Model State Plan

We are providing a Microsoft Word version of the revised draft Model State Plan (MSP) for CSBG state agencies to use for planning and development of their FY 2016 State plan. While OMB may require further adjustments to the MSP after they have finalized their review (currently undergoing), this document is the final clearance version.

Community Services Block Grant (CSBG) Model State Plan

Table of Contents

Mandatory Grant Application SF-424

Section 1: CSBG Lead Agency, CSBG Authorized Official, CSBG Point of Contact, and Official State Designation Letter

Section 2: State Legislation and Regulation

Section 3: State Plan Development and Statewide Goals

Section 4: CSBG Hearing Requirements

Section 5: CSBG Eligible Entities

Section 6: Organizational Standards for Eligible Entities

Section 7: State Use of Funds

Section 8: State Training and Technical Assistance

Section 9: State Linkages and Communication

Section 10: Monitoring, Corrective Action, and Fiscal Controls

Section 11: Eligible Entity Tripartite Board

Section 12: Individual and Community Income Eligibility Requirements

Section 13: Results Oriented Management and Accountability (ROMA) System

Section 14: CSBG Programmatic Assurances and Information Narrative

Section 15: Federal Certifications

SECTION 1
CSBG Lead Agency, CSBG Authorized Official, CSBG Point of Contact, and Official State Designation Letter

1. Provide the following information in relation to the lead agency designated to administer CSBG in the State, as required by Section 676(a) of the CSBG Act. The following information should mirror the information provided on the Application for Federal Assistance, SF-424M.

1.1a. Lead agency [Narrative, 2500 Characters]

1.1b. Cabinet or administrative department of this lead agency [Check One and narrative where applicable]

• Community Services Department

• Human Services Department

• Social Services Department

• Governor’s Office

• Community Affairs Department

• Other, describe: ­­­­­­­­­­­­­­­­­­­­­­­­[Narrative, 2500 characters]

1.1c. Division, bureau, or office of the CSBG authorized official [Narrative, 2500 Characters]

1.1d. Authorized official of the lead agency [Narrative, 2500 Characters]

Instructional note: The authorized official could be the director, secretary, commissioner etc. as assigned in the designation letter (attached under item 1.3). The authorized official is the person indicated as authorized representative on the SF-424M.

1.1e. Street address [Narrative, 2500 characters]

1.1f. City [Narrative, 2500 characters]

1.1g. State [Dropdown]

1.1h. Zip [Narrative, 5 characters]

1.1i. Telephone number and extension [Narrative, 10 – 15 characters which includes option for 5 digit extension]

1.1j. Fax number [Narrative, 10 characters]

1.1k. Email address [Narrative, 2500 characters]

1.1l. Lead agency website [Narrative, 2500 characters]

2. Provide the following information in relation to the designated State CSBG point of contact.

Instructional Note: The State CSBG point of contact should be the person that will be the main point of contact for CSBG within the State.

1.2a. Agency name [Narrative, 2500 characters]

1.2b. Name of the point of contact [Narrative, 2500 characters]

1.2c. Street address [Narrative, 2500 characters]

1.2d. City [Narrative, 2500 characters]

1.2e. State [Dropdown]

1.2f. Zip [Narrative, 5 characters]

1.2g. Point of contact telephone number [Narrative, 10 – 15 characters which includes option for entering up to 5 digit extension]

1.2h. Fax number [Narrative, 10 characters]

1.2i. Point of contact email address [Narrative, 2500 characters]

1.2j. Point of contact agency website [Narrative, 2500 characters]

3. Designation Letter: Attach the State’s official CSBG designation letter. If either the governor or designated agency has changed, update the letter accordingly. [Attach a document]

Instructional Note: The letter should be from the chief executive officer of the State and include, at minimum, the designated State CSBG lead agency and title of the authorized official of the lead agency who is to administer the CSBG grant award.

SECTION 2

State Legislation and Regulation

2.1. CSBG State Legislation: Does the State have a statute authorizing CSBG?  Yes  No

2.2. CSBG State Regulation: Does the State have regulations for CSBG?  Yes  No

2.3. If yes was selected in item 2.1 or 2.2, attach a copy (or copies) of legislation and/or regulations or provide a hyperlink(s), as appropriate. [Attach a document and/or provide a link]

2.4. State Authority: Select a response for each question about the State statute and/or regulations authorizing CSBG:

2.4a. Did the State legislature enact authorizing legislation, or amendments to an existing authorizing statute, last year?  Yes  No

2.4b. Did the State establish or amend regulations for CSBG last year?  Yes  No

2.4c. Does the State statutory or regulatory authority designate the bureau, division, or office in the State government that is to be the State administering agency?  Yes  No

SECTION 3
State Plan Development and Statewide Goals

3.1. CSBG Lead Agency Mission and Responsibilities: Briefly describe the mission and responsibilities of the State agency that serves as the CSBG lead agency. [Narrative, 2500 characters]

3.2. State Plan Goals: Describe the State’s CSBG-specific goals for State administration of CSBG under this State Plan. [Narrative, 2500 characters]

Instructional Note: For examples of “goals,” see State Accountability Measure 1Sa(i).

Note: This information is associated with State Accountability Measure 1Sa(i) and may pre-populate the State’s annual report form.

3.3. State Plan Development: Indicate the information and input the State accessed to develop this State Plan.

3.3a. Analysis of [Check all that applies and narrative where applicable]

• State Performance Indicators and/or National Performance Indicators (NPIs)

• U.S. Census data

• State performance management data (e.g., accountability measures, ACSI survey information, and/or other information from annual reports)

• Other data (describe) [Narrative, 2500 characters]

• Eligible entity community needs assessments

• Eligible entity plans

• Other information from eligible entities, e.g., State required reports (describe) [Narrative, 2500 characters]

3.3b. Consultation with [Check all that applies and narrative where applicable]

• Eligible entities (e.g., meetings, conferences, webinars; not including the public hearing)

• State community action association and regional CSBG T & TA providers

• State partners and/or stakeholders (describe)­­­­­­­­­­­­­­­­­­­­­­­­­­­ [Narrative, 2500 characters]

• National organizations (describe)­­­­­­­­­­­­­­­­­­­­­­­­­­­ [Narrative, 2500 characters]

• Other (describe) [Narrative, 2500 characters]

3.4. Eligible Entity Involvement

3.4a. Describe the specific steps the State took in developing the State Plan to involve the eligible entities. [Narrative, 2500 Characters]

Note: This information is associated with State Accountability Measures 1Sa(ii) and may pre-populate the State’s annual report form.

