Hhs_5161_1

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

GRANT APPLICATION

For use by:

• State and Local Government Applicants

• Nongovernmental Applicants for Health Services Projects

FORM HHS-5161-1

(Revised 8/2007)

GENERAL INFORMATION AND INSTRUCTIONS FOR GRANT APPLICATION (FORM HHS-5161-1, Revised 8/2007)
INTRODUCTION This application form, the HHS 5161-1, is used for a variety of grant programs administered by the U.S. Department of Health and Human Services (HHS). The basic format (Standard Form 424) is prescribed by OMB Circular A-102 for use by State and local government applicants. The HHS-5161-1 is also intended for use by nongovernmental applicants seeking support for health services projects. The application consists of this section, General Information and Instructions, followed by seven additional sections which comprise the standard application. This section contains information about HHS policies and procedures. The second section, the SF-424, is the face page of the application which requests basic information about the applicant and the project. The third section, Budget Information (non-construction or construction) requests information on the applicant’s financial plan for carrying out the project or program. Both the Federal and non-Federal shares are to be included in the financial plan. The application kit contains budget forms for both non-construction (SF-424A) and construction (SF-424C) projects or programs. Please be sure that you use the correct form. The fourth section, Assurances (non-construction or construction) sets forth certain requirements with which applicants must certify that they will comply if a grant is awarded. The application kit includes assurances for both non-construction (SF-424B) and construction (SF-424D) projects or programs. Please be sure that you submit the correct assurance form. The fifth section, Certifications, sets forth certain requirements for grantees which have been legislatively implemented since the SF-424 assurances pages were last revised.. The sixth section, Program Narrative, requests the applicant to describe the objectives of the program and to relate how those objectives will be attained. For projects funded beyond the first year, this section is used to describe the objectives and activities to be undertaken during the next period of support and also as a progress or performance report for activities previously undertaken.		The seventh section is the Checklist, which must be included with all applications. The Checklist is designed to ensure that the applicants have submitted all necessary forms associated with the application kit. The eighth and last section is the Project Abstract Summary. The Project Abstract must contain a summary of the proposed activity, which will be published for public dissemination. It should be a self-contained description of the project and should include a statement of objectives and methods to be employed. Before completing the application, it is advisable to refer to program guidelines provided with the application kit. The kit may also contain supplementary instructions pertaining to unique program requirements set forth in legislation or regulations. For additional information about, or copies of, material referred to in this application; contact the grants management office which supplied the application kit. Comments concerning the accuracy of the burden estimates for the Program Narrative and the Checklist and any suggestions for reducing this burden should be addressed to: HHS Reports Clearance Officer 200 Independence Avenue, SW Humphrey Building, Room 531H Washington, DC 20201 Attention: PRA (0990-0317) NOTE: The grant application which you are submitting may be subject to the reporting requirements of the Public Health System Impact Statement. Consult the Program Announcement or the Grants Management Officer for the program to which you are applying for additional information. TYPES OF APPLICATIONS The Form HHS-5161-1 may be used for any of the following types of applications: 1. New - A new application is a request for financial assistance for a project or program not currently receiving HHS support. If recommended for approval it must compete with other new applications, competing continuation applications, and competing supplemental applications for any available funds in accordance with Federal awarding office funding priorities. A complete submission of all information requested, including budget justification, is required for all new applications.
2. Noncompeting Continuation - A noncompeting continuation application is a request for support beyond the initial budget period1 within a previously approved project period2. These applications do not compete with other applications, and the level of support is determined by the awarding office after considering the previously recommended level of support and the progress achieved on the project. A complete resubmission of the material contained in the initially approved application is not necessary, but the continuation application should include: a detailed justification, as necessary; information on the qualifying experience of key personnel added since the previous application; a report of progress relative to approved objectives; and a narrative discussing any significant changes to the originally approved project plan. Refer to Item 6(b) in the Program Narrative instructions, and to program guidelines for additional guidance on preparing the progress report. 3. Competing Continuation - A competing continuation application is a request for the extension of support for one or more budget periods of a project which would otherwise expire. These applications are subject to the same review and analysis as new applications and they compete for available funds with other competing continuation applications, new applications, and competing supplemental applications. The information requirements applicable to competing continuation applications are the same as those that apply to new applications except that competing continuation applications must also include a progress report as described under Item 6(b) of the Program Narrative section. 4. Supplemental - A supplemental application is a request for additional funding within an approved budget period for program expansion or administrative increases. Applications for funds to expand the scope of the project are subject to the same review procedures as new or competing continuation applications. Applications for funds to meet increases in costs incurred during a current budget period (such as increases in fringe benefits, salaries, or other project costs not included in the previous application) are generally 1Budget Period - The interval of the time (usually 12 months) into which the project period is divided for funding and reporting purposes. 2Project Period - The total time for which support of a project has been programmati- cally approved. A project period may consist of one or more budget periods	noncompeting, but are subject to the approval of the awarding office and the availability of funds. A supplemental application must justify the need for the additional funds. It should describe how the supplemental award, or lack of it, would influence program results. On the budget page(s), show only the supplemental funds requested, and any matching/cost participation amounts (as appropriate). As part of the budget justification, include a statement as to whether any changes have been made or are anticipated in the allocation of funds among categories for the previously approved budget. PROJECT DEVELOPMENT All new applicants are urged to discuss their interests and ideas for developing projects early in the planning stage with State, regional, and local planning agencies and/or health departments. Community support should be assured by providing opportunities for public and private participation in the planning and development phases. When applicable, comments must be sought from State Single Points of Contact in accord with requirements under Executive Order 12372 as implemented by HHS regulations at 45 CFR Part 100 (see checklist instructions). Staff members of the administering office from which funds are being requested are also available to assist applicants. COMPLETING THE APPLICATION In preparing the application, use English language and avoid jargon. Using a computer or typewriter, printed material must use black ink and be single spaced where possible. Instructions for completing the pages of the form are included with the form or on supplemental pages. If more space is needed than is provided, use a blank sheet of paper to complete the item, using the identical format. Clearly identify the continuation page as such, and the information item(s) contained thereon, and attach the page after the appropriate page of the application. Computer generated reproductions may be substituted for any of the forms provided in this packet. Such substitute forms should be printed in black ink and must maintain the exact wording and format of the government-printed forms, including all captions and spacing. Any deviation may be grounds for HHS to reject the entire application.

