Form 1 CSBG Model Tribal Plan

Tribal Plan 1.0
Tribal Plan and Application

OMB No.: ####-####
Expires: Month DD, YYYY

PUBLIC BURDEN STATEMENT
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): The purpose of this collection is to gather information about
planned activities related to and funded by CSBG for the upcoming fiscal year. Public reporting burden for this collection of
information is estimated to average 10 hours per grant recipient, including the time for reviewing instructions, gathering
and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information
(Sec. 676, Pub. L. 105-285, 112 Stat. 2735 (42 U.S.C. § 9908)). An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995,
unless it displays a currently valid OMB control number. The OMB # is XXX-XXXX and the expiration date is XX/XX/XXXX. If
you have any comments on this collection of information, please contact the Division of Community Assistance at
CSBGTribes@acf.hhs.gov.

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CSBG Tribal Plan Table of Contents
Standard Form (SF)-424M ........................................................................................................................................... 3
Section 1: CSBG Tribal Administrative Information .................................................................................................... 4
Section 2: Tribal Resolution and Recognition ............................................................................................................. 7
Section 3: CSBG Tribal Plan Goals and Objectives ...................................................................................................... 8
Section 4: CSBG Community-Based Feedback ............................................................................................................ 9
Section 5: Use of Funds and Fiscal Controls ............................................................................................................. 10
Section 6: Individual Eligibility and Targeted Community Eligibility ......................................................................... 12
Section 7: CSBG Statement of Assurances ................................................................................................................ 13
Section 8: Federal Certifications ............................................................................................................................... 16

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Standard Form (SF)-424M
All grant recipients must submit a SF-424M Form with their application materials electronically through
the Administration for Children and Families (ACF) On-Line Data Collection system (OLDC) available
through GrantSolutions.gov following SF-424-Instructions.pdf.

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Section 1: CSBG Tribal Administrative Information
Instructional Note:
Provide the following information in relation to the tribe or tribal organization designated to
administer CSBG as required in Sections 676 and 677 of the CSBG Act, the COATS Human Services
Reauthorization Act of 1998 (P.L.105-285), and relevant federal policy guidance. The following
information should mirror the information provided on the Application for Federal Assistance, SF424M.

1.1. Plan Coverage

Identify whether this is a one-year or two-year plan. (Note: CSBG Tribal Plans covering a two-year period are
strongly recommended to minimize administrative burden for grant recipients) [Radio Button]
☐
One Year
☐
Two-Year

1.1a. Provide the federal fiscal years covered by this plan
Year One ____

Year Two____

1.2. Tribal Grant Recipient Name

Update the following information for the Tribal Lead Agency. The information entered should reflect the
responses in the Application for Federal Assistance, SF-424M.

1.2.a. Name of tribe or tribal organization [Narrative, 50 characters]
1.2.b. If a tribe or tribal organization is representing more than one tribe, village, community, or
jurisdiction, please list the names of all tribes, villages, communities, and jurisdictions. [Narrative,
1000 characters]

1.3. Authorized Tribal Official

Provide the authorized official (e.g., chairperson, chief, president, governor, CEO) who is to receive the
CSBG grant award.
1.3.a. Authorized Tribal Official Name [Narrative, 50 characters]
1.3.b. Authorized Tribal Official Title [Narrative, 50 characters]

1.3.c. Street Address [Narrative, 200 characters]

1.3.d. City [Narrative, 50 characters]

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1.3.e. State [Dropdown]

1.3.f. Zip Code [Numerical Response, 5 digits]

1.3.g. Telephone [Numerical Response, 10-15 digits to include extensions]
1.3.h. Fax Number [Numerical Response, 10 digits]

1.3.i. Email Address [Narrative, 150 characters]

1.3.j. Website [Narrative, 200 characters]

1.4. Tribal CSBG Point of Contact
List the individual within the grant recipient organization with responsibility for managing the
Community Services Block Grant program and providing information about CSBG services and
activities.
1.4.a. Tribal CSBG Point of Contact Name [Narrative, 50 characters]