If this is the first year filling out the automated State Plan, skip the following question.

3.4b.    Performance Management Adjustment: How has the State adjusted State Plan development procedures under this State Plan, as compared to past plans, in order 1) to encourage eligible entity participation and 2) to ensure the State Plan reflects input from eligible entities? Any adjustment should be based on the State’s analysis of past performance in these areas, and should consider feedback from eligible entities, OCS, and other sources, such as the public hearing. If the State is not making any adjustments, provide further detail.  [Narrative, 2500 Characters]

Note: This information is associated with State Accountability Measures 1Sb(i) and (ii) and may pre-populate the State’s annual report form.

If this is the first year filling out the automated State Plan, skip the following question.

3.5. Eligible Entity Overall Satisfaction: Provide the State’s target for eligible entity Overall Satisfaction during the performance period: ___. [Numerical, 3 digits]

Instructional Note: The State’s target score will indicate improvement or maintenance of the States’ Overall Satisfaction score from the most recent American Customer Survey Index (ACSI) survey of the State’s eligible entities. (See information about the ACSI in the CSBG State Accountability Measures document.)

Note: Item 3.5 is associated with State Accountability Measure 8S and may pre-populate the State’s annual report form.

SECTION 4
CSBG Hearing Requirements

4.1. Public Inspection: Describe how the State made this State Plan, or revision(s) to the State Plan, available for public inspection, as required under Section 676(e)(2) of the Act. [Narrative, 2500 Characters]

4.2. Public Notice/Hearing: Describe how the State ensured there was sufficient time and statewide distribution of notice of the public hearing(s) to allow the public to comment on the State Plan, as required under 676(a)(2)(B) of the CSBG Act. [Narrative, 2500 Characters]

4.3. Public and Legislative Hearings: Specify the date(s) and location(s) of the public and legislative hearing(s) held by the designated lead agency for this State Plan, as required under Section 676(a)(2)(B) and Section 676(a)(3) of the Act. (If the State has not held a public hearing in the prior fiscal year and/or a legislative hearing in the last three years, provide further detail).

Instructional Note: The date(s) for the public hearing(s) must have occurred in the year prior to the first Federal fiscal year covered by this plan. Legislative hearings are held at least every three years, and must have occurred within the last three years prior to the first Federal fiscal year covered by this plan.

Date	Location	Type of Hearing [Select an option]
[Select a date]	[Narrative, Insert Address]	Public Legislative Combined
ADD a ROW function Note: rows will be able to be added for each additional hearing

4.4. Attach supporting documentation or a hyperlink for the public and legislative hearings. [Attach a document or provide a hyperlink.]

SECTION 5
CSBG Eligible Entities

5.1. CSBG Eligible Entities: In the table below, list each eligible entity in the State, and indicate public or private, the type(s) of entity, and the geographical area served by the entity. (This table should include every CSBG Eligible Entity to which the State plans to allocate 90 percent funds, as indicated in the table in item 7.2. Do not include entities that only receive remainder/discretionary funds from the State or tribes/tribal organizations that receive direct funding from OCS under Section 677 of the CSBG Act.)

CSBG Eligible Entity	Public or Nonprofit	Type of Entity (choose all that apply)	Geographical Area Served by county (Provide all counties)	Brief Description of “Other”
[Narrative, 2500 characters]	[Select Public or Nonprofit]	Community Action Agency Limited Purpose Agency Local Government Agency Migrant or Seasonal Farmworker Organization Tribe or Tribal Organization Other (describe in column 5)	[Narrative, 2500 characters]	[Narrative, 2500 characters] If “Other” is selected in column 3, provide further detail here
ADD A ROW function Note: rows will be able to be added for each eligible entity funded in the State

5.2. Total number of CSBG eligible entities: __##__ [This will automatically update based on chart in 5.1]

5.3. Changes to Eligible Entities List: Has the list of eligible entities under item 5.1 changed since the State’s last State Plan submission? If yes, briefly describe the changes.  Yes  No [If yes is selected – Narrative, 2500 characters]

Instructional Note: Limited Purpose Agency refers to an eligible entity that was designated as a limited purpose agency under title II of the Economic Opportunity Act of 1964 for fiscal year 1981, that served the general purposes of a community action agency under title II of the Economic Opportunity Act, that did not lose its designation as a limited purpose agency under title II of the Economic Opportunity Act as a result of failure to comply with that Act and that has not lost its designation as an eligible entity under the CSBG Act.

Instructional Note: 90 percent funds are the funds a State provides to eligible entities to carry out the purposes of the CSBG Act, as described under Section 675C of the CSBG Act.  A State must provide “no less than 90 percent” of their CSBG allocation, under Section 675B, to the eligible entities.

SECTION 6
Organizational Standards for Eligible Entities

Note: Reference IM 138, State Establishment of Organizational Standards for CSBG Eligible Entities, for more information on Organizational Standards. Click HERE for IM 138.

6.1. Choice of Standards: Check the box that applies. If using alternative standards, a) attach the complete list of alternative organizational standards, b) describe the reasons for using alternative standards, and c) describe how the standards are at least as rigorous as the COE-developed standards.

• The State will use the CSBG Organizational Standards Center of Excellence (COE) organizational standards (as described in IM 138)

• The State will use an alternative set of organizational standards [Attach supporting documentation if this option is selected]

6.2. If the State is using the COE-developed organizational standards, does the State propose making a minor modification to the standards, as described in IM 138?  Yes  No

6.2a. If yes was selected in item 6.2, describe the State’s proposed minor modification to the COE-developed organizational standards, and provide a rationale. [Narrative, 2500 characters]

6.3. How will/has the State officially adopt(ed) organizational standards for eligible entities in the State in a manner consistent with the State’s administrative procedures act? If “Other” is selected, provide a timeline and additional information, as necessary. [Check all that applies and narrative where applicable]

• Regulation

• Policy

• Contracts with eligible entities

• Other, describe:­­­­­­­­­­­­­­­­­­­­­ [Narrative, 2500 characters]

6.4. How will the State assess eligible entities against organizational standards, as described in IM 138? [Check all that applies]

• Peer-to-peer review (with validation by the State or State-authorized third party)

• Self-assessment (with validation by the State or State-authorized third party)

• Self-assessment/peer review with State risk analysis

• State-authorized third party validation

• Regular, on-site CSBG monitoring

• Other

6.4a. Describe the assessment process. [Narrative, 2500 characters]

6.5. Will the State make exceptions in applying the organizational standards for any eligible entities due to special circumstances or organizational characteristics, as described in IM 138?

