LIHWAP Plan

OMB #: 0970-0XXXX

Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES ADMINISTRATION FOR CHILDREN AND FAMILIES	OMB Clearance No: 0970-0XXXXX Expiration Date: XX-XX-XXXX
LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM (LIHWAP) MODEL PLAN 424 - MANDATORY
Section 1 – Program Needs, Goals and Allocations
Community Needs and Program Goals
Description of Emergency Household Drinking Water and Wastewater Needs The OCS priorities are restoration of household water services, reducing arrearages, reducing rates charged to households. Briefly describe current needs related to these priorities within your state, territory, or tribal areas. Describe any areas of concentrated need or special issues within communities served by water utilities within your state, territory, or tribal area.
Operational Priorities and Emergency Flexibilities Consistent with goal of the American Rescue Plan to provide immediate relief to the American people, briefly describe the operational priorities within your state. territory or tribal area (e.g. immediate restoration of services to households without current water services, immediate payment of existing arrearages to prevent disconnection of drinking water or wastewater services after a previous moratorium on water services due to Covid-19).
1.3. Expected Date for Initial Water Payments on Behalf of Households Provide an estimated date by which payments will be initiated based on the operational priorities identified above (e.g. first stage of payments to restore services for currently disconnected households, etc.).
Estimated Funding Allocations
1.4 Estimate what amount of available LIHWAP funds will be used for each component that you will operate: The total of all percentages must add up to 100%. The combined total of Administration (State) and Administration (Subrecipients) must not exceed 15% of the total for either the Consolidated Appropriations Act or the American Rescue Plan Award. Household Benefits Outreach/Eligibility Determination Administration - State Administration - Subrecipients Total		Consolidated Appropriations Act of 2021 Percentage (%)	American Rescue Plan Grant Percentage %
		0.00%	0.00%
		0.00%	0.00%
		0.00%	0.00%
		0.00%	0.00%
		0.00%	0.00%

Categorical Eligibility
As outlined in the Terms and Conditions, current recipients the following programs are categorically-eligible for LIHWAP assistance: Low-Income Home Energy Assistance Program (LIHEAP) Means-tested Veterans Programs Supplemental Security Income (SSI) Supplemental Nutrition Assistance Program (SNAP) Temporary Assistance for Needy Families (TANF) Briefly describe your operational plans for enrollment of categorically eligible populations based on operational priorities outlined in question 1.2 (e.g. automatic enrollment, acceptance of documentation of enrollment during intake processes). If it will not be possible to include any of these programs in your intake/eligibility processes, provide a brief explanation.
Determination of Eligibility for Direct Enrollment Note: The information below is focused on eligibility determination for households that are not categorically eligible based on the enrollment in one of the programs outlined in question 1.5.
1.6 What type of countable income do you use for eligibility determination?
☐	Gross Income
☐	Net Income
1.7 List all the applicable forms of countable income used to determine a household's income eligibility for LIHWAP. Note: The forms of countable income used for benefit eligibility are generally left to the discretion of the grantee; however, the following sources are not applicable forms of countable income used to determine a household’s income eligibility for LIHWAP: Temporary Assistance for Needy Families (TANF) benefits Supplemental Nutrition Assistance Program (SNAP) benefits Women, Infants, and Children Supplemental Nutrition Program (WIC) benefits Covid-19 Economic Impact Payments (Stimulus Checks)

If any of the above questions require further explanation or clarification that could not be made in the fields provided said explanation here.

