#  OMB Approval No: 0985-0018

# 

# 

# 

# Alzheimer's Disease Demonstration Grants to States (ADDGS) Program

# Program Announcement and Grant Application Instructions

# 

# 

# U.S. Administration on Aging

# 2007

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

**Administration on Aging (AoA)**

######## AoA Center for Wellness and Community-Based Services

######## Funding Opportunity Title: Alzheimer's Disease Demonstration Grants to States (ADDGS) Program

**Announcement Type: Initial**

**Funding Opportunity Number: HHS-2007-AoA-AZ-0703**

**Catalog of Federal Domestic Assistance (CFDA) Number: 93.051**

**Key Dates:** The deadline date for submission of applications is May
14, 2007.

***Additional Overview Content***

> The Administration on Aging (AoA) will hold a competition for grant
> awards to develop innovative approaches that enhance state systems and
> provide support to persons with Alzheimer's Disease and their family
> caregivers.
>
> All **project periods** are planned to begin July 1, 2007. Grant
> awards made under this announcement are subject to the availability of
> funds for the support of the priority area project activities
> described herein.
>
> With this announcement, AoA is continuing to strengthen the ADDGS
> Program by incorporating:

1.  A requirement that applicants, in the formulation of their project
    proposals, review and use findings from the research on
    evidence-based service models and techniques for supporting persons
    with Alzheimer's Disease and their family caregivers. (NOTE:
    Evidence-based research is defined as controlled research that has
    been published in scientific journals).

2.  A greater focus on using the ADDGS Program as a vehicle for
    advancing changes to a state's overall system of home and
    community-based care, including a requirement that project
    activities be linked to other state system change efforts, including
    state programs to streamline consumer access to services and family
    caregiver support programs.

3.  Due to the focus on systems change, a requirement that the State
    Project Director will devote at least 25% of their time to the
    implementation and management of this project.

4.  Implementation of an established OMB-approved data collection
    requirement that are necessary to fulfill our Government Performance
    and Results Act and statutory evaluation requirements.

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I.  **FUNDING OPPORTUNITY DESCRIPTION**

> The statutory authority for grant awards for the Alzheimer's Disease
> Demonstration Grants to States program is contained in Sec. 398 of the
> Public Health Service Act (P.L. 78-410; 42 U.S.C. 280c-3). It was
> amended by the Home Health Care and Alzheimer's Disease Amendments of
> 1990 (PL 101-557) and by the Health Professions Education Partnerships
> Act of 1998 (PL 105-392).
>
> AoA plans to fund approximately twenty-three (23) new one-year
> projects nationwide through this competition. The projects will be
> funded at a federal share of approximately \$250,000 - \$325,000 for a
> project period of one year (contingent on the availability of funds).
> A total of \$7,473,249 has been allocated for these one-year grants.
> **These 1-year grant options are available to all States that will not
> be receiving ADDGS funds as of July 1, 2007 or operating under a
> no-cost extension as of July 1, 2007.**
>
> Section 398 of the Public Health Service Act (42 U.S.C. 398 et seq.),
> as amended, requires that grantees provide a 25% match (cash or
> in-kind) during the first year of an ADDGS project. Under this
> program, AoA will fund no more than 75 % of the project's total cost
> in the first grant year, which means the applicant must cover at least
> 25% of the project's total cost with non-federal resources. Waivers to
> these match requirements are not allowed.
>
> States can use ADDGS grant funds to carry out demonstration projects
> for planning, establishing and operating programs:

1)  To coordinate the development and operation with public and private
    organizations of diagnostic, treatment, and care services provided
    within the State to individuals with Alzheimer's disease or related
    disorders and to the families and care providers of such
    individuals;

2)  To provide home health care, personal care, day care, companion
    services, short-term care in health facilities, and other respite
    care to individuals with Alzheimer's disease or related disorders
    who are living in single family homes or congregate settings. ([at
    least 50% of the total federal grant funds are to be spent on
    providing these direct services);]{.underline}

3)  To improve the access of such individuals to home-based or
    community-based long-term care services, particularly such
    individuals who are members of racial or ethnic minority groups, who
    have limited proficiency in speaking the English language, or who
    live in rural areas; and

4)  To provide, or to coordinate closely with Aging and Disability
    Resource Centers or other single point of entry systems to provide,
    to health care providers, to individuals with Alzheimer's disease or
    related disorders, to the families of such individuals, to
    organizations established for such individuals and such families,
    and to the general public, information with respect to:

    A.  diagnostic services, treatment services, and related services
        available to such individuals and to the families of such
        individuals;