 Yes  No

6.5a. If yes was selected in item 6.5, list the specific eligible entities the State will exempt from meeting organizational standards, and provide a description and a justification for each exemption. [Narrative, 2500 characters or attach document]

If this is the first year filling out the automated State Plan, skip the following question.

6.6. Performance Target: What percentage of eligible entities in the State does the State expect will meet all the State-adopted organizational standards in the next year? [Insert a percentage]

Note: This information is associated with State Accountability Measures 6Sa and may pre-populate the State’s annual report form.

SECTION 7

State Use of Funds

Eligible Entity Allocation (90 Percent Funds) [Section 675C(a) of the CSBG Act]

7.1 Formula: Select the method (formula) that best describes the current practice for allocating CSBG funds to eligible entities. [Check one and narrative where applicable]

• Historic

• Base + Formula

• Formula Alone

• Formula with Variables

• Hold Harmless + Formula

• Other [Narrative, 2500 Characters]

7.1a. Does the State statutory or regulatory authority specify the terms or formula for allocating the 90 percent funds among eligible entities?  Yes  No

7.2. Planned Allocation: Specify the planned allocation of 90 percent funds to eligible entities, as described under Section 675C(a) of the CSBG Act.  The estimated allocations may be in dollars or percentages. For each eligible entity receiving funds, provide the Funding Amount in either dollars (columns 2 and 4) or percentage (columns 3 and 5) for the fiscal years covered by this plan.

Planned CSBG 90 Percent Funds
CSBG Eligible Entity	Year One			Year Two
	Funding Amount $	Funding Amount %	Funding Amount $		Funding Amount %
Will be auto-populated from Section 5, Table 5.1, Column 1	Enter either the dollar amount or percentage for each eligible entity for the first year that this plan covers			Enter either the dollar amount or percentage for each eligible entity for the second year that this plan covers (If this is a one-year plan, these columns can be left blank)
Total	Totals will be auto-populated			Totals will be auto-populated

7.3. Distribution Process: Describe the specific steps in the State’s process for distributing 90 percent funds to the eligible entities and include the number of days each step is expected to take; include information about State legislative approval or other types of administrative approval (such as approval by a board or commission). [Narrative, 2500 Characters]

7.4. Distribution Timeframe: Does the State plan to make funds available to eligible entities no later than 30 calendar days after OCS distributes the Federal award?  Yes  No

7.4a. If no, describe State procedures to ensure funds are made available to eligible entities consistently and without interruption. [Narrative, 2500 Characters]

Note: Item 7.4 is associated with State Accountability Measure 2Sa and may pre-populate the State’s annual report form.

If this is the first year filling out the automated State Plan, skip the following question.

7.5.      Performance Management Adjustment: How is the State improving grant and/or contract administration procedures under this State Plan as compared to past plans? Any improvements should be based on analysis of past performance, and should consider feedback from eligible entities, OCS, and other sources, such as the public hearing. If the State is not making any improvements, provide further detail. [Narrative, 2500 Characters]

Note: This information is associated with State Accountability Measure 2Sb and may pre-populate the State’s annual report form.

Administrative Funds [Section 675C(b)(2) of the CSBG Act]

7.6. What amount of State CSBG funds does the State plan to allocate for administrative activities, under this State Plan? The estimate may be in dollars or a percentage. [Numeric response, specify $ or %]

7.7. How many State staff positions will be funded in whole or in part with CSBG funds under this State Plan? [Insert a number between 0 – 99]

7.8. How many State Full Time Equivalents (FTEs) will be funded with CSBG funds under this State Plan? [Insert a number between 0 – 99]

Remainder/Discretionary Funds [Section 675C(b) of the CSBG Act]

7.9. Does the State have remainder/discretionary funds?  Yes  No

If yes was selected, describe how the State plans to use remainder/discretionary funds in the table below.

Note: This response will link to the corresponding assurance, item 14.2.

Instructional Note: The assurance under 676(b)(2) of the Act (item 14.2 of this State Plan) specifically requires a description of how the State intends to use remainder/discretionary funds to “support innovative community and neighborhood-based initiatives related to the purposes of [the CSBG Act].” Include this description in row “f” of the table below and/or attach the information.

If a funded activity fits under more than one category in the table, allocate the funds among the categories. For example, if the State provides funds under a contract with the State Community Action association to provide training and technical assistance to eligible entities and to create a statewide data system, the funds for that contract should be allocated appropriately between row a and row c. If allocation is not possible, the State may allocate the funds to the main category with which the activity is associated.

Note: This information is associated with State Accountability Measures 3Sa; the responses may pre-populate the State’s annual report form.

Use of Remainder/Discretionary Funds
Remainder/ Discretionary Fund Uses (See 675C(b)(1) of the CSBG Act)	Year One		Year Two		Brief description of services/activities
	Planned $	Planned %	Planned $	Planned %
Training/technical assistance to eligible entities	[Enter either a planned $ or % for each item listed for the first year that this plan covers. If entering a percentage, the percentages must total 100%.]		[Enter either a planned $ or % for each item listed second year that this plan covers. If entering a percentage, the percentages must total 100%.] [If this is a one-year plan, these columns can be left blank]		[Not Fillable] These planned services/activities will be described in State Plan item 8.1
Coordination of State-operated programs and/or local programs					[Optional Narrative, 2500 characters] These planned services/activities will be described in State Plan section 9, State Linkages and Communication.
Statewide coordination and communication among eligible entities					[Optional Narrative, 2500 characters] These planned services/activities will be described in State Plan section 9, State Linkages and Communication.
Analysis of distribution of CSBG funds to determine if targeting greatest need					[Narrative, 2500 characters]
Asset-building programs					[Narrative, 2500 characters]
Innovative programs/ activities by eligible entities or other neighborhood groups					[REQUIRED Narrative, 2500 characters] Describe here or attach additional information.
State charity tax credits					[Narrative, 2500 characters]
Other activities, specify_________					[Narrative, 2500 characters]
Totals	Auto-Calculated	Auto-Calculated	Auto-Calculated	Auto-Calculated

