# OMB Approval No. 0985-0018

> Expiration 3/31/2007

# 

# 

# Disaster Assistance 

# Program Announcement and Grant Application Instructions

# 

# 

# U.S. Administration on Aging

*2006*

**Department of Health and Human Services (HHS)**

**Administration on Aging (AoA)**

**AoA Center: Policy and Programs**

######## Funding Opportunity Title: Disaster Assistance 

**Announcement Type: Initial**

**Funding Opportunity Number: HHS-2006-AOA-DA-0602**

**Catalog of Federal Domestic Assistance (CFDA) Number: 93.048**

**Key Dates: The deadline date for submission of applications is
September 22, 2006.**

I.  **FUNDING OPPORTUNITY DESCRIPTION**

> Grants awarded under this announcement are to provide disaster relief
> and assistance funds to those State Units on Aging (SUAs) and tribal
> organizations who are currently receiving a grant under Title VI of
> the Older Americans Act, as amended. These funds only become available
> when the President declares a National Disaster and may only be used
> in those areas designated in the Disaster Declaration issued by the
> President of the United States.
>
> Eligible SUAs and Title VI grantees should discuss all disaster
> applications with Regional staff before submitting a formal
> application. The amount of funds requested should be discussed with
> Regional staff before the application is completed and providing a
> draft of the planned application is helpful. This will expedite the
> application and award process.
>
> AoA encourages State Units on Aging (SUAs) and federally recognized
> tribal organizations currently receiving a grant under Title VI of the
> Older Americans Act to submit proposals electronically via
> [www.grants.gov](http://www.grants.gov/). **For assistance with
> [www.grants.gov](http://www.grants.gov/), please contact AoA's
> Grants.gov helpdesk at 202-357-3438.** At
> [www.grants.gov](http://www.grants.gov/), you will be able to download
> a copy of the application packet, complete it off-line, and then
> upload and submit the application via the Grants.gov website.
>
> **[Statutory Authority]{.underline}**
>
> The statutory authority for grants under this program announcement is
> contained in Title III of the Older Americans Act (OAA) (42U.S.C.
> 3030), as amended by the Older Americans Act Amendments of 2000, P.L.
> 106-501 (Catalog of Federal Domestic Assistance 93.048).

######## 

######## 

######## II. AWARD INFORMATION 

> Awards made will be grants. The amount of funding available to
> applicants is determined by three factors: (1) the number of older
> persons affected; (2) the amount and severity of need and (3) the
> amount of disaster funds available as prescribed in the Older
> Americans Act.
>
> Total funds available are approximately \$500,000.

**III. ELIGIBILITY INFORMATION**

**1. Eligible Applicants**

a.  State Units on Aging whose states have been declared a federal
    disaster area by the President of the United States

b.  Federally recognized tribal organizations within the areas declared
    a federal disaster area who are currently receiving a grant under
    Title VI of the Older Americans Act, as amended.

**2. Cost Sharing or Matching**

> None.
>
> **3. Application Screening Criteria**

a.  Applications must be from State Units on Aging from those states
    that have been declared a federal disaster area by the President of
    the United States.

b.  Federally recognized tribal organizations within the areas declared
    a federal disaster area who are currently receiving a grant under
    Title VI of the Older Americans Act, as amended.

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IV. **APPLICATION AND SUBMISSION INFORMATION**

## 1. Electronic Application Submission

> AoA encourages applicants to submit proposals electronically via
> [www.grants.gov](http://www.grants.gov/). **For assistance with
> [www.grants.gov](http://www.grants.gov/), please contact AoA's
> Grants.gov helpdesk at 202-357-3438.** At
> [www.grants.gov](http://www.grants.gov/), you will be able to download
> a copy of the application packet, complete it off-line, and then
> upload and submit the application via the Grants.gov website.
>
> Application materials are also available by writing to:
>
> U.S. Department of Health and Human Services
>
> Administration on Aging
>
> Center for Wellness & Community-Based Services
>
> Attn: Irma Tetzloff
>
> Washington, D.C. 20201
>
> Or by calling: 202-357-3525
>
> Or e-mailing: Irma.Tetzloff@aoa.hhs.gov
>
> Please note, AoA is requiring applications for this announcement to be
> submitted electronically through
> [www.grants.gov](http://www.grants.gov/). The Grants.gov registration
> process can take several days. If you are not currently registered
> with [www.grants.gov](http://www.grants.gov/), please begin this
> process immediately. **For assistance with
> [www.grants.gov](http://www.grants.gov/), please contact AoA's
> Grants.gov helpdesk at 202-357-3438.** At
> [www.grants.gov](http://www.grants.gov/), you will be able to download
> a copy of the application packet, complete it off-line, and then
> upload and submit the application via the Grants.gov website.
>
> Applications submitted via [www.grants.gov](http://www.grants.gov/) :

-   You may access the electronic application for this program on
    [www.Grants.gov](http://www.Grants.gov/). You must search the
    downloadable application page by the CFDA number (93.048).

