MH BG Funding Agreements

I.

State Information

Chief Executive Officer’s Funding Agreements, Assurances Non-Construction Programs and
Certifications (Form 03)
Fiscal Year 2020/21
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administrations
Funding Agreements
as required by
Community Mental Health Services Block Grant Program
as authorized by
Title XIX, Part B, Subpart I and Subpart III of the Public Health Service Act
and
Tile 42, Chapter 6A, Subchapter XVII of the United States Code

Section
Section 1911
Section 1912
Section 1913
Section 1914
Section 1915
Section 1916
Section 1917
Section 1941
Section 1942
Section 1943
Section 1946
Section 1947
Section 1953
Section 1955
Section 1956

Title XIX, Part B, Subpart I of the Public Health Service Act
Title
Formula Grants to States
State Plan for Comprehensive Community Mental Health Services for Certain
Individuals
Certain Agreements
State Mental Health Planning Council
Additional Provisions
Restrictions on Use of Payments
Application for Grant
Title XIX, Part B, Subpart III of the Public Health Service Act
Opportunity for Public Comment on State Plans
Requirement of Reports and Audits by States
Additional Requirements
Prohibition Regarding Receipt of Funds
Nondiscrimination
Continuation of Certain Programs
Services Provided by Nongovernmental Organizations
Services for Individuals with Co-Occurring Disorders

Chapter
42 USC § 300x
42 USC § 300x-1
42 USC § 300x-2
42 USC § 300x-3
42 USC § 300x-4
42 USC § 300x-5
42 USC § 300x-6
42 USC § 300x-51
42 USC § 300x-52
42 USC § 300x-53
42 USC § 300x-56
42 USC § 300x-57
42 USC § 300x-63
42 USC § 300x-65
42 USC § 300x-66

I hereby certify that the state or territory will comply with Title XIX, Part B, Subpart I and Subpart III of
the Public Health Service (PHS) Act, as amended, and summarized above, except for those sections in
the PHS Act that do not apply or for which a which a waiver has been granted or may be granted by the
Secretary for the period covered by this agreement.
State:
Name of Chief Executive Officer (CEO) or Designee:
Signature of CEO or Designee 1:
Title:
Date Signed:

1

mm/dd/yyyy

If the agreement is signed by an authorized designee, a copy of the designation must be attached.

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 standard 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. §§4728-4763)
relating to prescribed standards for merit systems for programs funded under one of the
nineteen statutes or regulations specified in Appendix A of OPM’s Standard for a Merit
System of Personnel Administration (5 C.F.R. 900, Subpart F).
6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not
limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits
discrimination on the basis of race, color or national origin; (b) Title IX of the Education
Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and 1685- 1686), which
prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of
1973, as amended (29 U.S.C. §§794), which prohibits discrimination on the basis of
handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101-6107),
which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment
Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug
abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and
Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the
basis of alcohol abuse or alcoholism; (g) §§523 and 527 of the Public Health Service Act of
1912 (42 U.S.C. §§290 dd-3 and 290 ee-3), as amended, relating to confidentiality of
alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42
U.S.C. §§3601 et seq.), as amended, relating to non- discrimination in the sale, rental or
financing of housing; (i) any other nondiscrimination provisions in the specific statute(s)
under which application for Federal assistance is being made; and (j) the requirements
of any other nondiscrimination statute(s) which may apply to the application.
7. Will comply, or has already complied, with the requirements of Title 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 wetland 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 Costal 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 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.

LIST of CERTIFICATIONS
1. CERTIFICATION REGARDING LOBBYING
Title 31, United States Code, Section 1352, entitled "Limitation on use of appropriated
funds to influence certain Federal contracting and financial transactions," generally
prohibits recipients of Federal grants and cooperative agreements from using Federal
(appropriated) funds for lobbying the Executive or Legislative Branches of the Federal
Government in connection with a SPECIFIC grant or cooperative agreement. Section
1352 also requires that each person who requests or receives a Federal grant or
cooperative agreement must disclose lobbying undertaken with non-Federal (nonappropriated) funds. These requirements apply to grants and cooperative agreements
EXCEEDING $100,000 in total costs (45 CFR Part 93). By signing and submitting this
application, the applicant is providing certification set out in Appendix A to 45 CFR
Part 93.
2. CERTIFICATION REGARDING PROGRAM FRAUD CIVIL REMEDIES
ACT (PFCRA)
The undersigned (authorized official signing for the applicant organization) certifies that
the statements herein are true, complete, and accurate to the best of his or her knowledge,
and that he or she is aware that any false, fictitious, or fraudulent statements or claims
may subject him or her to criminal, civil, or administrative penalties. The undersigned
agrees that the applicant organization will comply with the Department of Health and
Human Services terms and conditions of award if a grant is awarded as a result of this
application.
3. 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 programs 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 residence, portions of facilities used for
inpatient drug or alcohol treatment, service providers whose sole source of applicable
Federal funds is Medicare or 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.

The authorized official signing for the applicant organization certifies that the applicant
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 applicant organization agrees that it will require that the
language of this certification be included in any sub-awards which contain provisions
for children’s services and that all sub-recipients shall certify accordingly.
The Department of Health and Human Services strongly encourages all grant recipients
to provide a smoke-free workplace and promote the non-use of tobacco products. This
is consistent with the DHHS mission to protect and advance the physical and mental
health of the American people.