7.10. What types of organizations, if any, does the State plan to work with (by grant or contract using remainder/discretionary funds) to carry out some or all of the activities in table 7.9. [Check all that apply and narrative where applicable]

• CSBG eligible entities (if checked, include the expected number of CSBG eligible entities to receive funds) [Narrative, 2500 characters]

• Other community-based organizations

• State Community Action association

• Regional CSBG technical assistance provider(s)

• National technical assistance provider(s)

• Individual consultant(s)

• Tribes and Tribal Organizations

• Other [Narrative, 2500 characters]

• None (the State will carry out activities directly)

Note: This response will link to the corresponding CSBG assurance, item 14.2.

If this is the first year filling out the automated State Plan, skip the following question.

7.11.    Performance Management Adjustment: How is the State adjusting the use of remainder/discretionary funds under this State Plan as compared to past plans? Any adjustment should be based on the State’s analysis of past performance, and should consider feedback from eligible entities, OCS, and other sources, such as the public hearing. If the State is not making any adjustments, provide further detail.  [Narrative, 2500 Characters]

Note: This information is associated with State Accountability Measures 3Sb, and will pre-populate the State’s annual report form.

SECTION 8
State Training and Technical Assistance

8.1. Describe the State’s plan for delivering CSBG-funded training and technical assistance to eligible entities under this State Plan by completing the table below. Add a row for each activity: indicate the timeframe; whether it is training, technical assistance or both; and the topic. (CSBG funding used for this activity is referenced under item 7.9(a), Use of Remainder/Discretionary Funds.)

Note: 8.1 is associated with State Accountability Measure 3Sc and may pre-populate the State’s annual report form.

Training and Technical Assistance
Fiscal Year (Y) Quarter (Q) / Timeframe	Training, Technical Assistance, or Both	Topic	Brief Description of “Other”
Dropdown options: FY1 – Q1 FY1 – Q2 FY1 – Q3 FY1 – Q4 FY2 – Q1 FY2 – Q2 FY2 – Q3 FY2 – Q4 Ongoing / Multiple Quarters All quarters	Toggle Options: Training Technical Assistance Both	Dropdown Options: Fiscal Governance/Tripartite Boards Organizational Standards – General Organizational Standards – for eligible entities with unmet standards on Technical Assistance Plans (TAPs) or Quality Improvement Plans (QIPs) Correcting Significant Deficiencies Among Eligible Entities Reporting ROMA Community Assessment Strategic Planning Monitoring Communication Technology Other	[Narrative, 2500 characters] If “Other" is selected in column 3, describe in this column
ADD a ROW function Note: Rows will be able to be added for each additional training

SAMPLE: The following is a sample of how this table can be completed:

Training and Technical Assistance
Fiscal Year (FY) Quarter (Q) / Timeframe	Training, Technical Assistance, or Both	Topic	Brief Description of “Other”
			Conference to include but T/TA

8.1a. The planned budget for the training and technical assistance plan (as indicated in the Remainder/Discretionary Funds table in item 7.9): _____ [Prepopulated with the budget allocation for years one and two under 7.9a]

If this is the implementation year for organizational standards, skip question 8.2.

8.2. Does the State have in place Technical Assistance Plans (TAPs) or Quality Improvement Plans (QIPs) for all eligible entities with unmet organizational standards, if appropriate?  Yes  No

Note: 8.2 is associated with State Accountability Measure 6Sb. QIPs are described in Section 678C(a)(4) of the CSBG Act. If the State, according to their corrective action procedures, does not plan to put a QIP in place for an eligible entity with one or more unmet organizational standards, the State should put a TAP in place to support the entity in meeting the standard(s).

8.3. Indicate the types of organizations through which the State plans to provide training and/or technical assistance as described in item 8.1, and briefly describe their involvement? (Check all that apply.) [Check all that applies and narrative where applicable]

• CSBG eligible entities (if checked, provide the expected number of CSBG eligible entities to receive funds) [Narrative, 2500 characters]

• Other community-based organizations

• State Community Action association

• Regional CSBG technical assistance provider(s)

• National technical assistance provider(s)

• Individual consultant(s)

• Tribes and Tribal Organizations

• Other [Narrative, 2500 characters]

If this is the first year filling out the automated State Plan, skip the following question.

8.4.      Performance Management Adjustment: How is the State adjusting the training and technical assistance plan under this State Plan as compared to past plans? Any adjustment should be based on the State’s analysis of past performance, and should consider feedback from eligible entities, OCS, and other sources, such as the public hearing. If the State is not making any adjustments, provide further detail. [Narrative, 2500 Characters]

Note: This information is associated with State Accountability Measures 3Sd and may pre-populate the State’s annual report form.

SECTION 9
State Linkages and Communication

Note: This section describes activities that the State may support with CSBG remainder/discretionary funds, described under Section 675C(b)(1) of the CSBG Act. The State may indicate planned use of remainder/discretionary funds for linkage/communication activities in Section 7, State Use of Funds, items 7.9(b) and (c).

9.1. State Linkages and Coordination at the State Level: Describe the linkages and coordination at the State level that the State plans to create or maintain to ensure increased access to CSBG services to low-income people and communities under this State Plan and avoid duplication of services (as required by the assurance under Section 676(b)(5)). Describe or attach additional information as needed. [Check all that apply from the list below and provide a Narrative, 2500 Characters]

Note: This response will link to the corresponding CSBG assurance, item 14.5. In addition, this item is associated with State Accountability Measure 7Sa and may pre-populate the State’s annual report form.