-   At the www.grants.gov website, you will find information about
    submitting an application electronically through the site, including
    the hours of operation. AoA strongly recommends that you do not wait
    until the application due date to begin the application process
    through [www.grants.gov](http://www.grants.gov/) because of the time
    delay.

-   All applicants must have a Dun and Bradstreet (D&B) Data Universal
    Numbering System number and register in the Central Contractor
    Registry (CCR). You should allow a minimum of **five days** to
    complete the CCR registration.

-   You may submit all documents electronically, including all
    information included on the SF424 and all necessary assurances and
    certifications.

-   Your application must comply with any page limitation requirements
    described in this program announcement.

-   After you electronically submit your application, you will receive
    an automatic acknowledgement from www.grants.gov that contains a
    Grants.gov tracking number. The Administration on Aging will
    retrieve your application form from Grants.gov.

-   We may request that you provide original signatures on forms at a
    later date.

###### Content and Form of Application Submission 

> **a. DUNS Number**
>
> The Office of Management and Budget requires applicants to provide a
> Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number
> when applying for Federal grants or cooperative agreements on or after
> October 1, 2003. It is entered on the SF 424. It is a unique,
> **nine-digit identification number**, which provides unique
> identifiers of single business entities. The D-U-N-S number is *free
> and easy* to obtain.
>
> Organizations can receive a DUNS number at no cost by calling the
> dedicated toll-free DUNS Number request line at 1-866-705-5711 or by
> using this link:
> https://www.whitehouse.gov/omb/grants/duns_num_guide.pdf**.**
>
> **b. Project Narrative**

##  

> A brief narrative must be submitted. The project narrative should
> provide a clear and concise description of the number of older persons
> affected, the severity and the types of assistance needed. Plans for
> how the SUA or tribal organizations will use these funds should be
> indicated. Costs typically requested are for the following Title III
> types of gap-filling services: outreach, information and assistance,
> counseling, case management, advocacy on behalf of older persons
> unable or reluctant to speak for themselves, and staff overtime. Funds
> may be used for additional food, supplies, extra home delivered meals,
> home clean up and safety, emergency medications, transportation and
> other such immediate needs.
>
> **3. Submission Dates and Times**
>
> The deadline for the submission of applications under this program
> announcement for the current fiscal year is September 22, 2006.
> Applications must be: submitted electronically by midnight Eastern
> Time, September 22, 2006.
>
> **4. Other Submission Requirements**
>
> Electronic submissions must be sent to: http://www.grants.gov.
>
> For applicants submitting their application through www.grants.gov,
> you must register in the Central Contractor Registry (CCR) database in
> order to be able to submit the application. One element of the CCR is
> the DUNS number (see section IV.2), which must be obtained separately
> from CCR registration. Information about CCR is available at
> <http://www.grants.gov/CCRRegister> . You must also register with a
> Credential Provider to receive a username and password to securely
> submit your grant application. Information is available at
> <http://www.grants.gov/CredentialProvider> .
>
> **5. Intergovernmental Review**
>
> This funding opportunity announcement is not subject to the
> requirements of Executive Order 12372, "Intergovernmental Review of
> Federal Programs".
>
> **6.** **Funding Restrictions**
>
> The following activities are not fundable:

-   Construction and/or major rehabilitation of buildings

-   Basic research (e.g. scientific or medical experiments)

## 

V.  **APPLICATION REVIEW INFORMATION**

> **1**. ***Review and Selection***
>
> Under the Older Americans Act, as amended, "The Assistant Secretary
> may provide reimbursements to any State (or to any tribal organization
> receiving a grant under Title VI), upon application for such
> reimbursement, for funds such State makes available to area agencies
> on aging in such State (or funds used by such tribal organization) for
> the delivery of supportive services (and related supplies) during any
> major disaster declared by the President in accordance with the Robert
> T. Stafford Disaster Relief and Emergency Assistance Act\" \[42 U.S.C.
> 5121 et seq.\].

## 

## VI. AWARD ADMINISTRATION INFORMATION 

###### 1. *Award Notices* 

> Successful applicants will receive an Approval letter, and a Notice of
> Financial Assistance Award. The Notice of Financial Assistance Award
> is the authorizing document, and will be signed by the AoA grants
> officer, the AoA authorizing official, and the AoA budget office.

###### 2. *Administrative and National Policy Requirements* 

> The award is subject to DHHS Administrative Requirements, which can be
> found in 45CFR Part 74 and 92 and AoA Standard Terms and Conditions
> which are included with each grant Award Packet.

###### 3. *Reporting* 

> An original and two copies of the Final performance and SF-269 reports
> are due 90 days after the end of the project period. Awardees will
> receive a copy of the required program progress report form with their
> Notice of Financial Assistance Award. For more information see DHHS /
> AoA Standard Terms and Conditions.