    B.  sources of assistance in obtaining such services, including
        assistance under entitlement programs; and

    C.  the legal rights of such individuals and such families.

> Alzheimer\'s disease (AD) is a progressive, degenerative disease of
> the brain, and the most common form of dementia. Discovered and
> described in 1906 by Dr. Alois Alzheimer, AD now affects approximately
> 4 million Americans. Unless a cure or method of prevention is found,
> it is estimated that the number of Americans with Alzheimer's will
> climb to 14 million by the middle of the next century. Although AD is
> not a normal part of aging, one in 10 persons over 65 and nearly half
> of those over 85 may have Alzheimer's disease. A small percentage of
> people in their 30s and 40s also develop the disease. Although AD
> eventually results in death, the disease can progress for years. A
> person with AD lives an average of 8 years, but can live as many as 20
> years or more from the onset of symptoms.
>
> To focus attention on this need, to encourage states to develop models
> of assistance for persons with Alzheimer's disease, and to encourage
> close coordination and incorporation of those services into the
> broader home and community based care system, Congress created the
> Alzheimer's Disease Demonstration Grants to States (ADDGS) program in
> 1991. Congress transferred the administration of the program to the
> AoA in 1998, in an effort to ensure coordination with other programs
> for older Americans. To date, the ADDGS program has proven successful
> in targeting service and system development to traditionally
> underserved populations, including ethnic minorities, low-income and
> rural families coping with Alzheimer's disease.
>
> Since 1992, there have been fifty-one (51) states and territories
> funded through the Alzheimer's Disease Demonstration Grants to States
> program. In FY 2007, nine (9) states are not eligible to submit an
> application under this Program Announcement, because they are
> continuing current ADDGS grantees. These states include: Colorado,
> Illinois, Maryland, Michigan, Montana, New York, Texas, Washington,
> and West Virginia.
>
> Applications are sought from State Governmental agencies; the
> applicant agency is encouraged to have the support and active
> involvement of the Single State Agency on Aging (only one application
> per state will be funded) to carry out the following two program
> priorities, as applicable.

#### [Requirement 1:]{.underline} Use findings from evidence-based research on service models and techniques to support people with Alzheimer's Disease and their family caregivers, in the formulation of ADDGS projects. 

####  ALL STATES MUST ADDRESS REQUIRMENT 1. 

#### *[Discussion]{.underline}*

> With this Program Announcement, AoA will continue to move the ADDGS
> program towards the use of an evidence-based approach to service
> innovation. Consistent with AoA's new emphasis on the use of "the best
> available science" in designing and implementing community-based
> programs, it is AoA's expectation that **[ALL]{.underline}**
> applicants will review and use available scientific research findings
> in the formulation of their project proposals. Possible evidence-based
> projects to review include, but are not limited to, findings from
> ***REACH*** (Resources for Enhancing Alzheimer's Caregiver Health) and
> ***REACH II*** projects (National Institute on Aging), ***Savvy
> Caregiver*** (University of Minnesota), ***Making Sense of Memory
> Loss*** (Mather Life Ways), and ***Reducing Disability in Alzheimer's
> Disease*** (University of Washington). Applicants are not expected to
> replicate research findings; but they are expected to review and use
> the existing research in formulation their project proposal and to
> [document this process by citing in their proposals the specific
> research that was examined.]{.underline}

Additional information on these and other evidence-based research that
has relevance for the ADDGS program can be found on the AoA Alzheimer's
Resource Room Web page detailing "Programs That Work."
([**www.aoa.gov/alz**/public/alzprof/ADDGS/programs.asp](http://www.aoa.gov/alz/public/alzprof/ADDGS/programs.asp))

**[Requirement 2:]{.underline} Use the ADDGS project to improve the
responsiveness of the state's overall system of home and community-based
care to the needs and preferences of persons with Alzheimer's Disease
and related disorders, and link the project to other state systems
change activities, including state efforts to streamline access to
services and programs that support family caregivers.**

**ALL STATES MUST ADDRESS REQUIREMENT 2.**

######## *[Discussion]{.underline}* {#discussion-1 .unnumbered}

The Department of Health and Human Services, as part of the President's
New Freedom Initiative, has provided states with a number of tools, in
the form of various grant programs, that states are using to make their
systems of long term care more responsive to the needs and preferences
of people with disabilities and more supportive of home and
community-based care. These "tools" include the National Family
Caregiver Support Program, the Aging and Disability Resource Center
program, the Real Choice Systems Change grants, and the Cash and
Counseling Next Steps Program.

As states look to the continued development of their home and community
based care systems, it is essential they consider ways to ensure that
their systems of care are responsive to the needs and preferences of
people with Alzheimer's Disease and their family caregivers. As you
develop your program, be mindful of how you will coordinate and
collaborate with aging network partner agencies, such as state and area
agencies on aging and providers; health care staff; community
organizations that work directly with persons with dementia; and other
appropriate entities to affect policy and service delivery at the state
and local levels.

With this grant announcement, we expect states to strategically advance
changes in the state's overall system of care for people with
Alzheimer's disease. In particular, AoA expects ADDGS activities to be
coordinated with other state systems change activities, including
efforts to streamline access (e.g., the AoA/CMS Aging and Disability
Resource Center grants program) and to programs that support family
caregivers (e.g., the National Family Caregiver Support Program).
Applicants [must]{.underline} include in their proposal their plan for
working with the Aging and Disability Resource Centers (ADRC's), [if
any]{.underline}, or other single point of entry system currently
operating in their state. Applicants must also include in their proposal
their plan for offering some of their ADDGS-specific direct services
(home health care, personal care, \[adult\] day care, companion
services, short-term care in health facilities, and other respite care)
using a consumer-directed model. Some states are already directing their
service dollars to people with dementia and their caregivers using a
variety of consumer directed models of care. There are a variety of
models for offering consumer directed care. For more information, we
encourage you to go to
[www.cashandcounseling.org](http://www.cashandcounseling.org/) to help
you determine what consumer directed model of care would work best in
your communities. [AoA will not fund grant applications for discrete,
stand-alone projects that are not connected to the state's overall
system change activities.]{.underline}

> AoA understands that methods for advancing system change with ADDGS
> grant funds may vary from state to state. AoA also recognizes that not
> all states will start from the same position of integrating
> Alzheimer's Disease programs into their long-term care system.
> Accordingly, to help ensure no state has an undue advantage or
> disadvantage in competing for funds under this announcement, AoA will
> evaluate proposals based on the **extent of the progress** a state
> expects to make under the grant in advancing system changes, not on
> the current status of state efforts to support people with Alzheimer's
> Disease and their family caregivers. States that already have systems
> that include major elements of the ADDGS Program will be successful
> only to the extent that further progress can be demonstrated (e.g., by
> adding additional functions, expanding geographical coverage,
> expanding target group coverage, etc.).