• State Low Income Home Energy Assistance Program (LIHEAP) office

• State Weatherization office

• State Temporary Assistance for Needy Families (TANF) office

• State Head Start office

• State public health office

• State education department

• State Workforce Innovation and Opportunity Act (WIOA) agency

• State budget office

• Supplemental Nutrition Assistance Program (SNAP)

• State child welfare office

• State housing office

• Other­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­

9.2. State Linkages and Coordination at the Local Level: Describe the linkages and coordination at the local level that the State plans to create or maintain with governmental and other social services, especially antipoverty programs, to assure the effective delivery of and coordination of CSBG services to low-income people and communities and avoid duplication of services (as required by assurances under Sections 676(b)(5) and (b)(6)). Attach additional information as needed. [Narrative, 2500 Characters]

Note: This response will link to the corresponding CSBG assurances, items 14.5 and 14.6.

9.3. Eligible Entity Linkages and Coordination

9.3a State Assurance of Eligible Entity Linkages and Coordination: Describe how the State will assure that the eligible entities will coordinate and establish linkages to assure the effective delivery of and coordination of CSBG services to low-income people and communities and avoid duplication of services (as required by the assurance under Section 676(b)(5)). Attach additional information as needed. [Narrative, 2500 Characters]

Note: This response will link to the corresponding CSBG assurance, item 14.5.

9.3b State Assurance of Eligible Entity Linkages to Fill Service Gaps: Describe how the eligible entities will develop linkages to fill identified gaps in the services, through the provision of information, referrals, case management, and follow-up consultations, according to the assurance under Section 676(b)(3)(B) of the CSBG Act. [Narrative, 2500 Characters]

Note: This response will link to the corresponding CSBG assurance, item 14.3b.

9.4. Workforce Innovation and Opportunity Act (WIOA) Employment and Training Activities: Does the State intend to include CSBG employment and training activities as part of a WIOA Combined State Plan, as allowed under the Workforce Innovation and Opportunity Act (as required by the assurance under Section 676(b)(5) of the CSBG Act)?  Yes  No

Note: This response will link to the corresponding CSBG assurance, item 14.5.

9.4a If the State selected “yes” under item 9.4, provide the CSBG-specific information included in the State’s WIOA Combined Plan. This information includes a description of how the State and the eligible entities will coordinate the provision of employment and training activities through statewide and local WIOA workforce development systems. This information may also include examples of innovative employment and training programs and activities conducted by community action agencies or other neighbor­hood-based organizations as part of a community antipoverty strategy. [Narrative, 2500 Characters]

9.4b. If the State selected “no” under item 9.4, describe the coordination of employment and training activities, as defined in Section 3 of WIOA, by the State and by eligible entities providing activities through the WIOA system. [Narrative, 2500 Characters]

9.5. Emergency Energy Crisis Intervention: Describe how the State will assure, where appropriate, that emergency energy crisis intervention programs under title XXVI (relating to Low-Income Home Energy Assistance) are conducted in each community in the State, as required by the assurance under Section 676(b)(6) of the CSBG Act). [Narrative, 2500 Characters]

Note: This response will link to the corresponding CSBG assurance, item 14.6.

9.6. State Assurance: Faith-based Organizations, Charitable Groups, Community Organizations: Describe how the State will assure local eligible entities will coordinate and form partnerships with other organizations, including faith-based organizations, charitable groups, and community organizations, according to the State’s assurance under Section 676(b)(9) of the CSBG Act. [Narrative, 2500 characters OR attach a document]

Note: this response will link to the corresponding assurance, item 14.9

9.7 Coordination of Eligible Entity 90 Percent Funds with Public/Private Resources: Describe how the eligible entities will coordinate CSBG 90 percent funds with other public and private resources, according to the assurance under Section 676(b)(3)(C) of the CSBG Act. [Narrative, 2500 Characters]

Note: this response will link to the corresponding assurance, item 14.3c.

9.8. Coordination among Eligible Entities and State Community Action Association: Describe State activities for supporting coordination among the eligible entities and the State Community Action Association. [Narrative, 2500 Characters]

9.9 Communication with Eligible Entities and the State Community Action Association: In the table below, describe the State’s plan for communicating with eligible entities, the State Community Action Association, and other partners under this State Plan. Include communication about annual hearings and legislative hearings, as described under Section 4, CSBG Hearing Requirements.

Communication Plan
Topic	Expected Frequency	Format (drop down)	Brief Description of “Other”
[Narrative, 2500 characters]	Dropdown Options: Daily Weekly Twice-Monthly Monthly Quarterly Semi-Annually Annually Other	Dropdown Options: Newsletter Mailing Meetings/Presentation Blog Email Website Social Media Other	[Narrative, 2500 characters] If “Other" is selected in columns 2 and/or 3, describe in this column
ADD a ROW function Note: As many rows that are needed will be able to be added

9.10. Feedback to Eligible Entities and State Community Action Association: Describe how the State will provide feedback to local entities and State Community Action Associations regarding performance on State Accountability Measures. [Narrative, 2500 Characters]

Note: This information is associated with State Accountability Measure 5S(iii). The measure indicates feedback should be provided within 60 calendar days of the State getting feedback from OCS.

If this is the first year filling out the automated State Plan, skip the following question.

9.11.    Performance Management Adjustment: How is the State adjusting the Communication plan in this State Plan as compared to past plans? Any adjustment should be based on the State’s analysis of past performance, and should consider feedback from eligible entities, OCS, and other sources, such as the public hearing. If the State is not making any adjustments, provide further detail.  [Narrative, 2500 Characters]

Note: This information is associated with State Accountability Measures 7Sb; this response may pre-populate the State’s annual report form.

SECTION 10
Monitoring, Corrective Action, and Fiscal Controls

Monitoring of Eligible Entities (Section 678B(a) of the CSBG Act)

10.1. Specify the proposed schedule for planned monitoring visits including: full on-site reviews; on-site reviews of newly designated entities; follow-up reviews – including return visits to entities that failed to meet State goals, standards, and requirements; and other reviews as appropriate.

This is an estimated schedule to assist States in planning. States may indicate “no review” for entities the State does not plan to monitor in the performance period.

For States that have a monitoring approach that does not fit within the table parameters, attach the State’s proposed monitoring schedule.

Note: This information is associated with State Accountability Measure 4Sa(i); this response may pre-populate the State’s annual report form.