## 

## VI. AGENCY CONTACTS 

> [Project Officer:]{.underline}
>
> U.S. Department of Health and Human Services
>
> Administration on Aging
>
> Washington, DC 20201
>
> Attn: Irma Tetzloff
>
> Telephone: (202) 357-3525, e-mail: <Irma.Tetzloff@aoa.hhs.gov>
>
> [Grants Management Officer:]{.underline}
>
> U.S. Department of Health and Human Services
>
> Administration on Aging
>
> Washington, DC 20201
>
> Attn: Dan Berger
>
> Telephone: (202) 357-3440, e-mail: <Dan.Berger@aoa.hhs.gov>

## VIII. OTHER INFORMATION

###### 1. Order of Application Elements

> To expedite the processing of applications, we request that you
> arrange the components of your application in the following order:
>
> 1\. SF 424 -- Application for Federal Assistance. [Note]{.underline}:
> The original copy of the application [must]{.underline} have an
> original signature in item 21 on the SF 424.
>
> 2\. SF 424A -- Budget Information.
>
> 3\. Separate Budget Justification (See Attachments for Sample Format).
>
> 4 SF 424B -- Assurances. Note: Be sure to complete this form according
> to instructions and have it signed and dated by the authorized
> representative (see item 21 on the SF 424).
>
> 5\. AoA Certification.
>
> 6\. Project Narrative
>
> 7\. Completed Application Package Checklist
>
> **2. The Paperwork Reduction Act of 1995 (P.L. 104-13)**
>
> An agency may not conduct or sponsor, and a person is not required to
> respond to, a collection of information unless it displays a currently
> valid OMB control number.
>
> The project description and budget justification is approved under OMB
> control number 0985-0018 which expires on 3/31/07.
>
> Public reporting burden for this collection of information is
> estimated to average 10 hours per response, including the time for
> reviewing instructions, gathering and maintaining the data needed and
> reviewing the collection information.

**ATTACHMENTS**

**Attachment A:**

**Application Package Checklist**

**Attachment B:**

**Instructions for completing the Budget (SF424A) and Budget
Justification**

**Attachment C:**

**Budget Justification Format -- Sample Format with Examples**

**Attachment D:**

**Budget Justification -- Sample Format**

####### Attachment A:

####### Grant Application Package Checklist

The checklist below identifies the items that must be included in your
mail-in or hand-delivered application submission. Please check-off each
item to ensure your submission is complete, and include a copy of the
completed checklist in your application package. The components of your
submission should be ordered in the same sequence as the items listed
below.

I have checked my application package to ensure that it includes:

-   One original application plus two copies, with the SF 424 as the
    first page of each copy of the application.

-   SF 424 -- Application for Federal Assistance.

-   SF 424A -- Budget Information.

-   Budget Justification.

-   SF 424B - Assurances.

-   AoA Certification. Be sure this form is completed according to the
    instructions, signed and dated by the authorized representative (see
    item 18d on SF 424).

-   A copy of the current indirect cost rate agreement approved by the
    Department of Health and Human Services or another federal agency.
    (if applicable)

-   Project Narrative

-   Completed Grant Application Package Checklist

######### 

# Attachment B

# Instructions for completing the Budget (SF424A) and Budget Justification

  -----------------------------------------------------------------------
  This section provides step-by-step instructions for completing the four
  (4) standard federal forms required as part of your grant application,
  including special instructions for completing Standard Budget Forms 424
  and 424A. Standard Forms 424 and 424A are used for a wide variety of
  federal grant programs, and federal agencies have the discretion to
  require some or all of the information on these forms. AoA does not
  require all the information on these Standard Forms. Accordingly,
  please use the instructions below in lieu of the standard instructions
  attached to SF 424 and 424A to complete these forms. Please note that
  single-sided copies of all required forms must be used in submitting
  your application.

  -----------------------------------------------------------------------

###### a. Standard Form 424

## [Item 1]{.underline}. Mark "Non-Construction" under "Application".

[Item 2]{.underline}. Fill in the date you submit the application. The
three "Identifier" boxes to the right of Items 2 through 4 should be
left blank.

[Item 3]{.underline}. Not applicable -- Mark "NA".

[Item 4]{.underline}. Leave blank.

[Item 5]{.underline}. Enter the legal name of the applicant
organization; the name of the primary organizational unit responsible
for managing the project; the organization's DUNS number (received from
Dun and Bradstreet); the applicant's address; and the name and telephone
number of the person to contact on matters related to this application.

[Item 6]{.underline}. Enter the Employer Identification Number (EIN) of
the applicant organization that has been assigned to the organization by
the Internal Revenue Service. Please include the suffix to the EIN if
known.

[Item 7]{.underline}. Enter the appropriate letter in the box provided.

[Item 8]{.underline}. Check the "New" box.

[Item 9]{.underline}. Enter - Administration on Aging

[Item 10]{.underline}. Enter -- 93.048

[Item 11]{.underline}. Enter the title of the project.

[Item 12]{.underline}. List only one entity - it should be the largest
political entity affected.

[Item 13]{.underline}. Enter the start and end date for the upcoming
budget period for the project. (NOTE: The start date usually coincides
with the date AoA issues the grant award to the applicant organization,
with the end date usually being 12 months later.)

[Item 14]{.underline}. Enter the Congressional District(s) affected by
the project.