1.4.b. Point of Contact Title [Narrative, 50 characters]

1.4.c. Street Address [Narrative, 200 characters]

1.4.d. City [Narrative, 50 characters]
1.4.e. State [Dropdown]

1.4.f. Zip Code [Numerical Response, 5 digits]

1.4.g. Telephone [Numerical Response, 10-15 digits to include extensions]

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1.4.h. Fax [Numerical Response, 10 digits]

1.4.i. Email Address [Narrative, 150 characters]

1.5. Delegation of Authority

Is this tribe or tribal organization’s authorized tribal official (e.g., chairperson, president, governor, chief, CEO)
delegating signature authority to any other individual to sign assurances, certifications, and other required CSBG
documents on their behalf? [Radio Button]

1.5.a. ☐ No, authorized tribal official does not delegate authority to another individual. (If
signature authority is not being delegated, proceed to Section 2.)
☐ Yes, authorized tribal official does delegate authority to another individual. (If yes,
complete 1.5.c)
1.5.b. Additional Authorized Official
1.5.b.i. Name of Additional Authorized Official [Narrative, 50 characters]

1.5.b.ii. Title of Additional Authorized Official [Narrative, 50 characters]
1.5.b.iii. Telephone Number of Additional Authorized Official [Numerical Response, 10-15 digits to
include extensions]
1.5.b.iv. Email of Additional Authorized Official [Narrative, 150 characters]

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Section 2: Tribal Resolution and Recognition
2.1. Is the applicant representing more than one tribe? [Radio Button]
☐ No, the applicant does not represent more than one tribe.
☐ Yes, the applicant represents more than one tribe and will attach copies of the tribal
resolutions granting authority to receive CSBG funds.

2.2. Federal or State Recognition
2.2.a. Do all tribes, villages, communities, and jurisdictions served by the grant recipient have
state or federal recognition? [Radio Button]
☐ Yes (if yes, please provide information requested on item 2.2.b)
☐ No (if no, please explain in the box below)
2.2.b. State Recognition: if your tribes hold state recognition, provide a citation to the state
statute or code acknowledging state recognition. [Narrative, 500 characters]

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Section 3: CSBG Tribal Plan Goals and Objectives
3.1. CSBG Goals, Objectives, and Strategies:

The CSBG-specific goals and objectives for the proposed CSBG funding within the tribe or tribal organization
address the following:

-

Assisting families and individuals with low income in:
o Removing obstacles that block the achievement of self-sufficiency.
o Securing and retaining meaningful employment.
o Attaining adequate literacy and education.
o Making better use of available income.
o Obtaining and maintaining adequate housing.
o Obtaining emergency assistance.
o Achieving greater participation in the affairs of the communities.
o Supporting youth development in communities with low income.
o Coordinating with other programs related to the purposes of the CSBG Act.
o Linkages to fill service gaps.

Briefly describe the tribe or tribal organization’s CSBG-specific goals and objectives for the Community
Services Block Grant funding, as applicable. [Narrative, 5000 characters]

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Section 4: CSBG Community-Based Feedback
4.1. Community-Based Feedback:
4.1.a. Did the tribe or tribal organization solicit feedback from tribal members served that
demonstrates evidence of public participation? [Radio Button]
☐ Yes ☐ No
4.1.b. If yes, please describe how feedback was solicited. [Narrative, 5000 characters]

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Section 5: Use of Funds and Fiscal Controls
5.1. Planned CSBG Allocation Funds:

According to the CSBG Act, no more than 5% may be allocated to administrative items, and not less than 95% can
be allocated to program funds. For program funds, please specify the percentage of funds that will be allocated
for each of the CSBG core service delivery areas. The total of all percentages should add up to 100%.