Section 2 -Benefits

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB Clearance No: ________________________ ADMINISTRATION FOR CHILDREN AND FAMILIES Expiration Date: ______________ LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM (LIHWAP) MODEL PLAN Section 2 - Benefits
Eligibility 2.1 Designate the income eligibility threshold used for the water benefit.
Eligibility Threshold		Eligibility Threshold Percent
Federal Poverty Guideline State Median Income Hybrid Federal and State (Based on Household Size)		0.00%
2.2 Do you anticipate additional eligibility requirements beyond the income threshold noted in 2.1 for water assistance?			Yes No
If the answer to question 2.2. is “Yes” please provide an explanation below
2.3. How will you support households whose utility payments are included in their rental payments.
2.4 Check the variables you use to determine your benefit levels. (Check all that apply. Check both Household Drinking Water Burden and Household Wastewater Burden if households receive a combined bill for drinking water and wastewater):
☐ Income
☐ Household Size
☐ Household Drinking Water Burden
☐ Household Wastewater Burden
☐ Other (Please describe):
2.5 Describe estimated benefit levels for the project period for which this plan applies
Minimum Benefit	$0			Maximum Benefit		$0
2.6. Benefit periods
Is this a one-time benefit?					Yes No
If no, please explain the frequency of allowable benefit (e.g., monthly, quarterly, etc.):
2.7 Do you give priority in eligibility to:
People with Disabilities					Yes No
Young Children?					Yes No
Older Adult/Seniors (60 and over)?					Yes No
Households with high water burdens?					Yes No
Other?					Yes No
2.8 Describe how you prioritize the provision of water assistance to vulnerable populations (e.g., benefit amounts, early application periods, etc.)
2.9 Do you provide applicants, including those who are physically disabled, the means to submit applications for benefits without leaving their homes? Yes No
If No, explain.
2.10 For individual who are homebound or physically disabled, do you provide travel to the sites at which applications for assistance are accepted? Yes No
If No, explain and explain alternative means of intake to those who are homebound or physically disabled?
2.11 Are any of the utility vendors you work with subject to a moratorium on shut offs?
Yes No
If you responded "Yes" to question 2.11, you must respond to question 2.12. 2.12 Describe the terms of the moratorium and any special dispensation received by LIHWAP clients during or after the moratorium period.
2.13. Do you make payments contingent on vendors taking appropriate measures or maintaining existing supports to alleviate the water burden of eligible households? Yes No
If so, describe the measures vendors may take or maintain. Covid-Specific ☐ Disconnection moratorium ☐ No late fees, interest, or penalty charges ☐ Ability to enter into payment plan of 6 months or longer ☐ Reconnection of service for disconnected customers ☐ Enrollment in a discounted rate General (Not COVID-specific) ☐ Consumer protections regarding shutoffs (e.g., minimum notice period, protection of vulnerable populations, minimum amount overdue before disconnection allowed, opportunity for payment plan before disconnection, other procedural or substantive restrictions on shutoffs) ☐ Data reporting requirements for utilities – on a permanent basis – e.g., periodic reporting on number of shutoffs ☐ Percentage of income payment plan other utility-funded arrearage assistance ☐Lifeline rates ☐ Water efficiency assistance ☐ Provisions ensuring continued service for a specific time period (Describe below): ☐ Provisions ensuring reconnection within a specific time period (Describe below)
If any of the above questions require further explanation or clarification that could not be made in the fields provided said explanation here.

Section 3 - Outreach

_{U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES} ADMINISTRATION FOR CHILDREN AND FAMILIES ^{OMB Clearance No: ________________________} Expiration Date: ________________

LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM (LIHWAP) MODEL PLAN

Section 3: Outreach

3.1 Select all outreach activities that you conduct that are designed to assure that eligible households are made aware of all LIHWAP assistance available:

☐ Place posters/flyers in local and county social service offices, offices of aging, Social Security offices, VA, etc.

☐ Publish articles or public service announcements in local newspapers or broadcast media announcements.

☐ Work directly with water utilities to identify potential recipients.

☐ Include inserts in water vendor billings to inform individuals of the availability of all types of LIHWAP assistance.

☐ Mass mailing(s) to prior-year LIHEAP recipients or recipients of other government benefits:

☐ Automated phone campaigns and/or social media outreach

☐ Multi-lingual announcements in languages spoken by low income households within utility service area and/or notification in ethnic language news and broadcast media outlets

☐ Inform low income applicants of the availability of all types of LIHWAP assistance at application intake for other low-income programs.

☐ Execute interagency agreements with other low-income program offices and/or public health pathways created for Covid-19 outreach to perform outreach to target groups.

☐ Outreach to faith-based institutions, including those serving low-income people and people of color

☐ Other (specify):

If any of the above questions require further explanation or clarification that could not be made in the fields provided said explanation here.

Section 4 - Coordination

_{U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES} ADMINISTRATION FOR CHILDREN AND FAMILIES ^{OMB Clearance No: ________________________} Expiration Date: ________________

LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM (LIHWAP) MODEL PLAN

Section 4: Coordination

4.1 Describe how you will ensure that the LIHWAP program is coordinated with other programs available to low-income households (LIHEAP, TANF, SSI, SNAP, EPA, Emergency Rental Assistance Program, Homeowner Assistance Program, WAP, etc.)

etc.).