CSBG Eligible Entity	Review Type	Target Date	Date of Last Full Onsite Review (if applicable)	Brief Description of “Other”
Will auto-populate from item 5.1	Dropdown Options: Full onsite Newly Designated Follow-up Other No review	Dropdown Options: FY1 Q1 FY1 Q2 FY1 Q3 FY1 Q4 FY2 Q1 FY2 Q2 FY2 Q3 FY2 Q4	Select a date	[Narrative, 2500 characters] If “Other" is selected in column 2, describe in this column

10.2. Monitoring Policies: Provide a copy of State monitoring policies and procedures by attaching and/or providing a hyperlink. [Attach a document or add a link]

10.3. Initial Monitoring Reports: According to the State’s procedures, by how many calendar days must the State disseminate initial monitoring reports to local entities? [Insert a number from 1 – 100]

Note: This item is associated with State Accountability Measure 4Sa(ii) and may pre-populate the State’s annual report form.

Corrective Action, Termination and Reduction of Funding and Assurance Requirements (Section 678C of the Act)

10.4. Closing Findings: Are State procedures for addressing eligible entity findings/deficiencies, and the documenting of closure of findings included in the State monitoring protocols attached above?  Yes  No

10.4a. If no, describe State procedures for addressing eligible entity findings/deficiencies, and the documenting of closure of findings. [Narrative, 2500 characters]

10.5. Quality Improvement Plans (QIPs): How many eligible entities are currently on Quality Improvement Plans? [Numeric, 3 digits]

Note: The QIP information is associated with State Accountability Measures 4Sc.

10.6. Reporting of QIPs: Describe the State’s process for reporting eligible entities on QIPs to the Office of Community Services within 30 calendar days of the State approving a QIP? [Narrative, 2500 characters]

Note: This item is associated with State Accountability Measure 4Sa(iii)).

10.7. Assurance on Funding Reduction or Termination: Does the State assure, according to Section 676(b)(8), that “any eligible entity that received CSBG funding the previous fiscal year will not have its funding terminated or reduced below the proportional share of funding the entity received in the previous fiscal year unless, after providing notice and an opportunity for a hearing on the record, the State determines that cause exists for such termination or such reduction, subject to review by the Secretary as provided in Section 678C(b).”  Yes  No

Note: This response will link with the corresponding assurance under item 14.8.

Policies on Eligible Entity Designation, De-designation, and Re-designation

10.8. Does the State CSBG statute and/or regulations provide for the designation of new eligible entities?  Yes  No

10.8a. If yes, provide the citation(s) of the law and/or regulation. If no, describe State procedures for the designation of new eligible entities. [Narrative, 2500 Characters]

10.9. Does the State CSBG statute and/or regulations provide for de-designation of eligible entities?

 Yes  No

10.9a. If yes, provide the citation(s) of the law and/or regulation. If no, describe State procedures for de-designation of new eligible entities. [Narrative, 2500 Characters]

10.10. Does the State CSBG statute and/or regulations specify a process the State CSBG agency must follow to re-designate an existing eligible entity?  Yes  No

10.10a. If yes, provide the citation(s) of the law and/or regulation. If no, describe State procedures for re-designation of existing eligible entities. [Narrative, 2500 Characters]

Fiscal Controls and Audits and Cooperation Assurance

10.11. Fiscal Controls and Accounting: Describe how the State’s fiscal controls and accounting procedures will a) permit preparation of the SF-425 Federal fiscal reports (FFR) and b) permit the tracing of expenditures adequate to ensure funds have been used appropriately under the block grant, as required by Block Grant regulations applicable to CSBG at 45 CFR 96.30(a). [Narrative, 2500 Characters or attach a document]

10.12. Single Audit Management Decisions: Describe State procedures for issuing management decisions for eligible entity single audits, as required by Block Grant regulations applicable to CSBG at 45 CFR 75.521. If these procedures are described in the State monitoring protocols attached under item 10.2, indicate the page number. [Narrative, 2500 Characters]

Note: This information is associated with State Accountability Measure 4Sd.

10.13. Assurance on Federal Investigations: Will the State “permit and cooperate with Federal investigations undertaken in accordance with Section 678D” of the CSBG Act, as required by the assurance under Section 676(b)(7) of the CSBG Act?  Yes  No

Note: This response will link with the corresponding assurance, item 14.7

If this is the first year filling out the automated State Plan, skip the following question.

10.14. Performance Management Adjustment: How is the State adjusting monitoring procedures in this State Plan as compared to past plans? Any adjustment should be based on the State’s analysis of past performance, and should consider feedback from eligible entities, OCS, and other sources, such as the public hearing. If this State is not making any adjustments, provide further detail. [Narrative, 2500 Characters]

Note: This item is associated with State Accountability Measure 4Sb and may pre-populate the State’s annual report form.

SECTION 11

Eligible Entity Tripartite Board

11.1. Which of the following measures are taken to ensure that the State verifies CSBG Eligible Entities are meeting Tripartite Board requirements under Section 676B of the CSBG Act? [Check all that applies and narrative where applicable]

• Attend Board meetings

• Review copies of Board meeting minutes

• Track Board vacancies/composition

• Other [Narrative, 2500 characters]

11.2. How often does the State require eligible entities (which are not on TAPs or QIPs) to provide updates (e.g., copies of meeting minutes, vacancy alerts, changes to bylaws, low-income member selection process, etc.) regarding their Tripartite Boards? [Check all that applies and narrative where applicable]

• Annually

• Semiannually

• Quarterly

• Monthly

• Other [Narrative, 2500 characters]

11.3. Assurance on Eligible Entity Tripartite Board Representation: Describe how the State will carry out the assurance under Section 676(b)(10) of the CSBG Act that the State will require eligible entities to have policies and procedures by which individuals or organizations can petition for adequate representation on an eligible entities’ Tripartite Board. [Narrative, 2500 Characters]

Note: This response will link with the corresponding assurance, item 14.10.

11.4. Does the State permit public eligible entities to use, as an alternative to a Tripartite Board, “another mechanism specified by the State to assure decision-making and participation by low-income individuals in the development, planning, implementation, and evaluation of programs” as allowed under Section 676B(b)(2) of the CSBG Act.  Yes  No

11.4a. If yes, describe the mechanism used by public eligible entities as an alternative to a Tripartite Board. [Narrative, 2500 Characters]

Section 12
Individual and Community Income Eligibility Requirements

12.1. Required Income Eligibility: What is the income eligibility threshold for services in the State? [Check one item below.]