Note: If this is a two-year plan, please provide the planned allocation for both years.
Year 1

Year 2

% of CSBG
Funding

% of CSBG
Funding

Administrative
Funds
(Not more than 5%)
CSBG Program Funds for Core Services
(Not less than 95%)
Employment
Childcare, Early Childhood, Youth
Development, and Adult Education
Income and Asset Building
Housing
Health and Nutrition
Civic Engagement and Community
Involvement
Transportation
Partnership, Linkages, and Service
Coordination
Other (e.g.: emergency assistance,
management, and disaster relief)
Total

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5.2. Limitation on the Use of Funds:

The tribe or tribal organization acknowledges and assures that they will comply with the CSBG limitations
outlined in Section 678F of the CSBG Act as follows: [Radio Button]

☐ Funds will not be used for the purchase or improvement of land, or the purchase,
construction, or permanent improvement (other than low-cost residential weatherization or
other energy-related home repairs) of any building or other facility without an approved federal
waiver. (View instructions in Section 678F of the CSBG Act for information on waivers.)

5.3. Single Audit Review:

Provide the date and the period (timeframe) that the most recent audit covers, if applicable.
Date
Enter a date (mm/dd/yyyy)

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Section 6: Individual Eligibility and Targeted Community Eligibility
6.1. Individual Eligibility:

Describe policies and procedures for determining eligibility for individual services, including policies and
procedures when individual income verification is not possible or practical. [Narrative, 5000 characters]

6.2. Targeted Community Eligibility:

For those services that provide a community-wide benefit, describe how the tribe or tribal organization
ensures that services target and benefit communities with low income. [Narrative, 5000 characters]

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Section 7: CSBG Statement of Assurances
Community Services Block Grant Assurances
Community Services Block Grant Reauthorization Act of 1998: P.L. 105-285g
Review all sections of the CSBG Assurances (summarized below and detailed in Section 676 of the
Community Services Block Grant Reauthorization Act of 1998: P.L. 105-285). To affirm, enter the
authorized tribal official’s signature on “7.1.c. Authorized Tribal Official Signature.”

Statement of CSBG Assurances
As a part of the annual or biannual application and plan required by subsection 676 of Community
Services Block Grant Act, as amended, (412 U.S. C.9901 et seq.) (The Act), the designee of the Chief
Executive of the State hereby agrees to the Assurances in Section 676 of the Act (summarized below
and detailed in Section 676 of the CSBG Act) —