[Item 14a]{.underline}.Enter the Congressional District where the
applicant organization is located.

[Item 14b]{.underline}. Leave Blank

[Item 15]{.underline}. **No Matching Required.**

NOTE: **Indirect charges** may only be requested if: (1) the applicant
has a current indirect cost rate agreement approved by the Department of
Health and Human Services or another federal agency; or (2) the
applicant is a state or local government agency. State governments
should enter the amount of indirect costs determined in accordance with
DHHS requirements.

[Item 16]{.underline}. Check b. No - Program is not covered by E.O.
12372

[Item 17]{.underline}. This item applies to the applicant organization.
Categories of debt include delinquent audit disallowances, loans, and
taxes.

[Item 18]{.underline}. To be signed by the authorized representative of
the applicant organization. A document attesting to that sign-off
authority must be on file in the grantee's office.

**b. Standard Form 424A**

+-----------------------------------------------------------------------+
| > NOTE: Standard Form 424A is designed to accommodate applications    |
| > for multiple grant programs; thus, for purposes of this AoA         |
| > program, many of the budget item columns and rows are not           |
| > applicable. For your convenience, these non-applicable columns and  |
| > rows have been shaded-out on the form. You should only consider and |
| > respond to the budget items for which guidance is provided below.   |
+-----------------------------------------------------------------------+

##### Section A ‑ Budget Summary

> [Line 5]{.underline}: Leave columns ( c) and (d) blank. Enter TOTAL
> federal costs in column (e) and total non‑federal costs (including
> third party in‑kind contributions and any program income to be used as
> part of the grantee match) in column (f). Enter the sum of columns (e)
> and (f) in column (g).

##### 

##### Section B ‑ Budget Categories

> Column 3: Enter the breakdown of how you plan to use the federal funds
> being
>
> requested by object class category (see instructions for each object
> class category below).
>
> Column 4: Enter the breakdown of how you plan to use the non-federal
> share by object class category.
>
> Column 5: Enter the total funds required for the project (the sum of
> Columns 3 and 4) by object class category.

+-----------------------------------------------------------------------+
| ###### Separate Budget Justification Requirement                      |
|                                                                       |
| > You must submit a separate budget justification as part of your     |
| > application. **A blank sample format (and one with examples) has    |
| > been included in the attachments for your use in developing and     |
| > presenting your Budget Justification.** In your budget              |
| > justification, you should include a breakdown of the budget which   |
| > shows the costs for all of the object class categories noted in     |
| > Section B, across three columns: federal; non-federal cash; and     |
| > non-federal in-kind. The justification should fully explain and     |
| > justify the costs in each of the major budget items for each of the |
| > object class categories, as described below. Third party in-kind    |
| > contributions and program income designated as non-federal match    |
| > contributions should be clearly identified and justified separately |
| > from the justification for the budget line items. The full budget   |
| > justification should be included in the application immediately     |
| > following the SF 424 forms. **The budget justification should       |
| > provide a detailed breakdown of large dollar values.**              |
+-----------------------------------------------------------------------+