Joint application for multiple programs:

Intake referrals to/from other programs:

One - stop intake centers:

Other - Describe:

4.2 Describe how you will coordinate with relevant regulatory authorities that govern water suppliers.

If any of the above questions require further explanation or clarification that could not be made in the fields provided explanation here.

Section 5 - Agency Designation

_{U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES} ADMINISTRATION FOR CHILDREN AND FAMILIES ^{OMB Clearance No: ________________________} Expiration Date: ________________

LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM
(LIHWAP) MODEL PLAN

Section 5: Agency Designation (Required for State grantees and the Commonwealth of Puerto Rico)

5.1 How would you categorize the primary responsibility of your State agency?
☐	Administration Agency
☐	Commerce Agency
☐	Community Services Agency
☐	Energy / Environment Agency
☐	Housing Agency
☐	Human Service Agency
☐	Other - Describe:
5.2 LIHWAP Component Administration.		Drinking Water Service	Wastewater Service
5.2a Who determines client eligibility?
5.2b Who processes benefit payments to water service providers?
If any of your LIHWAP components are not centrally administered by a State agency, you must complete questions 5.3, 5.4 and 5.5.
5.3 What is your process for selecting local administering agencies?
5.4 How many local administering agencies do you use?
5.5 What types of local administering agencies do you use? ☐ Community Action Agencies ☐ Local Governments ☐ City Governments ☐ County Governments ☐ Other non-profits
If any of the above questions require further explanation or clarification that could not be made in the fields provided said explanation here.

Section 6 - Water Suppliers

_{U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES} ADMINISTRATION FOR CHILDREN AND FAMILIES ^{OMB Clearance No: ________________________} Expiration Date: ________________

LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM (LIHWAP) MODEL PLAN

Section 6: Water Suppliers

Note: Water suppliers refers to both drinking and/or wastewater suppliers as they may be different entities at the local level

6.1 The following question is specific to Tribes (only). Do you charge households drinking water and wastewater utility services? Y/N

If “Yes” please proceed to next questions.

If “No” please skip to question 6.6.

6.2 How do you notify the household of the amount of assistance paid, and the timing of the assistance payment?

6.3 How do you assure that no household receiving assistance under this title will be treated adversely because of their receipt of LIHWAP assistance?

6.4 How do you assure that water suppliers are restoring disconnected service or otherwise maintaining continuity of service due to the benefit payment?

6.5 For Tribes who answered “No” to question 6.2, please describe how you intend to maintain accurate records to show how LIHWAP funds are expended for drinking water and/or wastewater utilities on behalf of households. (I.E. Financial expenditure reports).

If any of the above questions require further explanation or clarification that could not be made in the fields provided said explanation here.

Section 7 - Program, Fiscal Monitoring, and Audit

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES ADMINISTRATION FOR CHILDREN AND FAMILIES OMB Clearance No: ________________________ Expiration Date: ________________ LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM (LIHWAP) MODEL PLAN Section 7: Program, Fiscal Monitoring, and Audit
7.1. How do you ensure good fiscal accounting and tracking of LIHWAP funds?
Audit Process
7.2. Describe any audit findings rising to the level of material weakness or reportable condition cited in the Single Audits (as required in the Single Audit Act), Grantee monitoring assessments, inspector general reviews, or other government agency reviews of the LIHWAP agency from the most recently audited fiscal year.
No Findings ☐
Finding	Type	Brief Summary	Resolved?	Action Taken
1
2
3
4
5
6
Compliance Monitoring
7.3. Identify e the Grantee's strategies for monitoring compliance with the Grantee's and Federal LIHWAP policies and procedures (e.g. certifications, Terms and Conditions, federal guidance, nondiscrimination requirements) : Select all that apply
Grantee employees:
☐ Internal program review
☐ Departmental oversight
☐ Secondary review of invoices and payments
☐ Reconciliation of water supplier records
☐ Other program review mechanisms are in place. Describe:
Local Administering Agencies / District Offices:
☐ On - site assessment
☐ Annual program review
☐ Monitoring through central database
☐ Desk reviews
☐ Client file testing/sampling
☐ Reconciliation of water supplier records
☐ Other program review mechanisms are in place. Describe:
7.4 Explain or attach a copy of your local agency monitoring schedule and protocol..
7.5. Describe how you select local agencies for monitoring reviews.
Site visits:
Desk reviews:
7.6. How often will each local agency be monitored? Note: This answer can be prospective.
7.7. How many local agencies are currently on corrective action plans for eligibility and/or benefit determination issues for LIHEAP or other programs administered by your agency?
7.8. How many local agencies are currently on corrective action plans for financial accounting or administrative issues for LIHEAP or other programs administered by your agency?
If any of the above questions require further explanation or clarification that could not be made in the fields provided said explanation here.