Programmatic Assurances
(1) An assurance that funds made available through the grant or allotment will be used for at least
one of the following purposes [per 676(b)1] —
a. To support activities that are designed to assist low-income families and individuals,
including families and individuals receiving assistance under Title IV of the Social Security
Act, homeless families and individuals, migrant or seasonal farmworkers, and elderly
low-income individuals and families, and a description of how such activities will enable
the families and individuals:
i. To remove obstacles and solve problems that block the achievement of selfsufficiency (particularly for families and individuals who are attempting to
transition off a State program carried out under part A of Title IV of the Social
Security Act);
ii. To secure and retain meaningful employment;
iii. To attain an adequate education with particular attention toward improving
literacy skills of the low-income families in the community, which may include
family literacy initiatives;
iv. To make better use of available income;
v. To obtain and maintain adequate housing and a suitable living environment;
vi. To obtain emergency assistance through loans, grants, or other means to meet
immediate and urgent individual and family needs;
vii. To achieve greater participation in the affairs of the communities involved to:
(a) Document best practices based on successful community engagement;
and
(b) Strengthen and improve relationships across tribal communities and tribal
government
b. To address the needs of youth in low-income communities through youth development
programs that support the primary role of the family, give priority to the prevention of
youth problems and crime, and promote increased community coordination and
collaboration in meeting the needs of youth, and support development and expansion of
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innovative community-based youth development programs that have demonstrated
success in preventing or reducing youth crime, such as:
i. Programs for the establishment of violent-free zones that would involve youth
development and intervention models (such as models involving youth
mediation, youth mentoring, life skills training, job creation, and
entrepreneurship programs);
ii. After-school childcare programs
c. To make more effective use of, and to coordinate with, other programs related to the
purposes of this subtitle
(2) An assurance that information provided by the tribe or tribal organization will contain the
following [per 676(b)3] —
a. A description of the service delivery system, for services provided or coordinated with
funds made available through grants made under section 675C(a), targeted to lowincome individuals and families in communities within the tribe;
b. A description of how linkages will be developed to fill identified gaps in the services,
through the provision of information, referrals, case management, and follow-up
consultations;
c. A description of how funds made available through grants made under section 675C(a)
will be coordinated with other public and private sources;
d. A description of how the tribe or tribal organization will use the funds to support
innovative initiatives, which may include fatherhood initiatives and other initiatives with
the goals of strengthening families and encouraging effective parenting
(3) An assurance that the tribe or tribal organization will involve low-income individuals and
families in assessing community needs and developing action plans [per 676(b)(9)]
(4) An assurance that the tribe or tribal organization establish clear goals and objectives for the use
of CSBG funds [per 672]
(5) An assurance that the tribe or tribal organization will permit and cooperate with federal
investigations undertaken in accordance with section 678D [per 676(b)7]
(6) An assurance that the tribe or tribal organization will participate in the performance
measurement system, e.g., Results Oriented Management Accountability (ROMA) System or
another performance measure system, for which the Secretary facilitated development
pursuant to section 678E(b), or an alternative system for measuring performance and results
that meets the requirements of that section, and a description of outcome measures to be used
to measure performance in promoting self-sufficiency, family stability, and community
revitalization [per 678E]
(7) An assurance by the tribe or tribal organization that no person shall, on the basis of race, color,
national origin, sex, age, or disability be excluded from participation in, be denied the benefits
of, or be subjected to discrimination under, any program or activity funded in whole or in part
with funds made available [per 678F(c)]

Administrative and Financial Assurances
The tribe or tribal organization further agrees to the following administrative assurances, as required
under the Community Services Block Grant Act —
(1) An assurance that the tribe or tribal organization submit their own plan to the Secretary that
meet prescribed criteria (Sec. 677(d))
(2) An assurance to expend for administrative expenses an amount not to exceed the greater of 5%
of its allotment or the percentage represented by the ratio of $55,000 to the smallest state
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allotment for the fiscal year [per 675(C)(b)(2)]
(3) An assurance that the tribe or tribal organization agrees to provide that fiscal control and fund
accounting procedures will be established as may be necessary to assure the proper disbursal of
the accounting for federal funds paid to the tribe or tribal organization under this subtitle,
including monitoring the assistance [per 678D(a)(1)(A)]
(4) An assurance that if the tribe or tribal organization expends $750,000 or more (during the fiscal
year) in all types of federal financial assistance it must conduct an audit in accordance with the
Single Audit Act, P.L. 98-502 (3) U.S.C 75 and OMB Circular A-133 Subpart B) [per 678D(2)(B)]
(5) An assurance by the tribe or tribal organization that any funding termination or reduction is
based on specified causes and after providing notice and an opportunity for a hearing [per
676(c)]
(6) An assurance that the tribe or tribal organization submit an annual report on performance and
expenditure of funds [per 678E(a)(2)]
(7) An assurance that the tribe or tribal organization conduct reviews and take corrective actions as
necessary to ensure compliance with standards [per 678B, 678C]
(8) An assurance that the tribe or tribal organization will provide technical and training assistance
to sub-recipients in need [per 678C]

Other Administrative Certifications
The Tribe or Tribal Organization also certifies the following —
(1) To provide assurances that cost and accounting standards of the Office of Management and
Budget shall apply to a recipient of Community Services Block Grant program funds [per
678D(a)(1)(B), as well as 2 CFR 200, Uniform Administrative Requirements and 45 CFR 75]

7.1. Authorized Tribal Official Signature
I hereby affirm that the tribe or tribal organization will ensure compliance with the certification above.
7.1.a Name of Tribe or Tribal Organization [Narrative, 50 characters]

7.1.b Authorized Tribal Official Name [Narrative, 50 characters]

7.1.c Authorized Tribal Official Signature [Signature]

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Section 8: Federal Certifications
Federal Certifications:

Below are each of the four required federal certifications. At the end of each certification, provide the authorized
tribal official’s signature to affirm compliance with the certifications, if required.

