendments when transferring funds between and among the object class categories within the total approved budget of the project, provided funds are used for allowable program costs.

3. Instructions for the Program Approach Form and the Line-Item Budget for Head Start and Early Head Start

Grantees with delegate agencies should submit a separate Program Approach Form and a separate Line-Item Budget for each delegate agency and for the grantee agency. Grantees should enter their official grant number and, if appropriate, the official delegate identification number on each page of the Program Design and Line-Item Budget forms

The Program Approach Form for Head Start and Early Head Start consists of two parts; a Summary of Program Design and a Program Schedule, and is self-explanatory.

For the Line-Item Budget for Head Start and Early Head Start, the line items (or rows) are organized into the same budget categories as in the Object Class Categories in Section B of the SF 424A:

(a) Personnel (b) Fringe Benefits (c) Travel (d) Equipment (e) Supplies (f) Contractual (g) Construction (h) Other (i) Total Direct Charges and (j) Indirect Charges.

Note that on the SF 424A submitted for the grantee’s entire program, the costs associated with delegate agencies are to be included in the Contractual Object Class Category.

On the Line-Budget form:

• Enter the budgeted HS/EHS costs for program operations in the first column

• Enter the budgeted HS/EHS costs for Training and Technical Assistance (known as Program Account 20) in the second column.

• Enter the value of all budgeted non‑Federal contributions (cash and in-kind contributions, including volunteers) in the third column.

• Identify the number of staff proposed for personnel line items.

The sum of all grantee and delegate agency costs reported in these columns must equal the amounts specified in SF 424A of the grant application.

THE PAPERWORK REDUCTION ACT OF 1995 (Public Law 104-13)

Public reporting burden for this collection of information is estimated to average 33 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed and reviewing the collection information. The project description is approved under the Office of Management and Budget (OMB) control number 0970-0207 which expires 4/30/2003.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Program Approach Form — Grantee/Delegate Number________________________ Agency Name_____________________________

I. Enrollment by Program Option This section should be filled out and submitted for each grantee and delegate agency.

1. Funded child enrollment by program option1: Center-based enrollment ___________ Home-based enrollment ___________ Combination option enrollment ___________ Family child care enrollment ___________ Other option enrollment ___________ Total Child Enrollment ___________

2. Number of pregnant women enrolled for EHS: ___________

II. Program Schedule This section should be filled out for each group of children served for different hours of service each year.

Complete #1-3 for all groups of children

Program schedule number

1

2

3

4

5

Program option identification

Funded enrollment

Complete #4-9 for center-based, family child care, combination, and other options

4a. Number of classes/groups/family child care settings

4b. Double session, enter D

Number of hours of classes/groups/FCC settings per child, per day

Number of days of classes/groups/FCC settings per child, per week

Number of days of classes/groups/FCC settings per child, per year

Number of home visits per child, per year

Number of hours per home visit

Complete #10-13 for home-based options

Number of home visits per child, per year

Number of hours per home visit

Number of hours per home-based socialization experience

Number of home-based socialization experiences per child, per year

Notes: Item 1: If more than 5 different schedules, photocopy form and write in 6, 7, 8, etc. Item 2: Identify each program schedule as center-based (CB), home-based (HB), combination program (CO), family child care (FC), or other program option (OT). For combination options (CO and other options (OT), the items on the form that more appropriately describe the services provided by these options should be filled out

Position	HS/EHS Cost for Program Operations	HS/EHS Cost for Training & Technical Assistance	Non-Federal Share (Cash and in-kind)	Number of People Employed
a. PERSONNEL (Object class 6a)
Child Health and Developmental Services Personnel
Program Managers & Content Area Experts
Teachers/Infant Toddler Teachers
Family Child Care Personnel
Home Visitors
Teacher Aides & Other Education Personnel
Health/Mental Health Services Personnel
Disabilities Services Personnel
Nutrition Services Personnel
Other Child Services Personnel

a1. Include program managers, supervisors, and content experts in child development, health, mental health, nutrition, and disabilities services. Include home-based and family child care supervisors.

a2. Include all teachers, including infant and toddler teachers.

a3. Include family child care staff, if they are agency employees. If providers are not agency employees, enter costs under item (f)(6) or (h)(10).

a6. Include nurses, health services aides, speech therapists, mental health staff and other health services personnel.

a8. Include nutritionists, cooks, and other food services staff.

a9. Include any personnel that provide services to children that cannot be reported in any other category.

Position	HS/EHS Cost for Program Operations	HS/EHS Cost for Training & Technical Assistance	Non-Federal Share (Cash and in-kind)	Number of People Employed
Family and Community Partnerships Personnel
Program Managers & Content Area Experts
Other Family & Community Partnerships Personnel
Program Design and Management Personnel
Managers
Staff Development
Clerical Personnel
Fiscal Personnel
Other Program Design Personnel
Other Personnel
Maintenance Personnel
Transportation Personnel
Other Personnel
TOTAL PERSONNEL (6a)

a10. Include program managers, coordinators, supervisors, and content experts in parent involvement, social services, volunteer coordination, or other family and community partnership activities.

a11. Include social workers, family service workers, social services aides, parent involvement aides, and other family and community partnerships staff.

a12. Include executive directors, Head Start or Early Head Start directors, deputy or assistant directors, and other administrators.

a13. Include staff responsible for coordinating staff development and training. (Note: Report any salaries paid by T&TA funds in the second column.)

a19. Include any personnel that cannot be reported in any other category.