_Section 8 - Timely and Meaningful Public Participation

_{U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES} ADMINISTRATION FOR CHILDREN AND FAMILIES ^{OMB Clearance No: ________________________} Expiration Date: ________________

LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM (LIHWAP) MODEL PLAN

Section 8: Public Participation

8.1 How did you obtain input from the public in the development of your LIHWAP plan? Select all that apply.

☐ Tribal Council meeting(s)

☐ Public hearing(s)

Enter the dates for Tribal Council meeting(s) or Public hearing(s):

☐ Draft Plan posted to website and available for comment

☐ Hard copy of plan is available for public view and comment

Enter how long draft plan and/or hard copy of plan was available for public view and comment:

☐ Comments from applicants are recorded

☐ Request for comments on draft Plan is advertised

☐ Stakeholder or consultation meeting(s)

☐ Comments are solicited during outreach activities

☐ Other - Describe:

8.2. How many parties commented on your plan?

8.3 Summarize the comments you received on your plan here:

8.4 What changes did you make to your LIHWAP plan as a result of the comments received?

If any of the above questions require further explanation or clarification that could not be made in the fields provided said explanation here.

_Section 9 - Fair Hearings

_{U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES} ADMINISTRATION FOR CHILDREN AND FAMILIES ^{OMB Clearance No: ________________________} Expiration Date: ________________

LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM (LIHWAP) MODEL PLAN

Section 9: Fair Hearings

Note: Administrative hearing opportunities will be comparable to and may utilize existing processes, procedures, and systems currently in place for the State, Territory, or Tribe’s Low Income Home Energy Assistance grant.

9.1 Describe your fair, independent hearing procedures for households whose applications are denied or where the applicant disputes the benefit amount.

9.2 When and how are applicants informed of these rights?

9.3 Describe your fair hearing procedures for households whose applications are not acted on in a timely manner.

9.4 When and how are applicants informed of these rights?

If any of the above questions require further explanation or clarification that could not be made in the fields provided said explanation here.

_Section 10 - Training

_{U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES} ADMINISTRATION FOR CHILDREN AND FAMILIES ^{OMB Clearance No: ________________________} Expiration Date: ________________

LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM (LIHWAP) MODEL PLAN

Section 10: Training

10.1. Training Strategy - Briefly describe the anticipated training strategy for ensuring that grantee staff, local administering agencies, and participating water utilities understand requirements outlined in the Terms and Conditions as well eligibility requirements and procedures described in this plan. Indicate any technical assistance or resources needed by the State, Territory or Tribe to carry out this training strategy.

_{U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES} ADMINISTRATION FOR CHILDREN AND FAMILIES ^{OMB Clearance No: ________________________} Expiration Date: ________________

LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM (LIHWAP) MODEL PLAN

Section 11: Performance Management

11.1 Describe any challenges you anticipate with collecting and reporting data to ACF each year regarding how you implemented your LIHWAP. Examples of data may include, but are not limited to, the number of households assisted, the average benefit amount provided, the number of households whose water or wastewater services were restored because of the benefit, demographics of applicants and beneficiaries, and the number of imminent disconnections of water or wastewater services avoided because of the benefit.

11.2 List any technical assistance resources you request of ACF related to data collection, analysis and reporting on your LIHWAP.