> [Line 6a]{.underline}: [Personnel]{.underline}: Enter total costs of
> salaries and wages of applicant/grantee staff. Do not include the
> costs of consultants; consultant costs should be included under 6h ‑
> Other. [In the Justification]{.underline}: Identify the project
> director, if known. Specify the key staff, their titles, brief summary
> of project related duties, and the percent of their time commitments
> to the project in the budget justification.
>
> [Line 6b]{.underline}: [Fringe Benefits]{.underline}: Enter the total
> costs of fringe benefits unless treated as part of an approved
> indirect cost rate. [In the Justification]{.underline}: Provide a
> break‑down of amounts and percentages that comprise fringe benefit
> costs, such as health insurance, FICA, retirement insurance, etc.
>
> [Line 6c]{.underline}: [Travel]{.underline}: Enter total costs of
> [out‑of‑town travel]{.underline} (travel requiring per diem) for staff
> of the project. Do not enter costs for consultant\'s travel - this
> should be included in line 6h. [In the Justification]{.underline}:
> Include the total number of trips, destinations, purpose, length of
> stay, subsistence allowances and transportation costs (including
> mileage rates).
>
> [Line 6d]{.underline}: [Equipment]{.underline}: Enter the total costs
> of all equipment to be acquired by the project. For all grantees,
> \"equipment\" is non‑expendable tangible personal property having a
> useful life of more than one year and an acquisition cost of \$5,000
> or more per unit. If the item does not meet the \$5,000 threshold,
> include it in your budget under Supplies, line 6e. [In the
> Justification]{.underline}: Equipment to be purchased with federal
> funds must be justified as necessary for the conduct of the project.
> The equipment must be used for project-related functions; the
> equipment, or a reasonable facsimile, must not be otherwise available
> to the applicant or its sub‑grantees. The justification also must
> contain plans for the use or disposal of the equipment after the
> project ends.
>
> [Line 6e]{.underline}: [Supplies:]{.underline} Enter the total costs
> of all tangible expendable personal property
>
> (supplies) other than those included on line 6d. [In the
> Justification:]{.underline} Provide general description of types of
> items included.
>
> [Line 6f]{.underline}: [Contractual]{.underline}: Enter the total
> costs of all contracts, including (1) procurement
>
> contracts (except those, which belong on other lines such as
> equipment, supplies, etc.). Also include any contracts with
> organizations for the provision of technical assistance. Do not
> include payments to individuals on this line. [In the
> Justification]{.underline}: Attach a list of contractors indicating
> the name of the organization, the purpose of the contract, and the
> estimated dollar amount. If the name of the contractor, scope of work,
> and estimated costs are not available or have not been negotiated,
> indicate when this information will be available. Whenever the
> applicant/grantee intends to delegate a substantial part (one-third,
> or more) of the project work to another agency, the applicant/grantee
> must provide a completed copy of Section B, Budget Categories for each
> contractor, along with supporting information and justifications.
>
> [Line 6g]{.underline}: [Construction]{.underline}: Leave blank since
> construction is not an allowable cost under this AoA program.
>
> [Line 6h]{.underline}: [Other]{.underline}: Enter the total of all
> other costs. Such costs, where applicable, may
>
> include, but are not limited to: insurance, medical and dental costs
> (i.e. for project volunteers this is different from personnel fringe
> benefits); non-contractual fees and travel paid directly to
> *individual* consultants; [local]{.underline} transportation (all
> travel which does not require per diem is considered local travel);
> postage; space and equipment rentals/lease; printing and publication;
> computer use; training and staff development costs (i.e. registration
> fees). If a cost does not clearly fit under another category, and it
> qualifies as an allowable cost, then rest assured this is where it
> belongs. [In the Justification:]{.underline} Provide a reasonable
> explanation for items in this category. For individual consultants,
> explain the nature of services provided and the relation to activities
> in the work plan. Describe the types of activities for staff
> development costs.
>
> [Line 6i]{.underline}: [Total Direct Charges]{.underline}: Show the
> totals of Lines 6a through 6h.
>
> [Line 6j]{.underline}: [Indirect Charges]{.underline}: Enter the total
> amount of indirect charges (costs), if any. If
>
> no indirect costs are requested, enter \"none.\" Indirect charges may
> be requested if: (1) the applicant has a current indirect cost rate
> agreement approved by the Department of Health and Human Services or
> another federal agency; or (2) the applicant is a state or local
> government agency.
>
> Justification: [State governments should enter the amount of indirect
> costs determined in accordance with DHHS requirements]{.underline}. An
> applicant that will charge indirect costs to the grant must enclose a
> copy of the current rate agreement. If the applicant organization is
> in the process of initially developing or renegotiating a rate, it
> should immediately upon notification that an award will be made,
> develop a tentative indirect cost rate proposal based on its most
> recently completed fiscal year in accordance with the principles set
> forth in the cognizant agency\'s guidelines for establishing indirect
> cost rates, and submit it to the cognizant agency. Applicants awaiting
> approval of their indirect cost proposals may also request indirect
> costs. It should be noted that when an indirect cost rate is
> requested, those costs included in the indirect cost pool should not
> also be charged as direct costs to the grant. Also, if the applicant
> is requesting a rate which is less than what is allowed under the
> program, the authorized representative of the applicant organization
> must submit a signed acknowledgement that the applicant is accepting a
> lower rate than allowed.
>
> [Line 6k]{.underline}: [Total]{.underline}: Enter the total amounts of
> Lines 6i and 6j.
>
> [Line 7]{.underline}: [Program Income]{.underline}: As appropriate,
> include the estimated amount of income, if any, you expect to be
> generated from this project that you wish to designate as match (equal
> to the amount shown for Item 15(f) on Form 424). [Note]{.underline}:
> Any program income indicated at the bottom of Section B and for item
> 15(f) on the face sheet of Form 424 will be included as part of
> non-Federal match and will be subject to the rules for documenting
> completion of this pledge. If program income is expected, but is not
> needed to achieve matching funds, do not include that portion here or
> on Item 15(f) of the Form 424 face sheet. Any anticipated program
> income that will not be applied as grantee match should be described
> in the Level of Effort section of the Program Narrative.

##### Section C ‑ Non‑Federal Resources

> [Line 12]{.underline}: Enter the amounts of non‑Federal resources that
> will be used in carrying out the proposed project, by source
> (Applicant; State; Other) and enter the total amount in Column (e). Do
> not include program income unless it is used to meet the match
> requirement. Keep in mind that if program income used to meet the
> match requirement and the projected level of program income is not
> met, thereby decreasing the level of match, the amount of federal
> funds available to the grantee may be reduced if the match falls below
> required levels.
>
> [Section D ‑ Forecasted Cash Needs]{.underline} - Not applicable.
>
> [Section E ‑ Budget Estimate of Federal Funds Needed for Balance of
> the Project]{.underline}
>
> [Line 20]{.underline}: NOTE: Leave this line blank. Section E is
> relevant only for multi-year grant applications, where the project
> period is 24 months or longer. This section does not apply to grant
> awards where the project period is less than 17 months.