Position	HS/EHS Cost for Program Operations	HS/EHS Cost for Training & Technical Assistance	Non-Federal Share (Cash and in-kind)
b. FRINGE BENEFITS (Object Class 6b)
Social Security (FICA), State Disability, Unemployment (FUTA), Workers Compensation
Health/Dental/Life Insurance
Retirement
Other Fringe
TOTAL FRINGE (6b)

c. TRAVEL (Object Class 6c)
Staff Out-of-Town Travel
TOTAL TRAVEL (6c)

d. EQUIPMENT (Object Class 6d)
Office Equipment
Classroom/Outdoor/Home-based/FCC
Vehicle Purchase
Other Equipment
TOTAL EQUIPMENT (6d)

c1. Enter the total costs of travel outside of the grantee service area for employees of the project, including per diem expenses. Do not include costs for consultant travel, parent travel, or local transportation. [A brief explanation of travel costs should be included in the budget justification.]

d. “Equipment” means an article of tangible, non expendable, personal property having a useful life of more than one year and an acquisition cost of $5,000, or more, per unit. Include leased equipment only if costs are $5,000 or more per unit; costs for other leased equipment may be reported in object class (h). [An itemized list of equipment should be included in the budget justification.]

d2. Includes equipment used for classrooms, group settings for infants and toddlers, family child care settings, playgrounds, home-based programs, and family and community partnerships.

Position	HS/EHS Cost for Program Operations	HS/EHS Cost for Training and Technical Assistance	Non-Federal Share (cash and in-kind)
e. SUPPLIES (Object Class 6e)
Office Supplies
Child and Family Services Supplies
Food Services Supplies
Other Supplies
TOTAL SUPPLIES (6e)

f. CONTRACTUAL (Object Class 6f)
Administrative Services (e.g., Legal, Accounting)
Health/Disabilities Services
Food Services
Child Transportation Services
Training & Technical Assistance
Family Child Care
Delegate Agency Costs
Other Contracts
TOTAL CONTRACTUAL (6f)

6. Enter the costs of contracts for services and goods, except those belonging in other categories, such as equipment, supplies, construction, etc. Include contracts with organizations for the provision of training or technical assistance. Do not include payments to individuals in this category; services of individuals (other than employees) should be reported in object class (h). Do no include service contracts; such maintenance agreements also may be reported in object class (h). [An itemized list of contracts should be included in the budget justification.]

f6. Include contracts with umbrella organizations. Contracts with individuals should be included in line (h)(10).

Position	HS/EHS Cost for Program Operations	HS/EHS Cost for Training and Technical Assistance	Non-Federal Share (cash and in-kind)
g. CONSTRUCTION (Object Class 6g)
New Construction
Major Renovation
Acquisition of Buildings/Modular Units
TOTAL CONSTRUCTION (6g)

h. OTHER (Object Class 6h)
Depreciation/Use Allowance
Rent
Mortgage
Utilities, Telephone
Building & Child Liability Insurance
Building Maintenance/Repair and Other Occupancy
Incidental Alterations/Renovations
Local Travel
Nutrition Services
Child Services Consultants

h1. Enter proposed occupancy expenses. Rent may be charged only when the applicant does not own or have substantial interest in the real property. Depreciation/Use Allowances should be charged when the building is owned by or has been donated to the applicant or there is a less-than-arms-length lease agreement. See OMB Circular A-122, Cost Principles for Non-Profit Organizations or OMB Circular A-87, Cost Principles for State and Local Governments.

h8. List proposed costs associated with transporting children to and from the center, on field trips, etc. Include all costs of maintaining, repairing, operating, and insuring vehicles that transport children.

h10. If individuals who provide direct service to children are paid as consultants rather than as staff, the cost should be included in this category. Include consultants providing education and child development services, medical or dental exams, screening care, mental health services, nutrition services, speech therapy, disability services, family child care services, or other child services.

Position	HS/EHS Cost for Program Operations	HS/EHS Cost for Training and Technical Assistance	Non-Federal Share (cash and in-kind)
h. OTHER (Object Class 6h)
Volunteers
Substitutes (if not paid benefits)
Parent Services
Accounting & Legal Services
Publications/Advertising/Printing
Training or Staff Development
Other
TOTAL OTHER (6h)
TOTAL DIRECT CHARGES Sum of Line 6a-6h
INDIRECT COSTS Enter Costs Not Reflected in i above
TOTALS ALL BUDGET CATEGORIES

h11. Enter the in-kind value of volunteers (parents or others) who participate in program activities in the non-Federal share column.

h13. Include parent activities, parent local and out-of-town travel, and other parent services.