If any of the above questions require further explanation or clarification that could not be made in the fields provided said explanation here

_Section 12 - Program Integrity

_{U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES} OMB Clearance No: ________________________

ADMINISTRATION FOR CHILDREN AND FAMILIES Expiration Date: ________________

LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM (LIHWAP) MODEL PLAN

Section 12: Program Integrity

12.1 Fraud Reporting Mechanisms
a. Identify all mechanisms that will be available to the public for reporting cases of suspected LIHWAP waste, fraud, and abuse. Select all that apply.
☐ Online fraud reporting
☐ Dedicated fraud reporting hotline
☐ Report directly to local agency/district office or Grantee office
☐ Report to State Inspector General or Attorney General
☐ Forms and procedures in place for local agencies/district offices and vendors to report fraud, waste, and abuse
☐ Other - Describe:
b. Identify strategies that will be used for advertising the above-referenced resources. Select all that apply
☐ Printed outreach materials
☐ Addressed on LIHWAP application
☐ Website
☐ Other - Describe: 12.2. Identification Documentation Requirements
a. Indicate which of the following forms of identification will be required or requested to be collected from LIHWAP applicants or their household members. Note: The types of documentation required is left to the discretion of the grantee. The types of documentation included in the list below are examples of documentation required by LIHEAP grantees for some or all household members based on policies within the State, Territory or Tribe. Comparable documentation and procedures may be instituted for LIHWAP households or may be modified or simplified for households that are categorically eligible based on enrollment in programs identified in question 1.5.
Type of Identification Collected	Collected from Whom?
	Applicant Only		All Adults in Household		All Household Members
Social Security Card is photocopied and retained	☐	Required	☐	Required	☐	Required
	☐	Requested	☐	Requested	☐	Requested

Social Security Number (Without Actual Card)	☐	Required	☐	Required	☐	Required
	☐	Requested	☐	Requested	☐	Requested
Government-issued identification card (i.e.: driver's license, State ID, Tribal ID, passport, etc.)	☐	Required	☐	Required	☐	Required
	☐	Requested	☐	Requested	☐	Requested
Other (Describe Below)	☐	Required	☐	Required	☐	Required
b. Describe any exceptions to the above policies.
12.3 Identification Verification
Identify what methods will be used to verify the authenticity of identification documents provided by clients or household members. Select all that apply
☐ Verify SSNs with Social Security Administration
☐ Match SSNs with death records from Social Security Administration or State agency
☐ Match SSNs with State eligibility/case management system (e.g., SNAP, TANF)
☐ Match with State Department of Labor system
☐ Match with State and/or federal corrections system
☐ Match with State child support system
☐ Verification using private software (e.g., The Work Number)
☐ In-person certification by staff (for Tribal grantees only)
☐ Match SSN/Tribal ID number with Tribal database or enrollment records (for Tribal grantees only)
☐ Other - Describe:
12.4. Citizenship/Legal Residency Verification
What are your procedures for ensuring that household members are U.S. citizens or permanent residents who are qualified to receive LIHWAP benefits? Select all that apply.
☐ Clients sign an attestation of citizenship or legal residency
☐ Client's submission of Social Security cards is accepted as proof of legal residency
☐ Noncitizens must provide documentation of immigration status
☐ Citizens must provide a copy of their birth certificate, naturalization papers, or passport
☐ Noncitizens are verified through the SAVE system
☐ Tribal members are verified through Tribal enrollment records/Tribal ID card
☐ Other - Describe:
12.5. Income Verification Note: Income verification applies only to households that have not been determined to be categorically eligible based on enrollment in other programs identified in question 1.5 above. Methods of income verification are left to the discretion of grantees and should be consistent with any sources of countable income identified in question 1.7 above.
What methods will your agency utilize to verify household income? Select all that apply.
☐ Require documentation of income for all adult household members
☐ Pay stubs
☐ Social Security award letters
☐ Bank Statements
☐ Tax Statements
☐ Zero-income Statements
☐ Unemployment insurance letters
☐ Other - Describe:
☐ Computer data matches:
☐ Income information matched against State computer system (e.g., SNAP, TANF)
☐ Proof of unemployment benefits verified with State Department of Labor

☐ Social Security income verified with SSA

☐ Utilize State directory of new hires

☐ Other - Describe:

12.6. Protection of Privacy and Confidentiality

Identify the financial and operating controls that will be in place to protect client information against improper use or disclosure. Select all that apply.