###### Section F ‑ Other Budget Information

> [Line 22]{.underline}: [Indirect Charges]{.underline}: Enter the type
> of indirect rate (provisional, predetermined,
>
> final or fixed) to be in effect during the funding period, the base to
> which the rate is applied, and the total indirect costs. Include a
> copy of your current Indirect Cost Rate Agreement.
>
> [Line 23]{.underline}: [Remarks]{.underline}: Provide any other
> comments deemed necessary.

###### c. Standard Form 424B - Assurances

> This form contains assurances required of applicants under the
> discretionary funds programs administered by the Administration on
> Aging. Please note that a duly authorized representative of the
> applicant organization must certify that the organization is in
> compliance with these assurances.

###### d. AoA Certification

> This form contains certifications that are required of the applicant
> organization regarding (a) lobbying; (b) debarment, suspension, and
> other responsibility matters; and (c) drug-free workplace
> requirements. Please note that a duly authorized representative of the
> applicant organization must attest to the applicant's compliance with
> these certifications.

###### e. Other Application Components

**Survey on Ensuring Equal Opportunity for Applicants**

> The Office of Management and Budget (OMB) has approved an HHS form to
> collect information on the number of faith-based groups applying for a
> HHS grant. Non-profit organizations, excluding private universities,
> are asked to include a completed survey with their grant application
> packet. Attached you will find the OMB approved HHS "Survey on
> Ensuring Equal Opportunity for Applicants" form (Attachment G). Your
> help in this data collection process is greatly appreciated.

**Proof of Non-Profit Status**

> Non-profit applicants must submit proof of non-profit status. Any of
> the following constitutes acceptable proof of such status:
>
> A copy of a currently valid IRS tax exemption certificate.
>
> A statement from a State taxing body, State attorney general, or other
> appropriate State official certifying that the applicant organization
> has a non-profit status and that none of the net earnings accrue to
> any private shareholders or individuals.
>
> A certified copy of the organization's certificate of incorporation or
> similar document that clearly establishes non-profit status.

## Indirect Cost Agreement

> Applicants that have included indirect costs in their budgets must
> include a copy of the current indirect cost rate agreement approved by
> the Department of Health and Human Services or another federal agency.
> This is optional for applicants that have not included indirect costs
> in their budgets.

**Attachment C: Budget Justification, Page 1 -- Sample Format with
EXAMPLES**

+----------+-------+------+------+------+-----------------------------+
| >        | **Fe  | **N  | **N  | # T  | ### Justification           |
| **Object | deral | on-F | on-F | OTAL |                             |
| > Class  | Fu    | eder | eder |      |                             |
| > Ca     | nds** | al** | al** |      |                             |
| tegory** |       |      |      |      |                             |
|          |       | **Ca | **I  |      |                             |
|          |       | sh** | n-Ki |      |                             |
|          |       |      | nd** |      |                             |
+----------+-------+------+------+------+-----------------------------+
| **Per    | \$4   |      |      | \$45 | Project Supervisor (name) = |
| sonnel** | 5,000 |      |      | ,000 | .3FTE @ \$50,000/yr =       |
|          |       |      |      |      | \$15,000                    |
|          |       |      |      |      |                             |
|          |       |      |      |      | Project Director (name) =   |
|          |       |      |      |      | 1FTE @ \$30,000 = \$30,000  |
+----------+-------+------+------+------+-----------------------------+
| **Fringe | \$1   |      |      | \$12 | Fringes on Supervisor and   |
| Be       | 2,600 |      |      | ,600 | Director @ 28% of salary.   |
| nefits** |       |      |      |      |                             |
|          |       |      |      |      | FICA (7.65%) = \$3,442      |
|          |       |      |      |      |                             |
|          |       |      |      |      | Health (12%) = \$5,400      |
|          |       |      |      |      |                             |
|          |       |      |      |      | Dental (5%) = \$2,250       |
|          |       |      |      |      |                             |
|          |       |      |      |      | Life (2%) = \$ 900          |
|          |       |      |      |      |                             |
|          |       |      |      |      | Workers Comp Insurance      |
|          |       |      |      |      | (.75%) = \$ 338             |
|          |       |      |      |      |                             |
|          |       |      |      |      | Unemployment Insurance      |
|          |       |      |      |      | (.6%) = \$ 270              |
+----------+-------+------+------+------+-----------------------------+
| **       | \$    |      |      | \$3  | Travel to Annual Grantee    |
| Travel** | 3,967 |      |      | ,967 | Meeting:                    |
|          |       |      |      |      |                             |
|          |       |      |      |      | Airfare: 1 RT x 2 people x  |
|          |       |      |      |      | \$750/RT = \$1,500          |
|          |       |      |      |      |                             |
|          |       |      |      |      | Lodging: 3 nights x 2       |
|          |       |      |      |      | people x \$100/night = \$   |
|          |       |      |      |      | 600                         |
|          |       |      |      |      |                             |
|          |       |      |      |      | Per Diem: 4 days x 2 people |
|          |       |      |      |      | x \$40/day = \$ 320         |
|          |       |      |      |      |                             |
|          |       |      |      |      | Out-of-Town Project Site    |
|          |       |      |      |      | Visits                      |
|          |       |      |      |      |                             |
|          |       |      |      |      | Car mileage: 3 trips x 2    |
|          |       |      |      |      | people x 350 miles/trip     |
|          |       |      |      |      |                             |
|          |       |      |      |      | x \$ .365/mile = \$ 767     |
|          |       |      |      |      |                             |
|          |       |      |      |      | Lodging: 3 trips x 2 people |
|          |       |      |      |      | x 1 night/ trip             |
|          |       |      |      |      |                             |
|          |       |      |      |      | x \$50/night = \$300        |
|          |       |      |      |      |                             |
|          |       |      |      |      | Per Diem: 3 trips x 2       |
|          |       |      |      |      | people x 2days/trip         |
|          |       |      |      |      |                             |
|          |       |      |      |      | x \$40/day = \$480          |
+----------+-------+------+------+------+-----------------------------+