ASSEMBLING AND MAILING To facilitate review and processing of the application by the awarding office, all pages should be numbered and preceded by a table of contents. Assemble the application with a cover letter on top indicating the specific program for which you are applying, followed by a table of contents, the printed forms, the program narrative, biographical sketches, and any remaining documents. If the application is submitted by paper, completed forms should be signed in ink by an authorized official of the applicant organization and duplicated in accord with applicable requirements of the funding opportunity announcement. Applications may also be submitted electronically via www.grants.gov (Grants.gov), as noted in the funding opportunity announcement. Mail completed applications to the appropriate grants management office (unless other instructions have been provided) in time to meet the deadline date for receipt established by the awarding office. ACKNOWLEDGMENT Applicants should use their delivery receipt as confirmation of receipt by HHS. If application is submitted via Grants.gov, an email to acknowledge successful submission will be sent to the authorized organization representative (AOR). LATE APPLICATIONS New/Competing Continuation Applications will be considered to be "on time" if they are received on or before the deadline date established by the awarding office, which is included in the funding opportunity announcement. Applicants should request a legibly dated U.S. Postal Service postmark or obtain a legibly dated receipt and delivery confirmation from a commercial carrier or the U.S. Postal Service. Private metered postmarks shall not be acceptable as proof of timely mailing. Late competing applications not accepted for processing may either be returned to the applicant or held for the next regularly scheduled review cycle. Noncompeting Continuation Applications which are not received in time to permit orderly review, processing, and award issuance on or before the beginning date of the continuation budget period, may result in: (1) an extension of the current budget period without additional Federal funds, and (2) a delay in the beginning date of the new budget period.

NONCONFORMING APPLICATIONS Applications which are determined to be non-responsive shall not be accepted for processing and shall be returned to the applicant. A grant application may be classified as non-responsive if it does not meet the requirements of the funding opportunity announcement to which it is responding. APPLICATION REVIEW Applications will be evaluated and rated according to criteria and priorities which are established for the particular grant program involved and which are described in the funding opportunity announcement and any respective program guidelines. UNSUCCESSFUL APPLICANTS After a decision has been reached either to disapprove or not fund a grant application during a given review cycle, a written notice shall be sent to the unsuccessful applicant (sent to the authorized official within 30 days after that decision. PRIVACY ACT The Privacy Act of 1974 (5 U.S.C. § 552a) gives individuals the right of access to information concerning themselves and provides a mechanism for correction or amendment of such records. The Privacy Act also provides for protection of information pertaining to an individual, but it does not prevent disclosure of such information if its release is required under the Freedom of Information Act. The Privacy Act requires that a Federal agency must advise each individual whom it asks to supply the information (1) of the authority which authorizes the solicitation, (2) whether disclosure is voluntary or mandatory, (3) the principal purpose or purposes for which the information is to be used, (4) the use outside the agency which may be made of the information, and (5) the effects on the individual, if any, of not providing all or any part of the requested information. HHS is requesting the information called for in this application pursuant to its statutory authority to award grants. Provision of the information requested is entirely voluntary. The collection of this information is for the purpose of aiding in the review of applications prior to grant award decisions and for management of HHS programs. Insufficient information may hinder HHS’ ability to review applications, monitor grantee performance, or perform overall management of grant programs.

This information will be used within the Department of Health and Human Services, and may also be disclosed outside the Department as permitted by the Privacy Act, including disclosures to the public as required by the Freedom of Information Act, to the Congress, the National Archives, the Bureau of the Census, law enforcement agencies upon their request, the General Accounting Office, and pursuant to court order. It may also be disclosed outside the Department, if necessary, for the following purposes: 1. To the cognizant audit agency for auditing. 2. To the Department of Justice as required for litigation. 3. To a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual. 4. To qualified experts not within the definition of Department employees as prescribed in the Department’s regulations [45 CFR Part 5(b)(2)] for their opinions, as part of the application review process. 5. To a Federal agency in response to its request, in connection with the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the record is relevant and necessary to the requesting agency’s decision on the matter.

6. To individuals and organizations deemed qualified by HHS to carry out specific research related to the review and award processes of HHS. 7. To organizations in the private sector with whom HHS has contracted for the purpose of collating, analyzing, aggregating, or otherwise refining records in a system. Relevant records will be disclosed to such a contractor. The contractor shall be required to maintain Privacy Act safeguards with respect to such records. 8. To the grantee institution relative to performance or administration under the terms and conditions of the award. FREEDOM OF INFORMATION ACT The Freedom of Information Act and the associated Public Information Regulations (45 CFR Part 5) of HHS require the release of certain information regarding grants requested by any member of the public. The intended use of the information will not be a criterion for release. Grant applications and grant related reports are generally available for inspection and copying except that information considered as an unwarranted invasion of personal privacy will not be disclosed. For specific guidance on the availability of information, refer to 45 CFR Part 5.

Application for Federal Assistance SF-424
*1. Type of Submission: Preapplication Application Changed/Corrected Application	*2. Type of Application: New Continuation Revision		*If Revision, select appropriate letter(s): *Other (Specify)
*3. Date Received: 4. Applicant Identifier:
5a. Federal Entity Identifier			*5b. Federal Award Identifier:
State Use Only:
6. Date Received by State:		7. State Application Identifier:
8. APPLICANT INFORMATION
*a. Legal Name:
*b. Employer/Taxpayer Identification Number (EIN/TIN):			*c. Organization DUNS:
d. Address
*Street1: Street2: *City: County/Parish: *State: Province: *Country: *Zip/Postal Code:
e. Organizational Unit
Department Name:			Division Name:
f. Name and contact information of person to be contacted on matters involving this application:
Prefix: *First Name: Middle Name: *Last Name: Suffix:
Title:
Organizational Affiliation:
*Telephone Number: Fax Number:
*Email:
Application for Federal Assistance SF-424
9. Type of Applicant 1: Select Applicant Type: Type of Applicant 2: Select Applicant Type: Type of Applicant 3: Select Applicant Type: * Other (specify)
10. Name of Federal Agency:
11. Catalog of Federal Domestic Assistance Number CFDA Title:
*12. Funding Opportunity Number: *Title:
13. Competition Identification Number: Title:
14. Areas Affected by Project (Cities, Counties, States, etc.):
15. Descriptive Title of Applicant’s Project:
Attach supporting documents as specified in agency instructions.
Application for Federal Assistance SF-424
16. Congressional Districts Of: *a. Applicant b. Program/Project
Attach an additional list of Program/Project Congressional Districts if needed:
17. Proposed Project: *a. Start Date: b. End Date:
18. Estimated Funding($):
*a. Federal *b. Applicant *c. State *d. Local *e. Other *f. Program Income *g. TOTAL
* 19. Is Application Subject to Review By State Under Executive Order 12372 Process? a. This application was made available to the State under the Executive Order 12372 Process for review on . b. Program is subject to E.O. 12372 but has not been selected by the State for review. c. Program is not covered by E.O. 12372.
*20. Is the Applicant Delinquent on Any Federal Debt? (If “Yes”, provide explanation in attachment.) Yes No If "Yes", provide explanation and attach.
21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties (U.S. Code, Title 218, Section 1001) ** I AGREE ** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions.
a. Authorized Representative
Prefix: *First Name:
Middle Name:
Last Name:
Suffix:
*Title:
*Telephone Number: Fax Number:
*Email:
*Signature of Authorized Representative: Date Signed:

Application for Federal Assistance SF-424

* Applicant Federal Debt Delinquency Explanation

The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debt. Maximum number of
characters that can be entered is 4,000. Try and avoid extra spaces and carriage returns to maximize the availability of space.