☐ Policy in place prohibiting release of information without written consent

☐ Grantee LIHWAP database includes privacy/confidentiality safeguards

☐ Employee training on confidentiality for:

☐ Grantee employees

☐ Local agencies/district offices

☐ Employees must sign confidentiality agreement

☐ Grantee employees

☐ Local agencies/district offices

☐ Physical files are stored in a secure location

☐ Other - Describe:

12.7. Verifying the Authenticity

What policies will be in place for verifying vendor authenticity? Select all that apply.

☐ All vendors must register with the State/Tribe.

☐ All vendors must supply a valid SSN or TIN/W-9 form

☐ Vendors are verified through water bills provided by the household

☐ Grantee and/or local agencies/district offices perform physical monitoring of vendors

☐ Other - Describe and note any exceptions to policies above:

12.8. Benefits Policy - Water and Wastewater Utilities

What policies will be in place to protect against fraud when making benefit payments to water utilities on behalf of clients? Select all that apply.

☐ Applicants required to submit proof of physical residency

☐ Applicants must submit current water or wastewater bill

☐ Data exchange with utilities that verifies:

☐ Account ownership

☐ Consumption

☐ Balances

☐ Payment history

☐ Account is properly credited with benefit

☐ Other - Describe:

☐ Centralized computer system/database tracks payments to all water suppliers

☐ Centralized computer system automatically generates benefit level

☐ Separation of duties between intake and payment approval

☐ Payments coordinated among other water and wastewater assistance programs to avoid duplication of payments

☐ Payments to water suppliers and invoices from water suppliers are reviewed for accuracy

☐ Computer databases are periodically reviewed to verify accuracy and timeliness of payments made to water suppliers

If yes, explain:

☐ Procedures are in place to require prompt refunds from utilities in cases of account closure

☐ Vendor agreements specify requirements selected above, and provide enforcement mechanism

☐ Other - Describe:

12.9. Investigations and Prosecutions

Identify the Grantee's procedures for investigating and prosecuting reports of fraud, and any sanctions placed on clients/staff/vendors found to have committed fraud. Select all that apply.

☐ Refer to State Inspector General

☐ Refer to local prosecutor or State Attorney General

☐ Refer to US DHHS Inspector General (including referral to OIG hotline)

☐ Local agencies/district offices or Grantee conduct investigation of fraud complaints from public

☐ Grantee attempts collection of improper payments. If so, describe the recoupment process

☐ Clients found to have committed fraud are banned from LIHWAP assistance. For how long is a household banned?

☐ Contracts with local agencies require that employees found to have committed fraud are reprimanded and/or terminated

☐ Vendors found to have committed fraud may no longer participate in LIHWAP

☐ Other - Describe:

If any of the above questions require further explanation or clarification that could not be made in the fields providedsaid explanation here.

Section 13: Certification Regarding Debarment, Suspension, and Other Responsibility Matters

Certification Regarding Debarment, Suspension, and Other Responsibility Matters--Primary Covered Transactions

Instructions for Certification

1. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below.

2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction.

3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.

4. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

5. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations.

6. The prospective primary participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency entering into this transaction.

7. The prospective primary participant further agrees by submitting this proposal that it will include the clause titled ``Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,''

provided by the department or agency entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

8. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs.

8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

8. Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.

Certification Regarding Debarment, Suspension, and Other Responsibility Matters--Primary Covered Transactions

1. The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:

1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency;

2. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false Statements, or receiving stolen property;

3. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and

4. Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default.

(2) Where the prospective primary participant is unable to certify to any of the Statements in this certification, such prospective participant shall attach an explanation to this proposal.

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Covered Transactions

Instructions for Certification

1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below.

2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

3. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or had become erroneous by reason of changed circumstances.

4. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations.

5. The prospective lower tier participant agrees by submitting this proposal that, [[Page 33043]] should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated.

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

7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transactions, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs.

8. Nothing contained in the foregoing shall be construed to require

establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

Certification Regarding Debarment, Suspension, Ineligibility an Voluntary Exclusion--Lower Tier Covered Transactions

1. The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

2. Where the prospective lower tier participant is unable to certify to any of the Statements in this certification, such prospective participant shall attach an explanation to this proposal.

☐ By checking this box, the prospective primary participant is providing the certification set out above.