• 125% of the HHS poverty line

• X % of the HHS poverty line (fill in the threshold):______% [insert up to a 3 digit percentage]

• Varies by eligible entity

12.1a. Describe any State policy and/or procedures for income eligibility, such as treatment of income and family/household composition. [Narrative, 2500 Characters, or attachment]

12.2. Income Eligibility for General/Short Term Services: For services with limited in-take procedures (where individual income verification is not possible or practical), how does the State ensure eligible entities generally verify income eligibility for services? An example of these services is emergency food assistance. [Narrative, 2500 Characters]

12.3. Community-targeted Services: For services that provide a community-wide benefit (e.g., development of community assets/facilities, building partnerships with other organizations), how does the State ensure eligible entities’ services target and benefit low-income communities? [Narrative, 2500 Characters]

SECTION 13

Results Oriented Management and Accountability (ROMA) System

13.1. ROMA Participation: In which performance measurement system will the State and all eligible entities participate, as required by Section 678E(a) of the CSBG Act and the assurance under Section 676(b)(12) of the CSBG Act? [Check one]

Note: This response will also link to the corresponding assurance, item 14.12.

• The Results Oriented Management and Accountability (ROMA) System

• Another performance management system that meets the requirements of section 678E(b) of the CSBG Act

• An alternative system for measuring performance and results

13.1a. If ROMA was selected in item 13.1, attach and/or describe the State’s written policies, procedures, or guidance documents on ROMA. [Attachment and Narrative, 2500 characters]

13.1b. If ROMA was not selected in item 13.1, describe the system the State will use for performance measurement. [Narrative, 2500 characters]

13.2. Indicate and describe the outcome measures the State will use to measure eligible entity performance in promoting self-sufficiency, family stability, and community revitalization, as required under Section 676(b)(12) of the CSBG Act? [Check one and Narrative, 2500 characters]

Note: This response will also link to the corresponding assurance, item 14.12.

• CSBG National Performance Indicators (NPIs)

• NPIs and others

• Others

13.3. How does the State support the eligible entities in using the ROMA system (or alternative performance measurement system)? [Narrative, 2500 characters or attach a document]

Note: The activities described under item 13.3 may include activities listed in “Section 8: Training and Technical Assistance.” If so, mention briefly, and/or cross-reference as needed. This response will also link to the corresponding assurance, item 14.12.

13.4. Eligible Entity Use of Data: How is the State validating that the eligible entities are using data to improve service delivery? [Narrative, 2500 characters or attach a document]

Note: This response will also link to the corresponding assurance, item 14.12.

Community Action Plans and Needs Assessments

13.5. Describe how the State will secure a Community Action Plan from each eligible entity, as a condition of receipt of CSBG funding by each entity, as required by Section 676(b)(11) of the CSBG Act. [Narrative, 2500 characters or attach a document]

Note: this response will link to the corresponding assurance, item 14.11.

13.6. State Assurance: Describe how the State will assure that each eligible entity includes a community needs assessment for the community served (which may be coordinated with community needs assessments conducted by other programs) in each entity’s Community Action Plan, as required by Section 676(b)(11) of the CSBG Act. [Narrative, 2500 characters or attach a document]

Note: this response will link to the corresponding assurance, item 14.11.

SECTION 14

CSBG Programmatic Assurances and Information Narrative

(Section 676(b) of the CSBG Act)

14.1 Use of Funds Supporting Local Activities

CSBG Services

14.1a. 676(b)(1)(A): Describe how the State will assure “that funds made available through grant or allotment will be used –

(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 self-sufficiency (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, including the development of public and private grassroots partnerships with local law enforcement agencies, local housing authorities, private foundations, and other public and private partners to –

(I) document best practices based on successful grassroots intervention in urban areas, to develop methodologies for widespread replication; and

(II) strengthen and improve relationships with local law enforcement agencies, which may include participation in activities such as neighborhood or community policing efforts;

[Narrative, 2500 or attach a document]

Needs of Youth

14.1b. 676(b)(1)(B) Describe how the State will assure “that funds made available through grant or allotment will be used –

(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 innovative community-based youth development programs that have demonstrated success in preventing or reducing youth crime, such as--

(i) programs for the establishment of violence-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); and

(ii) after-school child care programs;

[Narrative, 2500 characters OR attach a document]

Coordination of Other Programs

14.1c. 676(b)(1)(C) Describe how the State will assure “that funds made available through grant or allotment will be used –

(C) to make more effective use of, and to coordinate with, other programs related to the purposes of this subtitle (including State welfare reform efforts)

[Narrative, 2500 characters OR attach a document]

State Use of Discretionary Funds

14.2 676(b)(2) Describe “how the State intends to use discretionary funds made available from the remainder of the grant or allotment described in section 675C(b) in accordance with this subtitle, including a description of how the State will support innovative community and neighborhood-based initiatives related to the purposes of this subtitle.”

Note: the State describes this assurance under “State Use of Funds: Remainder/Discretionary,” items 7.9 and 7.10

[No response; links to items 7.9 and 7.10.]

Eligible Entity Service Delivery, Coordination, and Innovation

14.3. 676(b)(3) “Based on information provided by eligible entities in the State, a description of…”

Eligible Entity Service Delivery System

14.3a. 676(b)(3)(A) Describe “the service delivery system, for services provided or coordinated with funds made available through grants made under 675C(a), targeted to low-income individuals and families in communities within the State;

[Narrative, 2500 characters OR attach a document]

Eligible Entity Linkages – Approach to Filling Service Gaps

14.3b. 676(b)(3)(B) Describe “how linkages will be developed to fill identified gaps in the services, through the provision of information, referrals, case management, and followup consultations.”

Note: the State describes this assurance in the State Linkages and Communication section, item 9.3b.

[No response; links to 9.3b.]

Coordination of Eligible Entity Allocation 90 Percent Funds with Public/Private Resources

14.3c. 676(b)(3)(C) Describe how funds made available through grants made under 675C(a)will be coordinated with other public and private resources.”

Note: the State describes this assurance in the State Linkages and Communication section, item 9.7.

[No response; links to 9.7]

Eligible Entity Innovative Community and Neighborhood Initiatives, Including Fatherhood/Parental Responsibility

14.3d. 676(b)(3)(D) Describe “how the local entity will use the funds [made available under 675C(a)] to support innovative community and neighborhood-based initiatives related to the purposes of this subtitle, which may include fatherhood initiatives and other initiatives with the goal of strengthening families and encouraging parenting.”