The Federal and non-Federal costs proposed in the SF 424A and the Line-Item Budget are the costs that, when agreed upon, will be included in the Head Start grant award. There may be other cash or in-kind resources that are necessary to support the services that will be provided to Head Start children and their families. Applicants are asked to explain these resources in their 3 Budget and Budget Justification. The value of these resources should be shown below. (Resources that the applicant uses to serve children who are not enrolled in Head Start should not be included.)	Value
Federal Funding Federal Child Development and Child Care funds USDA Funds for Nutrition Services Other Federal Funding (__________________________________________________)	__________________ __________________ __________________
State Funding State Preschool Programs Other State Funding (____________________________________________________)	__________________ __________________
Local Government Funding School District Funding Other Local Government Funding (_________________________________________)	__________________ __________________
Other Funding Tribal Government Funding Fund-raising Activities Other (_______________________________________________________________)	__________________ __________________ __________________
TOTAL	__________________

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

COMPENDIUM OF REQUIRED CERTIFICATIONS AND ASSURANCES

SF 424B

ASSURANCES - NON-CONSTRUCTION PROGRAMS

Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified.

As the duly authorized representative of the applicant, I certify that the applicant:

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

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

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

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

5. Will comply with the intergovernmental Personnel Act of 1970 (42 U.S.C. 4278-4763) relating to prescribed standards for merit systems for programs funded under one of the nineteen statutes or regulations specified in Appendix A of OPM=s Standards for a Merit System of Personnel Administration (5 CFR 900, Subpart F).

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

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

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

9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. 276a to 276a-7), the Copeland Act (40 U.S.C. 276c and 18 U.S.C. 874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. 327-333), regarding labor standards for Federally assisted construction subagreements.

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

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

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

13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. 470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. 469a-1 et seq.).

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

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

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

17. Will cause to be performed the required financial and compliance audits in accordance with the single Audit Act of 1984.

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

DRUG-FREE WORKPLACE REQUIREMENTS

GRANTEES OTHER THAN INDIVIDUALS

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

This certification is required by regulations implementing the Drug-Free Workplace Act of 1988, 45 CFR, Part 76, Subpart F. The regulations published in the January 31, 1989 Federal Register, require certification by grantees that they will maintain a drug-free workplace. The certification set out below is a material representation of fact upon which reliance will be placed when HHS determines to award the grant. False certification or violation of the certification shall be grounds for suspension of payments, suspension or termination of grants, or government-wide suspension or debarment.

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

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

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

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 USC 812) and as further defined by regulations (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 of 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 of 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).

The grantee certifies that it will 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 a drug-free awareness program to inform employees about:

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

(2) The grantee's policy of maintaining a drug-free workplace;

(3) Any available drug counseling, rehabilitation, 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 be 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 of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction;

e) Notifying the agency in writing within ten days after receiving notice under subparagraph (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 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 days of receiving notice under subparagraph (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.

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

CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE

Public Law 103-227, also known as the Pro-Children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal program either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable Federal funds in medicare of medicaid; or facilities where WIC coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity.

By signing this certification, the offeror/contractor (for acquisitions) or applicant/grantee (for grants) certifies that the submitting organization will comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act.

The submitting organization agrees that it will require that the language of this certification be included in any subawards which subrecipients shall certify accordingly.

CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER

RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS

By signing and submitting this proposal, the applicant, defined as the primary participant in accordance with 45 CFR Part 76 certifies to the best of his or her knowledge and believe that it and its principals:

(a) are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from covered transaction by any Federal Department or agency;

(b) have not within a 3-year period preceding this proposal been convicted or had a civil judgement 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 statement, or receiving stolen property;

(c) are not presently indicted 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 3-year period preceding this application/proposal had one or more public transaction (Federal, State or local) terminated for cause or default.

The inability of a person to provide the certification required above will not necessarily result in denial of participation in this covered transaction. If necessary, the prospective participant shall submit an explanation of why it cannot provide the certification. The Department of Health and Human Services' (HHS) 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.

The prospective primary participant agrees that by submitting this proposal, it will include the clause entitled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions," provided below without modification in all lower tier covered transactions.

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY

AND VOLUNTARY EXCLUSION - LOWER TIER COVERED TRANSACTIONS

(TO BE SUPPLIED TO LOWER TIER PARTICIPANTS)

By signing and submitting this lower tier proposal, the prospective lower tier participant, as defined in 45 CFR, Part 76, 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 from participation in this transaction by any Federal department or agency.

(b) where the prospective lower tier participant is unable to certify to any of the above, such prospective participant shall attach an explanation to this proposal.

The prospective lower tier participant further agrees by submitting this proposal that it will include this clause entitled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions," without modification in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

CERTIFICATION REGARDING LOBBYING

FOR CONTRACTS, GRANTS, LOANS

AND COOPERATIVE AGREEMENTS

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

(1) No Federal appropriate 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 any 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 influencing or attempting to influence an officer or employee or an 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 or not less than $10,000 and not more than $100,000 for each such failure.

I hereby agree to the above certifications and assurances.

_________________________________________________ _____________________

Signature of Certifying Official Date

_________________________________________________

Title

_________________________________________________

Applicant Organization

1Funded enrollment by program option must equal the total number of children supported through the budget contained on the SF 424A and the Line-Item Budget.

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