Attachment C: Budget Justification, Page 2 - Sample Format with EXAMPLES

+------+------+------+------+------+----------------------------------+
| **Ob | **F  | #    | *    | ##   | ### Justification                |
| ject | eder | #### | *Non | ## * |                                  |
| Cla  | al** |  Non | -Fed | [TOT |                                  |
| ss** |      | -Fed | eral | AL]{ |                                  |
|      | # F  | eral | I    | .und |                                  |
| **Ca | unds |      | n-Ki | erli |                                  |
| tego |      | ##   | nd** | ne}* |                                  |
| ry** |      | ###  |      |      |                                  |
|      |      | Cash |      |      |                                  |
+------+------+------+------+------+----------------------------------+
| *    | 0    | 0    | 0    | 0    | No equipment requested           |
| *Equ |      |      |      |      |                                  |
| ipme |      |      |      |      |                                  |
| nt** |      |      |      |      |                                  |
+------+------+------+------+------+----------------------------------+
| **Su | \$3  |      |      | \$3  | Laptop computer for use in       |
| ppli | ,500 |      |      | ,500 | client intakes = \$1,340         |
| es** |      |      |      |      |                                  |
|      |      |      |      |      | Consumable supplies (paper,      |
|      |      |      |      |      | pens, etc.)                      |
|      |      |      |      |      |                                  |
|      |      |      |      |      | \$100/mo x 12 months = \$1,200   |
|      |      |      |      |      |                                  |
|      |      |      |      |      | Copying \$80/mo x 12 months = \$ |
|      |      |      |      |      | 960                              |
+------+------+------+------+------+----------------------------------+
| **C  | \    |      | 0    | \    | Contracts to A,B,C direct        |
| ontr | $250 |      |      | $250 | service providers (name          |
| actu | ,000 |      |      | ,000 | providers)                       |
| al** |      |      |      |      |                                  |
|      |      |      |      |      | adult day care contractor =      |
|      |      |      |      |      | \$75,000                         |
|      |      |      |      |      |                                  |
|      |      |      |      |      | respite care contractor in home= |
|      |      |      |      |      | \$75,000                         |
|      |      |      |      |      |                                  |
|      |      |      |      |      | respite care contractor-NF =     |
|      |      |      |      |      | \$50,000                         |
|      |      |      |      |      |                                  |
|      |      |      |      |      | personal care/companion provider |
|      |      |      |      |      | = \$50,000                       |
|      |      |      |      |      |                                  |
|      |      |      |      |      | See detailed budget              |
|      |      |      |      |      | justification for each provider  |
|      |      |      |      |      | (and then provide it!)           |
+------+------+------+------+------+----------------------------------+