INSTRUCTIONS FOR THE SF-424

Public reporting burden for this collection of information is estimated to average 45 minutes per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction
Project (0348-0043), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.

SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

This is a standard form used by applicants as a required face sheet for pre-applications and applications submitted
for Federal assistance. It will be used by Federal agencies to obtain applicant certification that States which have
established a review and comment procedure in response to Executive Order 12372 and have selected the program
to be included in their process, have been given an opportunity to review the applicant’s submission.

Item	Entry:		Item	Entry:
1.	Type of Submission: (Required): Select one type of submission in accordance with agency instructions. Preapplication Application Changed/Corrected Application – If requested by the agency, check if this submission is to change or correct a previously submitted application. Unless requested by the agency, applicants may not use this to submit changes after the closing date.		10.	Name Of Federal Agency: (Required) Enter the name of the Federal agency from which assistance is being requested with this application.
			11.	Catalog Of Federal Domestic Assistance Number/Title: Enter the Catalog of Federal Domestic Assistance number and title of the program under which assistance is requested, as found in the program announcement, if applicable.
2.	Type of Application: (Required) Select one type of application in accordance with agency instructions. New – An application that is being submitted to an agency for the first time. Continuation - An extension for an additional funding/budget period for a project with a projected completion date. This can include renewals. Revision - Any change in the Federal Government’s financial obligation or contingent liability from an existing obligation. If a revision, enter the appropriate letter(s). More than one may be selected. If "Other" is selected, please specify in text box provided. A. Increase Award B. Decrease Award C. Increase Duration D. Decrease Duration E. Other (specify)		12.	Funding Opportunity Number/Title: (Required) Enter the Funding Opportunity Number and title of the opportunity under which assistance is requested, as found in the program announcement.
			13.	Competition Identification Number/Title: Enter the Competition Identification Number and title of the competition under which assistance is requested, if applicable.
			14.	Areas Affected By Project: List the areas or entities using the categories (e.g., cities, counties, states, etc.) specified in agency instructions. Use the continuation sheet to enter additional areas, if needed.
3.	Date Received: Leave this field blank. This date will be assigned by the Federal agency.		15.	Descriptive Title of Applicant’s Project: (Required) Enter a brief descriptive title of the project. If appropriate, attach a map showing project location (e.g., construction or real property projects). For pre-applications, attach a summary description of the project.
4.	Applicant Identifier: Enter the entity identifier assigned by the Federal agency, if any, or applicant’s control number, if applicable.
5a	Federal Entity Identifier: Enter the number assigned to your organization by the Federal Agency, if any.		16.	Congressional Districts Of: (Required) 16a. Enter the applicant’s Congressional District, and 16b. Enter all District(s) affected by the program or project. Enter in the format: 2 characters State Abbreviation – 3 characters District Number, e.g., CA-005 for California 5th district, CA-012 for California 12th district, NC-103 for North Carolina’s 103rd district. If all congressional districts in a state are affected, enter “all” for the district number, e.g., MD-all for all congressional districts in Maryland. If nationwide, i.e. all districts within all states are affected, enter US-all. If the program/project is outside the US, enter 00-000.
5b.	Federal Award Identifier: For new applications leave blank. For a continuation or revision to an existing award, enter the previously assigned Federal award identifier number. If a changed/corrected application, enter the Federal Identifier in accordance with agency instructions.
6.	Date Received by State: Leave this field blank. This date will be assigned by the State, if applicable.
7.	State Application Identifier: Leave this field blank. This identifier will be assigned by the State, if applicable.
8.	Applicant Information: Enter the following in accordance with agency instructions: a. Legal Name: (Required): Enter the legal name of applicant that will undertake the assistance activity. This is the name that the organization has registered with the Central Contractor Registry. Information on registering with CCR may be obtained by visiting the Grants.gov website.
			17.	Proposed Project Start and End Dates: (Required) Enter the proposed start date and end date of the project.
	b. Employer/Taxpayer Number (EIN/TIN): (Required): Enter the Employer or Taxpayer Identification Number (EIN or TIN) as assigned by the Internal Revenue Service. If your organization is not in the US, enter 44-4444444.
			18.	Estimated Funding: (Required) Enter the amount requested or to be contributed during the first funding/budget period by each contributor. Value of in-kind contributions should be included on appropriate lines, as applicable. If the action will result in a dollar change to an existing award, indicate only the amount of the change. For decreases, enclose the amounts in parentheses.
	c. Organizational DUNS: (Required) Enter the organization’s DUNS or DUNS+4 number received from Dun and Bradstreet. Information on obtaining a DUNS number may be obtained by visiting the Grants.gov website.
	d. Address: Enter the complete address as follows: Street address (Line 1 required), City (Required), County, State (Required, if country is US), Province, Country (Required), Zip/Postal Code (Required, if country is US).
			19.	Is Application Subject to Review by State Under Executive Order 12372 Process? Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process. Select the appropriate box. If “a.” is selected, enter the date the application was submitted to the State
	e. Organizational Unit: Enter the name of the primary organizational unit (and department or division, if applicable) that will undertake the assistance activity, if applicable.
	f. Name and contact information of person to be contacted on matters involving this application: Enter the name (First and last name required), organizational affiliation (if affiliated with an organization other than the applicant organization), telephone number (Required), fax number, and email address (Required) of the person to contact on matters related to this application.
			20.	Is the Applicant Delinquent on any Federal Debt? (Required) Select the appropriate box. This question applies to the applicant organization, not the person who signs as the authorized representative. Categories of debt include delinquent audit disallowances, loans and taxes. If yes, include an explanation on the continuation sheet.
9.	Type of Applicant: (Required) Select up to three applicant type(s) in accordance with agency instructions.		21.	Authorized Representative: (Required) To be signed and dated by the authorized representative of the applicant organization. Enter the name (First and last name required) title (Required), telephone number (Required), fax number, and email address (Required) of the person authorized to sign for the applicant. A copy of the governing body’s authorization for you to sign this application as the official representative must be on file in the applicant’s office. (Certain Federal agencies may require that this authorization be submitted as part of the application.)
	State Government County Government City or Township Government Special District Government Regional Organization U.S. Territory or Possession Independent School District Public/State Controlled Institution of Higher Education Indian/Native American Tribal Government (Federally Recognized) Indian/Native American Tribal Government (Other than Federally Recognized) Indian/Native American Tribally Designated Organization Public/Indian Housing Authority	Nonprofit with 501C3 IRS Status (Other than Institution of Higher Education) Nonprofit without 501C3 IRS Status (Other than Institution of Higher Education) Private Institution of Higher Education Individual For-Profit Organization (Other than Small Business) Small Business Hispanic-serving Institution Historically Black Colleges and Universities (HBCUs) Tribally Controlled Colleges and Universities (TCCUs) Alaska Native and Native Hawaiian Serving Institutions Non-domestic (non-US) Entity Other (specify)