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

[One-year Grant Option:]{.underline}

-   Anticipated Total Priority Area Funding: \$7,473,249

-   Anticipated Number of Awards: 23

-   Ceiling on Amount of Individual Awards: \$325,000

-   Floor of Individual Amounts: none

-   Average Projected Award Amount: \$250,000 to \$325,000

-   Project Period for Awards: 12 month project with 12 month

> budget period, subject to the
>
> availability of funds

-   **These grants are available to all States that will not be
    receiving ADDGS funds as of July 1, 2007.**

**III. ELIGIBILITY INFORMATION**

**1. Eligible Applicants**

> This is a limited grant competition. Awards will only be made to
> agencies of State Governments. The applicant agency is encouraged to
> have the support and active involvement of the Single State Agency on
> Aging. Only one application per State will be funded; however,
> multiple state and local agencies are encouraged to collaborate in
> planning and carrying out the project.
>
> All States, except those who will be receiving ADDGS funds as of July
> 1, 2007, are eligible to apply. Preference, however, will be given to
> States that have not previously been funded through this program.
>
> **2. Cost Sharing or Matching**
>
> Section 398 of the Public Health Service Act (42 U.S.C. 398 et seq.),
> as amended, requires that grantees provide a 25% match (cash or
> in-kind) of total costs during the first year of an ADDGS project.
> Waivers to these match requirements are not allowed.

**The formula for calculating the required first year match is:**

> [Federal Funds requested (i.e., \$320,000) x Applicant Match Rate
> (i.e., 25%)]{.underline} = Project
>
> Federal Match Rate (i.e., 75%) Match
>
> Under this program, AoA will fund no more than 75 % of the project's
> total cost in the first grant year, which means the applicant must
> cover at least 25% of the project's total cost with non-federal
> resources. In other words, for every three (3) dollars received in
> federal funding, the applicant must contribute at least one (1) dollar
> in non-federal resources toward the project's total cost (i.e., the
> amount on line 15g.). This "three-to-one" ratio is reflected in the
> above formula which you can use to calculate your minimum required
> match: A common error applicants make is to match 25% of the federal
> share, rather than 25% of the project's total cost, so be sure to use
> the above formula to calculate your match requirement.
>
> **3. Other**
>
> Applicants must involve community-based organizations in the planning
> and implementation of their project. Applicants must also include
> disadvantaged populations, including limited-English speaking
> populations, as a target population for their proposed intervention.
> Priority will be given to States that propose to focus their
> activities and services to support populations that are underserved by
> public and private programs in the state or territory because of their
> income, culture or language, geographic location (rural), and
> developmental disability.
>
> Due to the focus on systems change, it is expected that the State
> Project Director will devote at least 25% of their time to the
> implementation and management of this project. This information should
> be reflected in the budget justification included with all
> applications. States that fail to meet this requirement will not be
> funded.
>
> In an effort to replicate best practices and implement 'lessons
> learned' in the field, applicants are encouraged to look to other
> ADDGS program models as they develop a plan for their state and
> communities. For example, many current ADDGS grantees (42%) are
> collaborating with their ADRCs or other single point of entry systems;
> many (66%) are directing their service dollars to people with dementia
> and their caregivers using a variety of consumer directed models of
> care; and several (37%) are implementing evidence-based research
> programs in their communities.
>
> The ADDGS National Resource Center is compiling toolkits to assist
> states with dementia capable delivery of key components of the
> upcoming services. Toolkits will cover (1) Working with your ADRC; (2)
> Dementia Capable Consumer Directed Services; and (3) Implementing
> Evidence-Based Research that is specific to persons with dementia and
> their caregivers. ADDGS National Resource Center staff is available to
> provide information and technical assistance regarding best practice
> models or resources, on a variety of topics, to all prospective
> applicants. To speak with an ADDGS National Resource Center staff
> person, please call 202-393-7737.
>
> Finally, a few online resources available to assist you with your
> planning and program implementation include:

-   AoA's Alzheimer's Resource Room:
    [www.aoa.gov/alz](http://www.aoa.gov/alz).

-   ADDGS National Resource Center:
    <http://www.aoa.gov/alz/public/alzprof/ADDGS/ADDGS.asp>.

-   Aging and Disability Resource Centers:
    [www.adrc-tae.org](http://www.adrc-tae.org/).

-   Models of consumer directed care:
    [www.cashandcounseling.org](http://www.cashandcounseling.org/).

-   Evidence-Based Research: <http://www.healthyagingprograms.com/>.