8.1. Certification Regarding Lobbying
Certification for Contracts, Grants, Loans, and Cooperative Agreements –
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or employee of
an agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with the awarding of any federal contract, the making of any
federal grant, the making of any federal loan, the entering into of any cooperative agreement,
and the extension, continuation, renewal, amendment, or modification of any federal contract,
grant, loan, or cooperative agreement.
(2) If any funds other than federal appropriated funds have been paid or will be paid to any person
for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress or an employee of a Member of Congress in
connection with this federal contract, grant, loan, or cooperative agreement, the undersigned
shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in
accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly. This certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this certification is a
prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S.
Code. Any person who fails to file the required certification shall be subject to a civil penalty of
not less than $10,000 and not more than $100,000 for each such failure.

Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that: If any funds have been
paid or will be paid to any person for influencing or attempting to influence an officer or employee of
any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member
of Congress in connection with this commitment providing for the United States to insure or guarantee
a loan, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report
Lobbying,” in accordance with its instructions. Submission of this statement is a prerequisite for making
or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to
file the required statement shall be subject to a civil penalty of not less than $10,000 and not more
than $100,000 for each such failure.
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8.1.a Authorized Tribal Official Signature
I hereby affirm that the tribe or tribal organization will ensure compliance with the certification
above.
8.1.a.i Name of Tribe or Tribal Organization [Narrative, 50 characters]
8.1.a.ii Authorized Tribal Official Name [Narrative, 50 characters]
8.1.a.iii Authorized Tribal Official Signature [Signature]

8.2. 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 point is: Division of Grants Management and Oversight, Office of Management and Acquisition,
Department of Health and Human Services, Room 517-D, 200 Independence Avenue, SW Washington,
DC 20201.
Instructions for Certifications:
(1) By signing or submitting this application or grant agreement, the grant recipient 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 grant recipient 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 grant recipients other than individuals, Alternate I applies.
(4) For grant recipients who are individuals, Alternate II applies.
(5) Workplaces under grants, for grant recipients other than individuals, need to be identified on
the certification. If known, they may be identified in the grant application. If the grant recipient
does not identify the workplaces at the time of application, or upon award, if there is no
application, the grant recipient 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 grant recipient’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).
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(7) If the workplace identified to the agency changes during the performance of the grant, the grant
recipient 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. Grant recipients 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 grant recipient 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 grant recipient’s payroll. This definition does not include workers not
on the payroll of the grant recipient (e.g., volunteers, even if used to meet a matching
requirement; consultants or independent contractors not on the grant recipient’s payroll; or
employees of subrecipients or subcontractors in covered workplaces).
Certification Regarding Drug-Free Workplace Requirements
Alternate I. (Grant Recipients Other Than Individuals)
The grant recipient certifies that it will or will continue to provide a drug-free workplace by:
(a) Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the grant recipient’s
workplace and specifying the actions that will be taken against employees for violation of such
prohibition
(b) Establishing an ongoing drug-free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace
(2) The grant recipient’s policy of maintaining a drug-free workplace
(3) Any available drug counseling, rehabilitation, and employee assistance programs
(4) The penalties that may be imposed upon employees for drug abuse violations occurring
in the workplace
(c) Making it a requirement that each employee to be engaged in the performance of the grant be
given a copy of the statement required by paragraph (a)
(d) Notifying the employee in the statement required by paragraph (a) that, as a condition of
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employment under the grant, the employee will:
(1) Abide by the terms of the statement
(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug
statute occurring in the workplace no later than five calendar days after such conviction
(e) Notifying the agency in writing, within 10 calendar days after receiving notice under paragraph
(d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of
convicted employees must provide notice, including position title, to every grant officer or other
designee on whose grant activity the convicted employee was working, unless the federal
agency has designated a central point for the receipt of such notices. Notice shall include the
identification number(s) of each affected grant.
(f) Taking one of the following actions, within 30 calendar days of receiving notice under paragraph
(d)(2), with respect to any employee who is so convicted:
(1) Taking appropriate personnel action against such an employee, up to and including
termination, consistent with the requirements of the Rehabilitation Act of 1973, as
amended; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a federal, state, or local health,
law enforcement, or other appropriate agency
(g) Making a good faith effort to continue to maintain a drug-free workplace through
implementation of paragraphs (a), (b), (c), (d), (e) and (f)
The grant recipient may insert in the space provided below the site(s) for the performance of work
done in connection with the specific grant:
8.2.a. Place of Performance (street, city, county, state, zip code) [Narrative, 100 characters]