BUDGET INFORMATION - Non- Construction Programs
SECTION A - BUDGET SUMMARY
Grant Program Function or Activity (a)	Catalog of Federal Domestic Assistance Number (b)	Estimated Unobligated Funds		New or Revised Budget
		Federal (c)	Non-Federal (d)	Federal (e)	Non- Federal (f)	Total (g)
1.      	     	$      	$      	$      	$      	$ 00.00
2.      	     	$      	$      	$      	$      	$ 00.00
3.      	     	$      	$      	$      	$      	$ 00.00
4.      	     	$      	$      	$      	$      	$ 00.00
5. TOTALS	     	$ 00.00	$ 00.00	$ 00.00	$ 00.00	$ $0.000.00
SECTION B - BUDGET CATEGORIES
6. Object Class Categories		GRANT PROGRAM, FUNCTION OR ACTIVITY				Total (5)
		(1)	(2)	(3)	(4)
a. Personnel		$      	$      	$      	$      	$ 00.00
b. Fringe Benefits		$      	$      	$      	$      	$ 00.00
c. Travel		$      	$      	$      	$      	$ 00.00
d. Equipment		$      	$      	$      	$      	$ 00.00
e. Supplies		$      	$      	$      	$      	$ 00.00
f. Contractual		$      	$      	$      	$      	$ 00.00
g. Construction		$      	$      	$      	$      	$ 00.00
h. Other		$      	$      	$      	$      	$ 00.00
i.i Total Direct Charges (sum of 6a -6h)		$ 00.00	$ 00.00	$ 00.00	$ 00.00	$ $0.000.00
j. Indirect Charges		$      	$      	$      	$      	$ 00.00
k. TOTALS (sum of 6i and 6j)		$ $0.000.00	$ $0.000.00	$ $0.000.00	$ $0.000.00	$ $0.000.00
7. Program Income		$      	$      	$      	$      	$ 00.00

SECTION C - NON- FEDERAL RESOURCES
(a) Grant Program		(b) Applicant		(c) State	(d) Other Sources	(e) TOTALS
8.      		$      		$      	$      	$ 00.00
9.      		$      		$      	$      	$ 00.00
10.      		$      		$      	$      	$ 00.00
11.      		$      		$      	$      	$ 00.00
12. TOTALS (sum of lines 8 and 11)		$ 00.00		$ 00.00	$ 00.00	$ $0.000.00
SECTION D - FORECASTED CASH NEEDS
	Total for 1st Year	1st Quarter		2nd Quarter	3rd Quarter	4th Quarter
13. Federal	$ 00.00	$      		$      	$      	$      
14. Non- Federal	$ 00.00	$      		$      	$      	$      
15. TOTAL (sum of lines 13 and 14)	$ $0.000.00	$ 00.00		$ 00.00	$ 00.00	$ 00.00
SECTION E - BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT
(a) Grant Program		FUTURE FUNDING PERIODS (Years)
		(b) First		(c) Second	(d) Third	(e) Fourth
16.      		$      		$      	$      	$      
17.      		$      		$      	$      	$      
18.      		$      		$      	$      	$      
19.      		$      		$      	$      	$      
20. TOTALS (sum of lines 16 -19)		$ 00.00		$ 00.00	$ 00.00	$ 00.00
SECTION F - OTHER BUDGET INFORMATION
21. Direct Charges:			22. Indirect Charges:
     			     
23. Remarks
     

INSTRUCTIONS FOR THE SF-424A
Public reporting burden for this collection of information is estimated to average 180 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0044), Washington, DC 20503. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
General Instructions This form is designed so that application can be made for funds from one or more grant programs. In pre- paring the budget, adhere to any existing Federal grantor agency guidelines which prescribe how and whether budgeted amounts should be separately shown for different functions or activities within the program. For some programs, grantor agencies may require budgets to be separately shown by function or activity. For other programs, grantor agencies may require a breakdown by function or activity. Sections A, B, C, and D should include budget estimates for the whole project except when applying for assistance which requires Federal authorization in annual or other funding period increments. In the latter case, Sections A, B, C, and D should provide the budget for the first budget period (usually a year) and Section E should present the need for Federal assistance in the subsequent budget periods. All applications should contain a breakdown by the object class categories shown in Lines a - k of Section B. Section A. Budget Summary Lines 1 - 4, Columns (a) and (b) For applications pertaining to a single Federal grant program (Federal Domestic Assistance Catalog number) and not requiring a functional or activity breakdown, enter on Line 1 under Column (a) the catalog program title and the catalog number in Column (b). For applications pertaining to a single program requiring budget amounts by multiple functions or activities, enter the name of each activity or function on each line in Column (a), and enter the catalog number in Column (b). For applications pertaining to multiple programs where none of the programs require a breakdown by function or activity, enter the catalog program title on each line in Column (a) and the respective catalog number on each line in Column (b). For applications pertaining to multiple programs where one or more programs require a breakdown by function or activity, prepare a separate sheet for each program requiring the breakdown. Additional sheets should be used when one form does not provide adequate space for all breakdown of data required. However, when more than one sheet is used, the first page should provide the summary totals by programs. Lines 1 - 4, Columns (c) through (g.) For new applications, leave Columns (c) and (d) blank. For each line entry in Columns (a) and (b), enter in Columns (e), (f), and (g) the appropriate amounts of funds needed to support the project for the first funding period (usually a year).	Lines 1 - 4, Columns (c) through (g.) (continued) For continuing grant program applications, submit these forms before the end of each funding period as required by the grantor agency. Enter in Columns (c) and (d) the estimated amounts of funds which will remain unobligated at the end of the grant funding period only if the Federal grantor agency instructions provide for this. Otherwise, leave these columns blank. Enter in columns (e) and (f) the amounts of funds needed for the upcoming period. The amount(s) in Column (g) should be the sum of amounts in Columns (e) and (f). For supplemental grants and changes to existing grants, do not use Columns (c) and (d). Enter in column (e) the amount of the increase or decrease of Federal Funds and enter in Column (f) the amount of the increase or decrease of non-Federal funds. In Column (g) enter the new total budgeted amount (Federal and non-Federal) which includes the total previous authorized budgeted amounts plus or minus, as appropriate, the amounts shown in Columns (e) and (f). The amount(s) in Column (g) should not equal the sum of amounts in Columns (e) and (f). Line 5 - Show the totals for all columns used. Section B. Budget Categories In the column heading (1) through (4), enter the titles of the same programs, functions, and activities shown on Lines 1 - 4, Column (a), Section A. When additional sheets are prepared for Section A, provide similar column headings on each sheet. For each program, function or activity, fill in the total requirements for funds (both Federal and non-Federal) by object class categories. Lines 6a-i - Show the totals of Lines 6a to 6h in each column. Line 6j - Show the amount of indirect cost. Line 6k - Enter the total of amounts on Lines 6i and 6j. For all applications for new grants and continuation grants the total amount in column (5), Line 6k, should be the same as the total amount shown in Section A, Column (g), Line 5. For supplemental grants and changes to grants, the total amount of the increase or decrease as shown in Columns (1) - (4), Line 6k should be the same as the sum of the amounts in Section A, Columns (e) and (f) on Line 5. Line 7 - Enter the estimated amount of income, if any, expected to be generated from this project. Do not add or subtract this amount from the total project amount.