Section 14: Certification Regarding Drug-Free Workplace Requirements

Section 14: Certification Regarding Drug-Free Workplace Requirements

This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988: 45 CFR Part 76, Subpart, F. Sections 76.630(c) and (d)(2) and 76.645(a)(1) and (b) provide that a Federal agency may designate a central receipt point for STATE-WIDE AND STATE AGENCY-WIDE certifications, and for notification of criminal drug convictions. For the Department of Health and Human Services, the central pint is: Division of Grants Management and Oversight, Office of Management and Acquisition, Department of Health and Human Services, Room 517-D, 200 Independence Avenue, SW Washington, DC 20201.

Certification Regarding Drug-Free Workplace Requirements (Instructions for Certification)

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

2. The certification set out below is a material representation of fact upon which reliance is placed when the agency awards the grant. If it is later determined that the grantee knowingly rendered a false certification, or otherwise violates the requirements of the Drug-Free Workplace Act, the agency, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act.

3. For grantees other than individuals, Alternate I applies.

4. For grantees who are individuals, Alternate II applies.

5. Workplaces under grants, for grantees other than individuals, need 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.

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

7. If the workplace identified to the agency changes during the performance of

the grant, the grantee shall inform the agency of the change(s), if it previously identified the workplaces in question (see paragraph five).

8. Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common rule apply to this certification. Grantees' attention is called, in particular, to the following definitions from these rules:

Controlled substance means a controlled substance in Schedules I through V of the Controlled Substances Act (21 U.S.C. 812) and as further defined by regulation (21 CFR 1308.11 through 1308.15);

Conviction means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or both, by any judicial body charged with the responsibility to determine violations of the Federal or State criminal drug statutes;

Criminal drug statute means a Federal or non-Federal criminal statute involving the manufacture, distribution, dispensing, use, or possession of any controlled substance;

Employee means the employee of a grantee directly engaged in the performance of work under a grant, including: (i) All direct charge employees; (ii) All indirect charge employees unless their impact or involvement is insignificant to the performance of the grant; and, (iii) Temporary personnel and consultants who are directly engaged in the performance of work under the grant and who are on the grantee's payroll. This definition does not include workers not on the payroll of the grantee (e.g., volunteers, even if used to meet a matching requirement; consultants or independent contractors not on the grantee's payroll; or employees of subrecipients or subcontractors in covered workplaces).

Certification Regarding Drug-Free Workplace Requirements Alternate I. (Grantees Other Than Individuals)

The grantee certifies that it will or will continue to provide a drug-free workplace by:,

1. 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;

2. Establishing an ongoing drug-free awareness program to inform employees about --

   1. The dangers of drug abuse in the workplace;

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

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

programs; and (4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; c) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the Statement required by paragraph (a); Notifying the employee in the Statement required by paragraph (a) that, as a condition of employment under the grant, the employee will -- Abide by the terms of the Statement; and Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction; Notifying the agency in writing, within ten calendar days after receiving notice under paragraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant activity the convicted employee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant; Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d)(2), with respect to any employee who is so convicted -(1) Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; (g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e) and (f). (B) The grantee may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant: Place of Performance (Street address, city, county, State, zip code)
* Address Line 1
Address Line 2
Address Line 3
* City	* State	* Zip Code
Check if there are workplaces on file that are not identified here. Alternate II. (Grantees Who Are Individuals) (a) The grantee certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant;
(b) If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant activity, he or she will report the conviction, in writing, within 10 calendar days of the conviction, to every grant officer or other designee, unless the Federal agency designates a central point for the receipt of such notices. When notice is made to such a central point, it shall include the identification number(s) of each affected grant. [55 FR 21690, 21702, May 25, 1990] ☐ By checking this box, the prospective primary participant is providing the certification set out above.

Section 15: Certification Regarding Lobbying

Section 15: Certification Regarding Lobbying

The submitter of this application certifies, to the best of his or her knowledge and belief, that:

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, ``Disclosure Form to Report Lobbying,'' in accordance with its instructions

3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Statement for Loan Guarantees and Loan Insurance

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

If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, ``Disclosure Form to Report Lobbying,'' in accordance with its instructions. Submission of this Statement is a prerequisite for making or

entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required Statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

☐ By checking this box, the prospective primary participant is providing the certification set out above.

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