> As you prepare your application, please remember that there are no age
> restrictions on who may be served through the ADDGS Program. Any
> person with Alzheimer's Disease or a related disorder or their
> caregiver, regardless of age, is eligible for ADDGS services. For
> example, if services were needed by a person with Early Onset
> dementia, which has been diagnosed in people well below age 60, or
> their caregiver, it would be acceptable to provide services through
> the ADDGS Program.
>
> TRAVEL: The application should include funds for the project
> leadership to participate in a 3-day annual national meeting of funded
> projects held in Washington, D.C. each autumn. Up to three (3)
> persons, one of whom must be the State Project Director, from each
> project may attend the annual meeting using grant funds. The 2007
> meeting is expected to held in early November 2007. ADDGS funds can be
> used to send up to three (3) project staff, including the Project
> Director, to the annual grantees' training meeting. Additionally, the
> application should include funds for up to two (2) key project staff
> to participate in a Regional Technical Assistance Workshop. During
> September 2007, it is expected that grantee states east of the
> Mississippi River will meet in Chicago, Illinois and grantee states
> west of the Mississippi River will meet in Houston, Texas.

######  Application Screening Criteria

> All applications will be screened to assure a level playing field for
> all applicants. Applications that fail to meet the screening criteria
> described below will **[not]{.underline}** be reviewed and will
> receive **[no]{.underline}** further consideration.
>
> In order for an application to be reviewed, it must meet the following
> screening requirements:

1.  Applications must be submitted electronically via
    [www.grants.gov](http://www.grants.gov/) by midnight May 14, 2007.

2.  The Project Narrative section of the Application must be
    double-spaced, on 8 ½" x 11" plain white paper with 1" margins on
    both sides, and a font size of not less than 11.

3.  The Project Narrative must [not]{.underline} exceed 20 pages. NOTE:
    The Project Work Plan, Letters of Commitment, and Vitae of Key
    Project Personnel **[are not counted]{.underline}** as part of the
    Project Narrative for purposes of the 20-page limit.

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IV. **APPLICATION AND SUBMISSION INFORMATION**

## 1. Address to Request Application Package 

> Application materials can be obtained from
> <http://www.aoa.gov/doingbus/fundopp/fundopp.asp> or
> [http://www.grants.gov](http://www.grants.gov/).

Application materials are also available by writing to:

U.S. Department of Health and Human Services

Administration on Aging

Lori Stalbaum

Center for Wellness & Community-Based Services

Washington, D.C. 20201

Or by calling: 202-357-3452.

Or e-mailing: <Lori.Stalbaum@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 your organization is 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 them at**
[support@grants.gov](mailto:support@grants.gov?subject=Support) **or
1-800-518-4726 between 7 a.m. and 9 p.m. Eastern.** 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
    93.051]{.underline}.

-   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.

-   Each year organizations registered to apply for federal grants
    through [www.grants.gov](http://www.grants.gov/) will need to renew
    their registration with the Central Contractor Registry (CCR). You
    can register with the CCR online and it will take about 30 minutes
    ([www.grants.gov/CCRRegister](http://www.grants.gov/CCRRegister)).
    You should receive your CCR registration within 7 -- 10 business
    days.  

-   You will not receive additional point value because you submit a
    grant application in paper format.

-   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 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.

-   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 (93.051).

###### 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**

##  

> The Project Narrative must be double-spaced, on 8 ½" x 11" paper with
> 1" margins on both sides, and a font size of not less than 11. You can
> use smaller font sizes to fill in the Standard Forms and Sample
> Formats. The suggested length for the Project Narrative is ten to
> twenty pages; twenty pages is the maximum length allowed. AoA will not
> accept applications with a Project Narrative that exceeds 20 pages.
> The Project Work Plan, Letters of Cooperation, and Vitae of Key
> Personnel are not counted as part of the Project Narrative for
> purposes of the 20-page limit, but all of the other sections noted
> below are included in the limit.
>
> The components counted as part of the 20 page limit include:

-   Summary/Abstract

-   Problem Statement

-   Goal(s) and Objective(s)

-   Proposed Intervention

-   Special Target Populations and Organizations

-   Outcomes

-   Project Management

-   Evaluation

-   Dissemination

-   Organizational Capability

The Project Narrative is the most important part of the application,
since it will be used as the primary basis by AoA to determine whether
or not your project meets the minimum requirements for grants under Sec.
398 of the Public Health Service Act (42 U.S.C. 398 et seq.), as amended
by Public Law 101-157 and by 105-379, the Health Professions Education
Partnerships Act of 1998.

+-----------------------------------------------------------------------+
| **[Special Requirements of the Alzheimer's Demonstration              |
| Program]{.underline}**                                                |
|                                                                       |
| The statute governing the ADDGS program states, "the State agrees to  |
| expend not less than 50 percent of the grant for the provision of     |
| \[direct\] services" to persons with Alzheimer's disease and their    |
| families. \[EXAMPLE: if a State receives \$300,000 in Federal grant   |
| funds in their first project year, the State match would be 25% or    |
| \$100,000, therefore, first year funds available would be \$400,000.  |
| Of this \$400,000, the State would be expected to spend not less than |
| \$150,000 (1/2 of the federal grant amount of \$300,000) on the       |
| provision of direct services.\]                                       |
|                                                                       |
| Those services which are listed as "direct services" in the program's |
| statute                                                               |
|                                                                       |
| are: "...home health care, personal care, \[adult\] day care,         |
| companion services, short-term care in health facilities, and other   |
| respite care to individuals with Alzheimer's disease or related       |
| disorders that are living in single family homes or congregate        |
| settings."                                                            |
|                                                                       |
| > Also, keep in mind **that no more than 10% of the overall project   |
| > can be spent on administrative costs**. This is required by         |
| > statute. AoA encourages states to maximize all resources and keep   |
| > administrative costs as low as possible.                            |
|                                                                       |
| Proposals cannot be funded if they do not meet the minimum 50% in     |
| provision of direct service (see example above) and if they exceed    |
| the 10% administrative costs (see example below) requirements. For    |
| the purpose of this program [only]{.underline}, administrative        |
| functions are those that are necessary but adjunct to the work being  |
| conducted to achieve the project goals and work plan objectives.      |
|                                                                       |
| *For Example*: If the project has goals and activities related to     |
| systems change, and one of the strategies in the work plan is to      |
| establish a committee of various community and public stakeholders    |
| that collaborate in a variety of ways to create, maintain, & support  |
| systems change, then the staff time necessary to coordinate, staff,   |
| and manage that committee, including related supply and travel        |
| expenses for committee members, is **[not]{.underline}** an           |
| administrative function.                                              |
|                                                                       |
| The project director's behind the scenes work, however, such as       |
| shepherding a contract through the state procurement process,         |
| personnel management functions, etc., **[are]{.underline}**           |
| considered administrative costs. While these functions are necessary  |
| to achieve the overall project goals, they are additional             |
| (administrative) activities being conducted as part of the work plan. |
+-----------------------------------------------------------------------+