INSTRUCTIONS FOR THE SF-424A (Continued)

Line 7 - (continued) Show under the program narrative statement the nature and source of income. The estimated amount of program income may be considered by the Federal grantor agency in determining the total amount of the grant. Section C. Non-Federal Resources Lines 8 - 11 - Enter amounts of non-Federal resources that will be used on the grant. If in-kind contributions are included, provide a brief explanation on a separate sheet. Column (a) - Enter the program titles identical to Column (a), Section A. A breakdown by function or activity is not necessary. Column (b) - Enter the contribution to be made by the applicant. Column (c) - Enter the amount of the State’s cash and in-kind contribution if the applicant is not a State or State agency. Applicants which are a State or State agencies should leave this column blank. Column (d) - Enter the amount of cash and in-kind contributions to be made from all other sources. Column (e) - Enter totals of Columns (b), (c), and (d). Line 12 - Enter the total for each of Columns (b) - (e). The amount in Column (e) should be equal to the amount on Line 5, Column (f), Section A. Section D. Forecasted Cash Needs Line 13 - Enter the amount of cash needed by quarter from the grantor agency during the first year. Line 14 - Enter the amount of cash from all other sources needed by quarter during the first year.

Line 15 - Enter the totals of amounts on Lines 13 and 14. Section E. Budget Estimates of Federal Funds Needed for Balance of the Project Lines 16 - 19 - Enter in Column (a) the same grant program titles shown in column (a), Section A. A breakdown by function or activity is not necessary. For new applications and continuation grant applications, enter in the proper columns amounts of Federal funds which will be needed to complete the program or project over the succeeding funding periods (usually in years). This section need not be completed for revisions (amendments, changes, or supplements) to funds for the current year of existing grants. If more than four lines are needed to list the program titles, submit additional schedules as necessary. Line 20 - Enter the total for each of the Columns (b) - (e). When additional schedules are prepared for this Section, annotate accordingly and show the overall totals on this line. Section F. Other Budget Information Line 21 - Use this space to explain amounts for individual direct object-class cost categories that may appear to be out of the ordinary or to explain the details as required by the Federal grantor agency. Line 22 - Enter the type of indirect rate (provisional, predetermined, final or fixed) that will be in effect during the funding period, the estimated amount of the base to which the rate is applied, and the total indirect expense. Line 23 - Provide any other explanations or comments deemed necessary.

OMB Approval No. 0348- 0041 BUDGET INFORMATION - Construction Programs NOTE: Certain Federal assistance programs require additional computations to arrive at the Federal share of project costs eligible for participation. If such is the case you will be notified.
COST CLASSIFICATION	a. Total Cost			b. Costs Not Allowable for Participation	c. Total Allowable Costs (Column a- b)
1. Administrative and legal expenses	$      .00			$      .00	$ $0.000.00
2. Land, structures, rights-of-way, appraisals, etc.	$      .00			$      .00	$ $0.000.00
3. Relocation expenses and payments	$      .00			$      .00	$ $0.000.00
4. Architectural and engineering fees	$      .00			$      .00	$ $0.000.00
5. Other architectural and engineering fees	$      .00			$      .00	$ $0.000.00
6. Project inspection fees	$      .00			$      .00	$ $0.000.00
7. Site work	$      .00			$      .00	$ $0.000.00
8. Demolition and removal	$      .00			$      .00	$ $0.000.00
9. Construction	$      .00			$      .00	$ $0.000.00
10. Equipment	$      .00			$      .00	$ $0.000.00
11. Miscellaneous	$      .00			$      .00	$ $0.000.00
12. SUBTOTAL (sum of lines 1- 11)	$ $0.000.00			$ $0.000.00	$ $0.000.00
13. Contingencies	$      .00			$      .00	$ $0.000.00
14. SUBTOTAL	$ $0.000.00			$ $0.000.00	$ $0.000.00
15. Project (program) income	$      .00			$      .00	$ $0.000.00
16. TOTAL PROJECT COSTS (subtract #15 from #14)	$ $0.000.00			$ $0.000.00	$ $0.000.00
FEDERAL FUNDING
17. Federal assistance requested, calculate as follows: (Consult Federal agency for Federal percentage share). Enter the resulting Federal share.
Enter eligible costs from line 16c Multiply X (include decimal point in number)		     			$ $0.000.00