Check if there are workplaces on file that are not identified here. Alternate II. (Grant recipients
Who Are Individuals)
(a) The grant recipient 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]

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8.2.b. Authorized Tribal Official Signature
I hereby affirm that the tribe or tribal organization will ensure compliance with the certification
above.
8.2.b.i. Name of Tribe or Tribal Organization [Narrative, 50 characters]
8.2.b.ii. Authorized Tribal Official Name [Narrative, 50 characters]
8.2.b.iii. Authorized Tribal Official Signature [Signature]

8.3. 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

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proposed covered transaction be entered into, it shall not knowingly enter into any lower tier
covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart
9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this
covered transaction, unless authorized by the department or agency entering into this
transaction.
(7) The prospective primary participant further agrees by submitting this proposal that it will
include the clause titled “Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusive-Lower Tier Covered Transaction,” provided by the department or agency
entering into this covered transaction, without modification, in all lower tier covered
transactions and in all solicitations for lower tier covered transactions.
(8) A participant in a covered transaction may rely upon a certification of a prospective participant
in a lower tier covered transaction that is not proposed for debarment under 48 CFR part 9,
subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from the covered
transaction, unless it knows that the certification is erroneous. A participant may decide the
method and frequency by which it determines the eligibility of its principals. Each participant
may, but is not required to, check the List of Parties Excluded from Federal Procurement and
Nonprocurement Programs.
(9) Nothing contained in the foregoing shall be construed to require establishment of a system of
records in order to render in good faith the certification required by this clause. The knowledge
and information of a participant is not required to exceed that which is normally possessed by a
prudent person in the ordinary course of business dealings.
(10) Except for transactions authorized under paragraph 6 of these instructions, if a participant in a
covered transaction knowingly enters into a lower tier covered transaction with a person who is
proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or
voluntarily excluded from participation in this transaction, in addition to other remedies
available to the federal government, the department or agency may terminate this transaction
for cause or default.
************
Certification Regarding Debarment, Suspension, and Other Responsibility Matters – Primary Covered
Transactions
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and
its principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded by any federal department or agency.
(b) Have not within a three-year period preceding this proposal been convicted of or had
a civil judgment rendered against them for commission of fraud or a criminal offense
in connection with obtaining, attempting to obtain, or performing a public (federal,
state or local) transaction or contract under a public transaction; violation of federal
or state antitrust statutes or commission of embezzlement, theft, forgery, bribery,
falsification or destruction of records, making false statements, or receiving stolen
property.
(c) Are not presently indicted for or otherwise criminally or civilly charged by a
governmental entity (federal, state or local) with commission of any of the offenses
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enumerated in paragraph (1)(b) of this certification.
(d) Have not within a three-year period preceding this application/proposal had one or
more public transactions (federal, state or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.
Certification Regarding Debarment, Suspension, and Other Responsibility Matters – 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 or debarment,
or both.
(3) The prospective lower tier participant shall provide immediate written notice to the person
to which this proposal is submitted if at any time the prospective lower tier participant
learns that its certification was erroneous when submitted or had become erroneous by
reason of changed circumstances.
(4) The terms covered transaction, debarred, suspended, ineligible, lower tier covered
transaction, participant, person, primary covered transaction, principal, proposal, and
voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and
Coverage sections of rules implementing Executive Order 12549. You may contact the