The Project Narrative should provide a **clear and concise** description
of your project. AoA recommends that your project narrative include the
following components:

> **Summary/Abstract.** This section should include a brief - no more
> than 180 words maximum - description of the proposed project,
> including: the goal, the list of objectives and the products to be
> developed. Detailed instructions for completing the summary/abstract
> are included in the appendix of this document.
>
> **Problem Statement.** This section should describe, in both
> quantitative and qualitative terms, the nature and scope of the
> particular problem or issue the proposed intervention is designed to
> address, including how the project will potentially affect the elderly
> population and/or their caregivers (including specific subgroups
> within those populations), and possibly the health care and social
> services systems (e.g., the use of health care and/or nursing home
> services.) (Suggested Length and Format: two to four paragraphs.)
>
> **Goals and Objectives.** This section should consist of a description
> of the project's goal(s) and major objectives. NOTE: Unless the
> project involves multiple, complex interventions, we recommend you
> have only one overall goal. (Suggested Length and Format: Preferably,
> include this information in the attached project work plan grid;
> alternatively, use a bulleted format or describe in one paragraph.)
>
> **Proposed Intervention.** This section should provide a clear and
> concise description of the intervention you are proposing to use to
> address the problem described in section 2. You should also describe
> the rationale for using the particular intervention, including factors
> such as: "lessons learned" for similar projects previously tested,
> whether in your community or in other areas of the country; factors in
> the larger environment that have created the "right conditions" for
> the intervention (e.g., existing social, economic or political factors
> that you'll be able to take advantage of, etc.). Also note any major
> barriers you anticipate encountering, and how your project will be
> able to overcome those barriers. Be sure to describe the role and
> makeup of any strategic partnerships you plan to involve in
> implementing the intervention, including other organizations, funders,
> and/or consumer groups. (Suggested Length and Format: Four to six
> paragraphs.)
>
> **Special Target Populations and Organizations.** This section should
> describe how you plan to involve community-based organizations in a
> meaningful way in the planning and implementation of the proposal
> project. This section should also describe how the proposed
> intervention will target disadvantaged populations, including
> limited-English speaking populations.
>
> **Outcomes**. This section of the project narrative must clearly
> identify the [measurable]{.underline} outcome(s) that will result from
> the project. (NOTE: AoA will not fund any project that does not
> include measurable outcomes). This section should also describe how
> the project's findings might benefit the field at large, (e.g., how
> the findings could help other organizations throughout the nation to
> address the same or similar problems.) List measurable outcomes in the
> attached work plan grid (Attachment D) under "Measurable Outcomes" in
> addition to any discussion included in the narrative along with a
> description of how the project might benefit the field at large.
>
> A "measurable outcome" is an observable end-result that describes how
> a particular intervention benefits consumers. It demonstrates the
> functional status, mental well-being, knowledge, skill, attitude,
> awareness or behavior.) It can also describe a change in the degree to
> which consumers exercise choice over the types of services they
> receive, or whether they are satisfied with the way a service is
> delivered. Additional examples include: a change in the responsiveness
> or cost-effectiveness of a service delivery system; a new model of
> support or care that can be replicated in the aging network; or new
> knowledge that can contribute to the field of aging. A measurable
> outcome is not a measurable "output", such as: the number of clients
> served; the number of training sessions held; or the number of service
> units provided.
>
> You should keep the focus of this section on describing
> [what]{.underline} outcome(s) will be produced by the project. You
> should use the Evaluation section noted below to describe
> [how]{.underline} the outcome(s) will be measured and reported.
>
> Your application will be scored on the clarity and nature of your
> proposed outcomes, not on the number of outcomes cited. It is totally
> appropriate for a project to have only ONE outcome that it is trying
> to achieve through the intervention reflected in the project's design.
>
> **Project Management**. This section should include a clear
> delineation of the roles and responsibilities of project staff,
> consultants and partner organizations, and how they will contribute to
> achieving the project's objectives and outcomes. It should specify who
> will have day-to-day responsibility for key tasks such as: leadership
> of project; monitoring the project's on-going progress, preparation of
> reports; communications with other partners and AoA. It should also
> describe the approach that will be used to monitor and track progress
> on the project's tasks and objectives. Remember the state Project
> Director needs to allocate 25% of their FTE (full-time equivalency) to
> the direction, management, and oversight of the state's ADDGS Program.
> (Suggested Length and Format: Three paragraphs.)
>
> **Evaluation**. This section should describe the method(s), techniques
> and tools that will be used to: 1.) determine whether or not the
> proposed intervention achieved its anticipated outcome(s), and 2.)
> document the "lessons learned" -- both positive and negative - from
> the project that will be useful to people interested in replicating
> the intervention, if it proves successful. (Suggested Length and
> Format: Five to eight paragraphs.)
>
> **Dissemination.** This section should describe the method that will
> be used to disseminate the project's results and findings in a timely
> manner and in easily understandable formats, to parties who might be
> interested in using the results of the project to inform practice,
> service delivery, program development, and/or policy-making, including
> and especially those parties who would be interested in replicating
> the project. (Suggested Length -- three to five paragraphs.)
>
> **Data Collection**. Applicants for this funding opportunity must
> demonstrate a clear commitment to ADDGS program evaluation as a
> critical component of success and to ensure an environment of
> continuous improvement. AoA is establishing OMB-approved data
> collection requirements that are necessary to fulfill our Government
> Performance and Results Act and statutory evaluation requirements. AoA
> will work with grantees to efficiently implement the data collection
> requirements in an effort to minimize any disruption to existing data
> collection efforts states may have underway when starting the
> Alzheimer's Demonstration project. Copies of data collection protocols
> and instruments to be used in the Alzheimer's Demonstration Program
> are attached to this grant announcement. Applicants should provide
> confirmation in the application that the project will comply with
> these data collection requirements. Appropriate budgetary allowances
> should be proposed, if necessary, to cover any associated costs of
> data collection compliance. Grantees will be expected to begin
> collecting data immediately, however program data will only need to be
> submitted annually (no later than September 30^th^ of each project
> year).