INSTRUCTIONS FOR THE SF-424C
Public reporting burden for this collection of information is estimated to average 180 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0041), Washington, DC 20503. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
This sheet is to be used for the following types of applications: (1) "New" (means a new [previously unfunded] assistance award); (2) "Continuation" (means funding in a succeeding budget period which stemmed from a prior agreement to fund); and (3) "Revised" (means any changes in the Federal government’s financial obligations or contingent liability from an existing obligation). If there is no change in the award amount there is no need to complete this form. Certain Federal agencies may require only an explanatory letter to effect minor (no cost) changes. If you have questions please contact the Federal agency.
Column a.- If this is an application for a "New" project, enter the total estimated cost of each of the items listed on the lines 1 through 16 (as applicable) under "COST CLASSIFICATIONS." If this application entails a change to an existing award, enter the eligible amounts approved under the previous award for the items under "COST CLASSIFICATION." Column b. - If this is an application for "New" project, enter that portion of the cost of each item in Column a. which is not allowable for Federal assistance. Contact the Federal agency for assistance in determining the allowability of specific costs. If this application entails a change to an existing award, enter the adjustment [+ or (-)] to the previously approved costs (from column a.) reflected in this application. Column c. - This is the net of lines 1 through 16 in columns "a." and "b." Line 1 - Enter estimated amounts needed to cover administrative expenses. Do not include costs which are related to the normal functions of the government. Allowable legal costs are generally only those associated with the purchase of the land which is allowable for Federal participation and certain services in support of construction of the project. Line 2 - Enter estimated site and right(s)-of-way acquisition costs (this includes purchase, lease, and/or easements). Line 3 - Enter estimated costs related to relocation advisory assistance, replacement housing, relocation payments to displaced persons and businesses, etc.	Line 4 - Enter estimated basic engineering fees related to construction (this includes start-up services and preparation of project performance work plan). Line 5 - Enter estimated engineering costs, such as surveys, tests, soil borings, etc. Line 6 - Enter estimated engineering inspection costs. Line 7 - Enter estimated costs of site preparation and restoration which are not included in the basic construction contract. Line 9 - Enter estimated cost of the construction contract. Line 10 - Enter estimated cost of office, shop, laboratory, safety equipment, etc. to be used at the facility, if such costs are not included in the construction contract. Line 11 - Enter estimated miscellaneous costs. Line 12 - Total of items 1 through 11. Line 13 - Enter estimated contingency costs. (Consult the Federal agency for the percentage of the estimated construction cost to use.) Line 14 - Enter the total of lines 12 and 13. Line 15 - Enter estimated program income to be earned during the grant period, e.g., salvaged materials, etc. Line 16 - Subtract line 15 from line 14. Line 17 - This block is for the computation of the Federal share. Multiply the total allowable project costs from line 16, column "c." by the Federal percentage share (this may be up to 100 percent; consult Federal agency for Federal percentage share) and enter the product in line 17.

OMB Approval No. 0990-0317 PROGRAM NARRATIVE

Public Burden Statement: Public reporting burden of this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0428). Do not send the completed form to this address. Prepare the program narrative statement in accordance with the following instructions for all new and competing continuation applications. Noncompeting continuation applications and requests for changes to an approved project should respond to Item 6(b) only. Requests for supplemental assistance should respond to Item 6(c) only. The Program Narrative provides a major means by which the application is evaluated and ranked to compete with other applications for available funds. It should be concise and complete and should address the activity for which Federal funds are requested. Supporting documents should be included where they can present information clearly and succinctly. Cross-referencing should be used rather than repetition. PHS is particularly interested in specific factual information and statements of measurable goals in quantitative terms. Narratives are evaluated on the basis of substance, not length. Extensive exhibits are not required. (Supporting information concerning activities which will not be directly funded by the grant or information which does not directly pertain to an integral part of the grant-funded activity should be placed in an appendix.) Pages should be numbered for easy reference, continuing the numerical sequence of the printed form. 1. PROJECT DESCRIPTION Because many and varied programs employ this application form, it is not possible to provide specific guidance for developing a project description which would be appropriate in all cases. One aspect of the description that is applicable to all proposals, however, is the requirement that all project information described in this part relate directly to the budget information requested. The budget consists of the funds (both Federal and non-Federal)

which the applicant estimates are required to carry out activities under the proposed project. (A narrative budget justification must also be provided; see Budget Narrative, below.) Applicants must clearly identify the physical, economic, social, financial, institutional, or other problem(s) requiring a solution. The need for assistance must be demonstrated and the principal and subordinate objectives of the project must be clearly stated; supporting documentation or other testimonies from concerned interests other than the applicant may be included. Any relevant data based on planning studies should be included or referenced in footnotes. In developing the narrative, the applicant may volunteer or be requested to provide information on the total range of health programs currently conducted and supported (or to be initiated), some of which may be outside the scope of the program announcement. Applicants are encouraged to provide information on their organizational structure, staff, related experience, and other information considered to be relevant. Awarding offices use this and other information to determine whether the applicant has the capability and resources necessary to carry out the proposed project. It is important, therefore, that this information be included in the application. It is equally important that the narrative distinguish between applicant resources which are directly related to the proposed budget and those which will not be used in support of the specific project for which funds are requested. 2. RESULTS OR BENEFITS EXPECTED Identify results and benefits to be derived. For example, when applying for a grant to establish a neighborhood health center, provide a description of who will occupy the facility, how the facility will be used, and how the facility will benefit the general public. 3. APPROACH (a) Outline a plan of action which describes the scope and detail of how the proposed work will be accomplished for each grant program, function or activity provided in the budget. Cite factors which might accelerate or decelerate the work and state your reason for takings this

approach rather than others. Describe any unusual features of the project such as design or technological innovations, reductions in cost or time, or extraordinary social and community involvement. (b) Provide quantitative monthly or quarterly projections of the accomplishments to be achieved for each grant program, function or activity in such terms as the number of people to be served and the number of patients to be treated. When accomplishments cannot be quantified by activity or function, list them in chronological order to show the schedule of accomplishments and their target dates. (c) Identify the kinds of data to be collected and maintained. (d) List organizations, cooperating entities, consultants, or other key individuals who will work on the project along with a short description of the nature of their effort or contribution. 4. EVALUATION Provide a narrative addressing how you will evaluate 1) the results of your project, and 2) the conduct of your program. In addressing the evaluation of results, state how you will determine the extent to which the program has achieved its stated objectives and the extent to which the accomplishment of objectives can be attributed to the program. Discuss the criteria to be used to evaluate results and successes; explain the methodology that will be used to determine if the needs identified and discussed are being met and if the results and benefits identified in Item 2 (above) are being achieved. With respect to the conduct of your program, define the procedures you will employ to determine whether the program is being conducted in a manner consistent with the work plan you presented and discuss the impact of the program’s various activities upon the program’s effectiveness. 5. GEOGRAPHIC LOCATION Give the precise location of the project or area to be served by the proposed project. Maps or other graphic aids may be attached.