+-----+-----+------+------+------+-----------------------------------+
| A   |     |      |      |      |                                   |
| tta |     |      |      |      |                                   |
| chm |     |      |      |      |                                   |
| ent |     |      |      |      |                                   |
| C:  |     |      |      |      |                                   |
| Bud |     |      |      |      |                                   |
| get |     |      |      |      |                                   |
| Ju  |     |      |      |      |                                   |
| sti |     |      |      |      |                                   |
| fic |     |      |      |      |                                   |
| ati |     |      |      |      |                                   |
| on, |     |      |      |      |                                   |
| P   |     |      |      |      |                                   |
| age |     |      |      |      |                                   |
| 3   |     |      |      |      |                                   |
| --  |     |      |      |      |                                   |
| Sam |     |      |      |      |                                   |
| ple |     |      |      |      |                                   |
| For |     |      |      |      |                                   |
| mat |     |      |      |      |                                   |
| w   |     |      |      |      |                                   |
| ith |     |      |      |      |                                   |
| EX  |     |      |      |      |                                   |
| AMP |     |      |      |      |                                   |
| LES |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| **O | \$  |      |      | \$37 | Local conference registration fee |
| the | 37, |      |      | ,800 | (name conference) = \$ 200        |
| r** | 800 |      |      |      |                                   |
|     |     |      |      |      | Printing brochures (50,000 @ \$   |
|     |     |      |      |      | .05 ea) = \$ 2,500                |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Video production = \$19,800       |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Video Reproduction = \$ 3,500     |
|     |     |      |      |      |                                   |
|     |     |      |      |      | NF Respite Training Manual        |
|     |     |      |      |      | reproduction                      |
|     |     |      |      |      |                                   |
|     |     |      |      |      | \$3/manual x \$2000 manuals = \$  |
|     |     |      |      |      | 6,000                             |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Postage \$150/mo x 12 months = \$ |
|     |     |      |      |      | 1,800                             |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Caregiver Forum meeting room      |
|     |     |      |      |      | rentals                           |
|     |     |      |      |      |                                   |
|     |     |      |      |      | \$200/day x 12 forums = \$ 2,400  |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Respite Training Scholarships =   |
|     |     |      |      |      | \$1,600                           |
+-----+-----+------+------+------+-----------------------------------+
| *   | 0   | 0    | 0    | 0    | None                              |
| *In |     |      |      |      |                                   |
| dir |     |      |      |      |                                   |
| ect |     |      |      |      |                                   |
| Cha |     |      |      |      |                                   |
| rge |     |      |      |      |                                   |
| s** |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| ##  | \$3 |      |      | \    |                                   |
| ### | 54, |      |      | $354 |                                   |
|  TO | 267 |      |      | ,267 |                                   |
| TAL |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+

Attachment D: Budget Justification -- Page 1 -- Sample Format

+------+-----+-----+-----+------+-----------------------------------+
| >    | **F | **N | **N | # T  | ### Justification                 |
| **Ob | ede | on- | on- | OTAL |                                   |
| ject | ral | Fed | Fed |      |                                   |
| > C  | F   | era | era |      |                                   |
| lass | und | l** | l** |      |                                   |
| > Ca | s** |     |     |      |                                   |
| tego |     | **  | **  |      |                                   |
| ry** |     | Cas | In- |      |                                   |
|      |     | h** | Kin |      |                                   |
|      |     |     | d** |      |                                   |
+------+-----+-----+-----+------+-----------------------------------+
| *    |     |     |     |      |                                   |
| *Per |     |     |     |      |                                   |
| sonn |     |     |     |      |                                   |
| el** |     |     |     |      |                                   |
+------+-----+-----+-----+------+-----------------------------------+
| **Fr |     |     |     |      |                                   |
| inge |     |     |     |      |                                   |
| Be   |     |     |     |      |                                   |
| nefi |     |     |     |      |                                   |
| ts** |     |     |     |      |                                   |
+------+-----+-----+-----+------+-----------------------------------+
| **   |     |     |     |      |                                   |
| Trav |     |     |     |      |                                   |
| el** |     |     |     |      |                                   |
+------+-----+-----+-----+------+-----------------------------------+
| *    |     |     |     |      |                                   |
| *Equ |     |     |     |      |                                   |
| ipme |     |     |     |      |                                   |
| nt** |     |     |     |      |                                   |
+------+-----+-----+-----+------+-----------------------------------+

**Attachment D: Budget Justification -- Page 2 -- Sample Format**

+------+------+------+----+------+-----------------------------------+
| >    | *    | **N  | *  | # T  | ### Justification                 |
| **Ob | *Fed | on-F | *N | OTAL |                                   |
| ject | eral | eder | on |      |                                   |
| > C  | Fun  | al** | -F |      |                                   |
| lass | ds** |      | ed |      |                                   |
| > Ca |      | **Ca | er |      |                                   |
| tego |      | sh** | al |      |                                   |
| ry** |      |      | ** |      |                                   |
|      |      |      |    |      |                                   |
|      |      |      | *  |      |                                   |
|      |      |      | *I |      |                                   |
|      |      |      | n- |      |                                   |
|      |      |      | Ki |      |                                   |
|      |      |      | nd |      |                                   |
|      |      |      | ** |      |                                   |
+------+------+------+----+------+-----------------------------------+
| **Su |      |      |    |      |                                   |
| ppli |      |      |    |      |                                   |
| es** |      |      |    |      |                                   |
+------+------+------+----+------+-----------------------------------+
| **C  |      |      |    |      |                                   |
| ontr |      |      |    |      |                                   |
| actu |      |      |    |      |                                   |
| al** |      |      |    |      |                                   |
+------+------+------+----+------+-----------------------------------+
| *    |      |      |    |      |                                   |
| *Oth |      |      |    |      |                                   |
| er** |      |      |    |      |                                   |
+------+------+------+----+------+-----------------------------------+
| **   |      |      |    |      |                                   |
| Indi |      |      |    |      |                                   |
| rect |      |      |    |      |                                   |
| C    |      |      |    |      |                                   |
| harg |      |      |    |      |                                   |
| es** |      |      |    |      |                                   |
+------+------+------+----+------+-----------------------------------+
| ###  |      |      |    |      |                                   |
| ## T |      |      |    |      |                                   |
| OTAL |      |      |    |      |                                   |
+------+------+------+----+------+-----------------------------------+