person to which this proposal is submitted for assistance in obtaining a copy of those
regulations.
(5) The prospective lower tier participant agrees by submitting this proposal that, should the
proposed covered transaction be entered into, it shall not knowingly enter into any lower
tier covered transaction with a person who is proposed for debarment under 48 CFR part 9,
subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by the department or agency
with which this transaction originated.
(6) The prospective lower tier participant further agrees by submitting this proposal that it will
include this clause titled “Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion-Lower Tier Covered Transaction,” without modification, in all lower tier
covered transactions and in all solicitations for lower tier covered transactions.
(7) A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that it is not proposed for debarment under
48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from
covered transactions, unless it knows that the certification is erroneous. A participant may
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decide the method and frequency by which it determines the eligibility of its principals. Each
participant may, but is not required to, check the List of Parties Excluded from Federal
Procurement and Nonprocurement Programs.
(8) Nothing contained in the foregoing shall be construed to require establishment of a system
of records in order to render in good faith the certification required by this clause. The
knowledge and information of a participant is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.
(9) Except for transactions authorized under paragraph five of these instructions, if a participant
in a covered transaction knowingly enters into a lower tier covered transaction with a
person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended,
debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition
to other remedies available to the federal government, the department or agency with
which this transaction originated may pursue available remedies, including suspension or
debarment, or both.
************
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion – Lower Tier
Covered Transactions
(1) The prospective lower tier participant certifies, by submission of this proposal, that
neither it nor its principals is presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from participation in this transaction by any
Federal department or agency.
(2) Where the prospective lower tier participant is unable to certify to any of the statements
in this certification, such prospective participant shall attach an explanation to this
proposal.
8.3.a. Authorized Tribal Official Signature
I hereby affirm that the tribe or tribal organization will ensure compliance with the certification
above.
8.3.a.i. Name of Tribe or Tribal Organization [Narrative, 50 characters]
8.3.a.ii. Authorized Tribal Official Name [Narrative, 50 characters]
8.3.a.iii. Authorized Tribal Official Signature [Signature]

8.4. Certificate Regarding Environmental Tobacco Smoke
Public Law 103227, Part C Environmental Tobacco Smoke, also known as the Pro Children Act of 1994,
requires that smoking not be permitted in any portion of any indoor routinely owned or leased or
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contracted for by an entity and used routinely or regularly for provision of health, day care, education,
or library services to children under the age of 18, if the services are funded by federal programs either
directly or through state or local governments, by federal grant, contract, loan, or loan guarantee. The
law does not apply to children’s services provided in private residences, facilities funded solely by
Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment.
Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty
of up to $1000 per day or the imposition of an administrative compliance order on the responsible
entity, or both. By signing and submitting this application the applicant or grant recipient certifies that
it will comply with the requirements of the Act. The applicant or grant recipient further agrees that it
will require the language of this certification be included in any subawards which contain provisions for
the children’s services and that all subgrant recipients shall certify accordingly.
8.4.a. Authorized Tribal Official Signature
I hereby affirm that the tribe or tribal organization will ensure compliance with the certification
above.
8.4.a.i. Name of Tribe or Tribal Organization [Narrative, 50 characters]
8.4.a.ii. Authorized Tribal Official Name [Narrative, 50 characters]
8.4.a.iii. Authorized Tribal Official Signature [Signature]

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