6. ADDITIONAL INFORMATION (INCLUDE IF APPLICABLE) (a) STAFF AND POSITION DATA Some programs require a biographical sketch for key personnel appointed and a job description for a vacant key position; others require both for all positions. Refer to appropriate program guidelines for guidance in fulfilling this requirement. Generally, a biographical sketch is required for original staff and new members as appointed. Below are the suggested contents for the biographical sketch and job description where not otherwise set forth: Biographical Sketch: Existing curricula vitae of project staff members may be used if they are updated and contain all items of information requested below. You may add any information items listed below to complete existing documents. For development of new curricula vitae include items below in the most suitable format: (1) Name of staff member. (2) Educational background: school(s), location, dates attended, degrees earned (specify year), major field of study. (3) Professional experience. (4) Honors received and dates. (5) Recent relevant publications. (6) Other sources of support. [Other support is defined as all funds or resources, whether Federal, non-Federal, or institutional, available to the Project Director/Program Director (and other key personnel named in the application) in direct support of their activities through grants, cooperative agreements, contracts, fellowships, gifts, prizes, and other means.] Job Description: (1) Title of position. (2) Description of duties and responsibilities. (3) Qualifications for position. (4) Supervisory relationships. (5) Skills and knowledge required. (6) Prior experience required. (7) Personal qualities. (8) Amount of travel and any other special conditions or requirements. (9) Salary range. (10) Hours per day or week.

(b) OTHER INFORMATION Discuss accomplishments to date and list in chronological order a schedule of accomplishments, progress or milestones anticipated with the new funding request. If there have been significant changes in the project objectives, location or approach, or time delays, explain and justify. For other requests for changes or amendments, explain the reason for the change(s). If the scope or objectives have changed or an extension of time is necessary, explain the circumstances and justify.	If the total budget has been exceeded, or if individual budget items have changed more than the prescribed limits contained in the applicable Office of Management and Budget Circular (A-102 or A-110), explain and justify the change and its effect on the project. (c) SUPPLEMENTAL REQUESTS For supplemental assistance requests, explain the reason for the request and justify the need for additional funding.
BUDGET NARRATIVE
Provide a narrative budget justification which describes how the categorical costs are derived. Discuss the necessity, reasonableness, and allocability of the proposed costs. Only the direct costs requested in this application need to be justified. Do not include any items that are treated by the applicant organization as indirect costs according to a Federal rate negotiation agreement except for those indirect costs included in consortium/ contractual costs. If funds to be used for Matching/Cost Participation (whether voluntary or required) are included in the budget, only funds which will be used for this specific project should be so identified. If an award is made, all funds identified as dedicated to this project (including funds used for cost participation) will be subject to the applicable cost principles, audit and reporting requirements. For a Supplemental application, you need justify only those items for which additional funds are requested, prorating the personnel costs and other appropriate parts of the detailed budget if the first budget period of the zapplication is less than 12 months.	Describe the specific functions of the personnel, consultants, and collaborators. For all years, explain and justify any unusual items such as major equipment, foreign travel, alterations and renovations, patient care costs, and tuition remission. For additional years of support requested, itemize and justify any significant increases or decreases in any category over the first 12 month budget period. Identify such significant changes with asterisks against the appropriate amounts. If a recurring annual increase or decrease in personnel or other costs is anticipated, give the percentage. In addition, for Competing Continuation applications, justify any significant increases or decreases in any category over the current level of support. INDIRECT COSTS If indirect costs are requested in the budget, submit a copy of the applicant organization’s most current Federal negotiated indirect cost rate agreement. If your organization does not have a Federally negotiated rate, contact the grants management office identified in the program announcement for information on a contact point to assist in the development of such a rate.

OMB Approval No. 0990-0317 CHECKLIST Expiration Date: 08/31/2010
Public Burden Statement: Public reporting burden of this collection of information is estimated to average 4 - 50 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for	reducing this burden to HHS Reports Clearance Officer, 200 Independence Ave., SW, Humphrey Bldg., Room 531H, Washington, DC, 20201, ATTN: PRA (0990-0317). Do not send the completed form to this address. NOTE TO APPLICANT: This form must be completed and submitted with the original of your application. Be sure to complete each page of this form. Check the appropriate boxes and provide the information requested. This form should be attached as the last pages of the signed original of the application.
Type of Application: New Noncompeting Continuation Competing Continuation Supplemental
PART A: The following checklist is provided to assure that proper signatures, assurances, and certifications have been submitted. Included NOT Applicable 1. Proper Signature and Date on the SF 424 (FACE PAGE) ............................ 2. If your organization currently has on file with HHS the following assurances, please identify which have been filed by indicating the date of such filing on the line provided. (All four have been consolidated into a single form, HHS 690) Civil Rights Assurance (45 CFR 80) ………………………………………………. ____________________ Assurance Concerning the Handicapped (45 CFR 84) …………………………. ____________________ Assurance Concerning Sex Discrimination (45 CFR 86) ……………………….. ____________________ Assurance Concerning Age Discrimination (45 CFR 90 and 45 CFR 91) …….. ____________________ 3. Human Subjects Certification, when applicable (45 CFR 46) .......................................
PART B: This part is provided to assure that pertinent information has been addressed and included in the application. YES NOT Applicable 1. Has a Public Health System Impact Statement for the proposed program/project been completed and distributed as required? 2. Has the appropriate box been checked on the SF-424 (FACE PAGE) regarding intergovernmental review under E.O. 12372 ? (45 CFR Part 100) 3. Has the entire proposed project period been identified on the SF-424 (FACE PAGE)? 4. Have biographical sketch(es) with job description(s) been provided, when required? 5. Has the "Budget Information" page, SF-424A (Non-Construction Programs) or SF-424C (Construction Programs), been completed and included? 6. Has the 12 month narrative budget justification been provided? 7. Has the budget for the entire proposed project period with sufficient detail been provided? 8. For a Supplemental application, does the narrative budget justification address only the additional funds requested? 9. For Competing Continuation and Supplemental applications, has a progress report been included?
PART C: In the spaces provided below, please provide the requested information. Business Official to be notified if an award is to be made. Prefix: First Name: Middle Name: Last Name: Suffix: Title: Organization: Street1: Street2: City: State: ZIP/Postal Code: ZIP/Postal Code4: Email Address: Telephone Number: Fax Number: Program Director/Project Director/Principal Investigator designated to direct the proposed project or program. Prefix: First Name: Middle Name: Last Name: Suffix: Title: Organization: Street1: Street2: City: State: ZIP/Postal Code: ZIP/Postal Code4: Email Address: Telephone Number: Fax Number:

HHS Checklist (08/2007)

PART D: A private, nonprofit organization must include evidence of its nonprofit status with the application. Any of the following is acceptable evidence. Check the appropriate box or complete the "Previously Filed" section, whichever is applicable. (a) A reference to the organization’s listing in the Internal Revenue Service’s (IRS) most recent list of tax-exempt organizations described in section 501(c)(3) of the IRS Code. (b) A copy of a currently valid Internal Revenue Service Tax exemption certificate. (c) A statement from a State taxing body, State Attorney General, or other appropriate State official certifying that the applicant organization has a nonprofit status and that none of the net earnings accrue to any private shareholders or individuals. (d) A certified copy of the organization’s certificate of incorporation or similar document if it clearly establishes the nonprofit status of the organization. (e) Any of the above proof for a State or national parent organization, and a statement signed by the parent organization that the applicant organization is a local nonprofit affiliate. If an applicant has evidence of current nonprofit status on file with an agency of HHS, it will not be necessary to file similar papers again, but the place and date of filing must be indicated. Previously Filed with: (Agency) on (Date)
INVENTIONS If this is an application for continued support, include: (1) the report of inventions conceived or reduced to practice required by the terms and conditions of the grant; or (2) a list of inventions already reported, or (3) a negative certification.
EXECUTIVE ORDER 12372
Effective September 30, 1983, Executive Order 12372 (Intergovernmental Review of Federal Programs) directed OMB to abolish OMB Circular A-95 and establish a new process for consulting with State and local elected officials on proposed Federal financial assistance. The Department of Health and Human Services implemented the Executive Order through regulations at 45 CFR Part 100 (Inter-governmental Review of Department of Health and Human Services Programs and Activities). The objectives of the Executive Order are to (1) increase State flexibility to design a consultation process and select the programs it wishes to review, (2) increase the ability of State and local elected officials to influence Federal decisions and (3) compel Federal officials to be responsive to State concerns, or explain the reasons. The regulations at 45 CFR Part 100 were published in the Federal Register on June 24, 1983, along with a notice identifying the		Department’s programs that are subject to the provisions of Executive Order 12372. Information regarding HHS programs subject to Executive Order 12372 is also available from the appropriate awarding office. States participating in this program establish State Single Points of Contact (SPOCs) to coordinate and manage the review and comment on proposed Federal financial assistance. Applicants should contact the Governor’s office for information regarding the SPOC, programs selected for review, and the consultation (review) process designed by their State. Applicants are to certify on the face page of the SF-424 (attached) whether the request is for a program covered under Executive Order 12372 and, where appropriate, whether the State has been given an opportunity to comment.

BY SIGNING THE FACE PAGE OF THIS APPLICATION, THE APPLICANT ORGANIZATION CERTIFIES THAT THE STATEMENTS IN

THIS APPLICATION ARE TRUE, COMPLETE, AND ACCURATE TO THE BEST OF THE SIGNER’S KNOWLEDGE, AND THE

ORGANIZATION ACCEPTS THE OBLIGATION TO COMPLY WITH U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES’ TERMS AND CONDITIONS IF AN AWARD IS MADE AS A RESULT OF THE APPLICATION. THE SIGNER IS ALSO AWARE THAT ANY FALSE, FICTITIOUS, ORFRAUDULENT STATEMENTS OR CLAIMS MAY SUBJECT THE SIGNER TO CRIMINAL, CIVIL, OR ADMINISTRATIVE PENALTIES.

THE FOLLOWING ASSURANCES/CERTIFICATIONS ARE MADE AND VERIFIED BY THE SIGNATURE OF THE OFFICIAL SIGNING

FOR THE APPLICANT ORGANIZATION ON THE FACE PAGE OF THE APPLICATION:

Civil Rights – Title VI of the Civil Rights Act of 1964 (P.L. 88-352), as amended, and all the requirements imposed by or pursuant to the HHS regulation (45 CFR part 80).

Handicapped Individuals – Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and all requirements imposed by or pursuant to the HHS regulation (45 CFR part 84).

Sex Discrimination – Title IX of the Educational Amendments of 1972 (P.L. 92-318), as amended, and all requirements imposed by or

pursuant to the HHS regulation (45 CFR part 86).

Age Discrimination – The Age Discrimination Act of 1975 (P.L. 94-135), as amended, and all requirements imposed by or pursuant to the HHS regulation (45 CFR part 91).

Debarment and Suspension – Title 2 CFR part 376.

Certification Regarding Drug-Free Workplace Requirements – Title 45 CFR part 82.

Certification Regarding Lobbying – Title 32, United States Code, Section 1352 and all requirements imposed by or pursuant to the HHS regulation (45 CFR part 93).

Environmental Tobacco Smoke – Public Law 103-227.

Program Fraud Civil Remedies Act (PFCRA)

_____________________________________________________________________________________________________________________

HHS Checklist (08/2007)

DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB 0348-0046 Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure.)

1. Type of Federal Action:

2. Status of Federal Action

3. Report Type:

 

a. contract b. grant c. cooperative agreement d. loan e. loan guarantee f. loan insurance

 

a. bid/offer/application b. initial award c. post-award

 

a. initial filing b. material change

For Material Change Only:

Year

     

Quarter

     

date of last report

     

4. Name and Address of Reporting Entity:

5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime:

Prime Subawardee

     

Tier

     

, if known:

     

     

Congressional District, if known:

     

Congressional District, if known:

     

6. Federal Department/Agency:

7. Federal Program Name/Description:

     

     

CFDA Number, if applicable:

     

8. Federal Action Number, if known:

9. Award Amount, if known:

     

$      

10. a. Name and Address of Lobbying Entity (if individual, last name, first name, MI):

b. Individuals Performing Services (including address if different from No. 10a.) (last name, first name, MI):

     

     

11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Signature:

Print Name:

     

Title:

     

Telephone No.:

     

Date:

     

Federal Use Only:

     

Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97)

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. Section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks "subawardee", then enter the full name, address, city, state and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 [e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency]. Include prefixes, e.g., ‘‘RFP-DE-90-001.’’ 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter Last Name, First Name, and Middle Initial (MI). 11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to the lobbying entity (item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made.
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The valid OMB control number for this information collection is OMB No.0348-0046. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503.
Approved by OMB DISCLOSURE OF LOBBYING ACTIVITIES 0348-0046 CONTINUATION SHEET
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Authorized for Local Reproduction

Standard Form - LLL-A