## Organizational Capability Statement and Vitae for Key Project Personnel. Each application should include an organizational capability statement and vitae for key project personnel. The organizational capability statement should describe how the applicant agency (or the particular division of a larger agency which will have responsibility for this project) is organized, the nature and scope of its work and/or the capabilities it possesses. This description should cover capabilities of the applicant agency not included in the program narrative, such as any current or previous relevant experience and/or the record of the project team in preparing cogent and useful reports, publications, and other products. If appropriate, include an organization chart showing the relationship of the project to the current organization. Include short vitae for key project staff only. Also include information about any contractual organization(s) that will have a significant role(s) in implementing project and achieving project goals. 

> **Work Plan**. The Project Work Plan should reflect and be consistent
> with the Project Narrative and Budget. It should include a statement
> of the project's overall goal, anticipated outcome(s), key objectives,
> and the major tasks / action steps that will be pursued to achieve the
> goal and outcome(s). For each major task / action step, the work plan
> should identify the timeframes involved (including start- and
> end-dates), and the lead person responsible for completing the task. A
> Sample Work Plan format for your use is included in the Attachments.
> (Suggested Length and Format: use the sample grid; alternatively, not
> more than two pages preferably presented in bulleted format.)
>
> **Letters of Commitment from Key Participating Organizations and
> Agencies.**
>
> Include confirmation of the commitments to the project (should it be
> funded) made by [key]{.underline} collaborating organizations and
> agencies in this part of the application. Any organization that is
> specifically named to have a significant role in carrying out the
> project should be considered an essential collaborator.
>
> **3. Submission Dates and Times**

The deadline for the submission of applications under this program
announcement is

May 14, 2007. Applications must be submitted electronically by midnight
Eastern time, May 14, 2007.

Applications that fail to meet the application due date will
**[not]{.underline}** be reviewed and will receive **[no]{.underline}**
further consideration.

Grants.gov will automatically send applicants a tracking number and date
of receipt verification electronically once the application has been
successfully received and validated in Grants.gov.

**4. Intergovernmental Review**

> This funding opportunity announcement is not subject to the
> requirements of Executive Order 12372, "Intergovernmental Review of
> Federal Programs"

**5. Funding Restrictions**

The following activities are not fundable activities:

-   Construction and / or major rehabilitation of buildings

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

-   Income maintenance

-   Projects which do not involve new, innovative approaches and whose
    outcomes do not have the potential for nationwide dissemination and
    replication.

**6. Other Submission Requirements**

Electronic submissions must be sent to: http://www.grants.gov.

> Applicants submitting their application through
> [www.grants.gov](http://www.grants.gov/) 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> .

V.  **APPLICATION REVIEW INFORMATION**

> **1. *Criteria***

Applications are scored by assigning a maximum of 100 points across four
criteria:

-   Purpose and Need for Assistance (10 points);

-   Approach/Method -- Workplan and Activities (40 points);

-   Outcomes/Benefits/Impacts (25 points); and

-   Level of Effort, Program Management, Organizational Capacity (25
    points).