Note: The description above is about eligible entity use of 90 percent funds to support these initiatives. States may also support these types of activities at the local level using State remainder/discretionary funds, allowable under Section 675C(b)(1)(F). In this State Plan, the State indicates funds allocated for these activities under item 7.9(f).

[Narrative, 2500 characters OR attach a document]

Eligible Entity Emergency Food and Nutrition Services

14.4. 676(b)(4) Describe how the State will assure “that eligible entities in the State will provide, on an emergency basis, for the provision of such supplies and services, nutritious foods, and related services, as may be necessary to counteract conditions of starvation and malnutrition among low-income individuals.”

[Narrative, 2500 characters OR attach a document]

State and Eligible Entity Coordination/linkages and Workforce Innovation and Opportunity Act Employment and Training Activities

14.5. 676(b)(5) Describe how the State will assure “that the State and eligible entities in the State will coordinate, and establish linkages between, governmental and other social services programs to assure the effective delivery of such services, and [describe] how the State and the eligible entities will coordinate the provision of employment and training activities, as defined in section 3 of the Workforce Innovation and Opportunity Act, in the State and in communities with entities providing activities through statewide and local workforce development systems under such Act.”

Note: The State describes this assurance in the State Linkages and Communication section, items 9.1, 9.2, 9.3a, 9.4, 9.4a, and 9.4b.

[No response; links to items 9.1, 9.2, 9.3a, 9.4, 9.4a, and 9.4b]

State Coordination/Linkages and Low-income Home Energy Assistance

14.6. 676(b)(6) Provide “an assurance that the State will ensure coordination between antipoverty programs in each community in the State, and ensure, where appropriate, that emergency energy crisis intervention programs under title XXVI (relating to low-income home energy assistance) are conducted in such community.”

Note: The State describes this assurance in the State Linkages and Communication section, items 9.2 and 9.5.

[No response; links to 9.2 and 9.5]

Federal Investigations

14.7. 676(b)(7) Provide “an assurance that the State will permit and cooperate with Federal investigations undertaken in accordance with section 678D.”

Note: the State addresses this assurance in the Fiscal Controls and Monitoring section, item 10.13.

[No response; links to 10.13]

Funding Reduction or Termination

14.8. 676(b)(8) Provide “an assurance that any eligible entity in the State that received funding in the previous fiscal year through a community services block grant made under this subtitle will not have its funding terminated under this subtitle, or reduced below the proportional share of funding the entity received in the previous fiscal year unless, after providing notice and an opportunity for a hearing on the record, the State determines that cause exists for such termination or such reduction, subject to review by the Secretary as provided in section 678C(b).”

Note: the State addresses this assurance in the Fiscal Controls and Monitoring section, item 10.7.

[No response; links to 10.7]

Coordination with Faith-based Organizations, Charitable Groups, Community Organizations

14.9. 676(b)(9) Describe how the State will assure “that the State and eligible entities in the State will, to the maximum extent possible, coordinate programs with and form partnerships with other organizations serving low-income residents of the communities and members of the groups served by the State, including religious organizations, charitable groups, and community organizations.”

Note: the State describes this assurance in the State Linkages and Communication section, item 9.6.

[No response; links to 9.6]

Eligible Entity Tripartite Board Representation

14.10. 676(b)(10) Describe how “the State will require each eligible entity in the State to establish procedures under which a low-income individual, community organization, or religious organization, or representative of low-income individuals that considers its organization, or low-income individuals, to be inadequately represented on the board (or other mechanism) of the eligible entity to petition for adequate representation.”

Note: the State describes this assurance in the Eligible Entity Tripartite Board section, 11.3

[No response; links to item 11.3]

Eligible Entity Community Action Plans and Community Needs Assessments

14.11. 676(b)(11) Provide “an assurance that the State will secure from each eligible entity in the State, as a condition to receipt of funding by the entity through a community services block grant made under this subtitle for a program, a community action plan (which shall be submitted to the Secretary, at the request of the Secretary, with the State plan) that includes a community-needs assessment for the community served, which may be coordinated with community-needs assessments conducted for other programs.”

[No response; links to items 13.5 and 13.6]

State and Eligible Entity Performance Measurement: ROMA or Alternate system

14.12. 676(b)(12) Provide “an assurance that the State and all eligible entities in the State will, not later than fiscal year 2001, participate in the Results Oriented Management and Accountability System, 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 [describe] outcome measures to be used to measure eligible entity performance in promoting self-sufficiency, family stability, and community revitalization.”

Note: The State describes this assurance in the ROMA section, items 13.1, 13.2, 13.3, and 13.4.

[No response; links to 13.1, 13.2, 13.3, and 13.4]

Validation for CSBG Eligible Entity Programmatic Narrative Sections

14.13. 676(b)(13) Provide “information describing how the State will carry out the assurances described in this section.”

Note: The State provides information for each of the assurances directly in section 14 or in corresponding items throughout the State Plan, which are included as hyperlinks in section 14.

[No response for this item]

• By checking this box, the State CSBG authorized official is certifying the assurances set out above.

SECTION 15
Federal Certifications

The box after each certification must be checked by the State CSBG authorized official.

15.1 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.

• By checking this box, the State CSBG authorized official is providing the certification set out above.

15.2 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.

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 to 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;

3. 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);

4. Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant, the employee will - -

1. Abide by the terms of the statement; and

2. Notify the employer 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;

5. 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;

6. 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;

7. 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 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) [Narrative, 2500 characters]

Check if there are workplaces on file that are not identified here.

Alternate II. (Grantees Who Are Individuals)

1. 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;

2. 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 State CSBG authorized official is providing the certification set out above.

15.3 Debarment

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 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.

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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

3. 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.

4. 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.

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 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.

6. 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.

7. 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.

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 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.

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 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 and/or debarment.

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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.

• By checking this box, the State CSBG authorized official is providing the certification set out above.

15.4 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 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 and/or the imposition of an administrative compliance order on the responsible entity by signing and submitting this application the applicant/grantee certifies that it will comply with the requirements of the Act.

The applicant/grantee 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 subgrantees shall certify accordingly.

• By checking this box, the State CSBG authorized official is providing the certification set out above.