    a\. [Purpose and Need for Assistance]{.underline} [Weight: 10
    points]{.underline}

i.  Is the proposed project justified in terms of the most recent,
    relevant, and available information and knowledge? Are gaps in state
    systems of home and community-based care to AD patients and their
    family caregivers adequately identified and addressed? (5 points)

ii. Does the application adequately and appropriately describe and
    document the key problem(s)/ condition(s) relevant to its purpose?
    Does the applicant adequately and appropriately describe the needs
    of the targeted special population groups, i.e. low income,
    minority, and rural, and in identified system gaps when addressing
    problem(s)/condition(s) relevant to its proposal? (5 points)

    b\. [Approach/Method -- Work plan and Activities]{.underline}
    [Weight: 40 points]{.underline}

    i.  Does the proposed project adequately show that evidence-based
        scientific research findings were used to [inform]{.underline}
        project design, including the delivery of direct services? (7
        points) --

    ii. Does the proposed project effectively utilize a coordinated,
        collaborative approach, including partnerships with aging
        network agencies (state and area agencies on aging and
        providers), health care staff, community organizations that work
        directly with persons with AD, and other appropriate entities to
        strategically advance changes in the state's overall system of
        care for people with Alzheimer's Disease and related dementias?
        Are activities included in the work plan to engage and
        collaborate with state and local agencies and faith-based and
        dementia care organizations on crosscutting policy and service
        delivery issues? Are the proposed activities appropriate given
        the project goals and objectives? (10 points)

    iii. Does the applicant present a well-organized work plan that
         systematically includes specific goals, objectives, activities
         and implementation strategies that are responsive to the
         applicant's statement of needs and purpose? Are plans in
         sufficient detail to provide an understanding of the entire
         project's intended outcomes? (5 points)

    iv. Has the applicant adequately described their plan for the
        delivery of direct services for persons with Alzheimer's disease
        and their families, which should include the provision of a
        consumer-directed model for the delivery of some or all of the
        intended direct services to be provided? Are activities in the
        work plan, including those provided by contractors, adequate and
        appropriate to achieve direct service objectives? (10 points)

    v.  Has the applicant targeted at least one of the preferred target
        populations (i.e. ethnic minorities, low-income or rural persons
        with Alzheimer's disease and their families) AND are the
        proposed activities and collaborators adequate and appropriate
        for reaching the targeted population(s)? (5 points)

    vi. Does the work plan include a detailed timeline for the
        accomplishment of tasks and objectives? Is the sequence and
        timing of events logical and realistic? (3 points)

        c\. [Outcomes/Benefits/ Impact]{.underline} [Weight: 25
        points]{.underline}

```{=html}
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```
i.  Are the expected project outcomes measurable and clearly identified,
    realistic, and consistent with the objectives of the project? Will
    the outcomes enable the State to make significant progress, in
    relation to current state policy and programs, in meeting the needs
    and preferences of persons with Alzheimer's Disease and their family
    caregivers? (10 points)

ii. Does the proposal include a plan for dissemination that is likely to
    increase the awareness of project activities and events during
    project performance? (3 points)

iii. Is the long-term viability of the project discussed? Is the extent
     of progress a state expects to make under this grant in advancing
     state system changes reasonable and realistic given the states
     existing system? Does the proposal include a plan for streamlining
     access, which includes a plan for collaborating with any Aging &
     Disability Resource Centers operating in the applicant's state, and
     linking to programs and services that support family caregivers,
     such as the National Family Caregiver Support Program as well as
     other systems change programs in which the state is currently
     participating? (12 points)

     d\. [Level of Effort]{.underline} [Weight: 25 points]{.underline}

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```
i.  Does the applicant have an established track record of collaboration
    among a variety of local, state, and federal agencies and
    organizations, including those that are a part of this project? Are
    letters from [key]{.underline} participating organizations included
    and do they express the clear commitment and areas of responsibility
    of those organizations, consistent with the work plan description of
    their intended roles and contributions? (5 points)

ii. Are the roles and contribution of staff, consultants, and
    collaborative organizations clearly defined and linked to specific
    objects and tasks? Do the proposed project director(s), key staff,
    and consultants have the background, experience, and other
    qualifications required to carry out their designated roles? Is 25%
    of the Project Director's time allocated to this project? Are the
    writers of the proposal identified and will they be involved in the
    project's management and implementation? If not, is there a logical
    explanation for their non-participation? (5 points)

iii. Does the proposal provide adequate programmatic and logistical
     support at the state and local levels to ensure successful
     implementation of the project's goals and objectives? Does the
     Project Director have a significant level of effort in providing
     state oversight of community based direct service activities? Are
     tasks and services provided by contractors clearly spelled out in
     the program narrative and budget justification? (5 points)

iv. Does the applicant appear to have adequate data collection and
    reporting capacity? (4 points)

v.  Is the budget justified with respect to the adequacy and
    reasonableness of resources requested? Are budget line items
    consistent with and tied to the work plan objectives? (6 points)

    1.  Is at least 50% of the total federal grant allocated to direct
        services as defined in Program Scope of this announcement?

    2.  Are administrative costs under 10% of the total grant?

    3.  Is there adequate (25%) non-federal match provided? Are match
        resources reasonable?

**2. *Review and Selection Process***

> An independent review panel of at least three individuals will
> evaluate applications that pass the screening. These reviewers are
> experts in their field, and are drawn from academic institutions,
> non-profit organizations, state and local government, and federal
> government agencies other than AoA. Based on the specific programmatic
> considerations as outlined under "Requirement 1" and "Requirement 2,",
> section I, Funding Opportunity Description, the reviewers will comment
> on and score the applications, focusing their comments and scoring
> decisions on the criteria identified above.
>
> Final award decisions will be made by the Assistant Secretary for
> Aging (ASA). In making these decisions, the ASA will take into
> consideration: recommendations of the review panel; reviews for
> programmatic and grants management compliance; the reasonableness of
> the estimated cost to the government considering the available funding
> and anticipated results; and the likelihood that the proposed project
> will result in the benefits expected. Based on specific programmatic
> funding considerations as detailed under "Eligible Applicants,"
> section III, preference will be given to States that have not
> previously been funded through this program.

## Applicants have the option of omitting from the application copies (not the original) specific salary rates or amounts for individuals specified in the application budget and Social Security Numbers. The copies may include summary salary information. 

## 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. Unsuccessful
applicants are notified 30 days after successful applicants and will
receive a disapproval letter.

###### 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.

###### 3. *Reporting* 

> The SF-269 (Financial Status Report) is due annually and the AoA
> program progress report is due semi-annually. 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. Final
> performance and SF-269 reports are due 90 days after the end of the
> project period. For more information see DHHS / AoA Standard Terms and
> Conditions.

## VII. AGENCY CONTACTS 

> [Project Officer:]{.underline}
>
> U.S. Department of Health and Human Services
>
> Administration on Aging
>
> Washington, DC 20201
>
> Attn: Lori Stalbaum
>
> Telephone: (202) 357-3452, e-mail: <Lori.Stalbaum@aoa.hhs.gov>
>
> [Grants Management Officer:]{.underline}
>
> U.S. Department of Health and Human Services
>
> Administration on Aging
>
> Washington, DC 20201
>
> Attn: Stephen Daniels
>
> Telephone: (202) 357-3464, e-mail: <Stephen.daniels@aoa.hhs.gov>

## VIII. OTHER INFORMATION

###### A. 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 18d 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 18d on the SF 424).

> 5\. AoA Certification.
>
> 6\. Proof of non-profit status --N/A
>
> 7\. Copy of the applicant\'s most recent indirect cost agreement, as
> necessary.
>
> 8\. Project Narrative with Work Plan (See Attachments for Sample Work
> Plan Format).
>
> 9\. Organizational Capability Statement and Vitae for Key Project
> Personnel.
>
> 10\. Letters of Commitment from Key Partners.
>
> 11\. Completed Application Package Checklist
>
> 12\. "Survey on Ensuring Equal Opportunity for Applicants" (Optional
> non-profit applicants)
>
> **B**. **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.

**C. Additional Resources You Might Find Helpful**

As you prepare your proposal, you might find the following web resources
to be of assistance:

1\. [http://www.aoa.gov/alz]{.underline} The Administration on Aging's
Alzheimer's Resource Room, which provides general information on
Alzheimer's disease as well as a wealth of information and resources
developed by previous grantees of the Alzheimer's Demonstration program.

2\. [http://www.alz.org]{.underline} The Alzheimer's Association is a
good source for

information, support and assistance on issues related to Alzheimer's
disease.

3\. [http://www.nia.nih.gov/Alzheimers]{.underline} The Alzheimer's
Disease Education And Resource (ADEAR) Center, sponsored by the National
Institute on Aging, offers general information on Alzheimer's, clinical
trials and other Alzheimer's resources.

**ATTACHMENTS**

**Attachment A:**

**Instructions for completing the SF 424, Budget (SF 424A), Budget
Narrative and Other Required Forms**

**Attachment B:**

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

**Attachment C:**

**Budget Justification -- Sample Format**

**Attachment D:**

**Project Work Plan - Sample Format**

**Attachment E:**

**Instructions for Completing the Summary/Abstract**

**Attachment F:**

**"Survey on Ensuring Equal Opportunity for Applicants"**

**Attachment G:**

**Alzheimer's Demonstration Program**

**DATA COLLECTION PROTOCOL**

# Attachment A: 

# Instructions for completing the SF 424, Budget (SF 424A), Budget Narrative, and Other Required Forms

  -----------------------------------------------------------------------
  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
  in FY 2006, a new version of the SF 424 is being used for new grants.

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

###### a. Standard Form 424

[]{.mark}

1\. **Type of Submission:** (Required): Select one type of submission in
accordance with agency instructions.

• Preapplication • Application • Changed/Corrected Application -- If AoA
requests, check if this submission is to change or correct a previously
submitted application.

[]{.mark}

2\. **Type of Application**: (Required) Select one type of application
in accordance with agency instructions.

• New • Continuation • Revision

[]{.mark}

3\. **Date Received:** Leave this field blank.

4\. **Applicant Identifier**: Leave this field blank

5a **Federal Entity Identifier**: Leave this field blank

[]{.mark}

5b. **Federal Award Identifier**: For new applications leave blank. For
a continuation or revision to an existing award, enter the previously
assigned Federal award (grant) number.

[]{.mark}

6\. **Date Received by State:** Leave this field blank.

7\. **State Application Identifier:** Leave this field blank.

[]{.mark}

8\. **Applicant Information**: Enter the following in accordance with
agency instructions:

**a. Legal Name**: (Required): Enter the name that the organization has
registered with the Central Contractor Registry. Information on
registering with CCR may be obtained by visiting the Grants.gov website.

[]{.mark}

**b. Employer/Taxpayer Number (EIN/TIN):** (Required): Enter the
Employer or Taxpayer Identification Number (EIN or TIN) as assigned by
the Internal Revenue Service.

**c. Organizational DUNS**: (Required) Enter the organization's DUNS or
DUNS+4 number received from Dun and Bradstreet. Information on obtaining
a DUNS number may be obtained by visiting the Grants.gov website.

**d. Address**: (Required) Enter the complete address including the
county.

**e. Organizational Unit:** Enter the name of the primary organizational
unit (and department or division, if applicable**)** that will undertake
the project.

**f. Name and contact information of person to be contacted on matters
involving this application**: Enter the name (First and last name
required), organizational affiliation (if affiliated with an
organization other than the applicant organization), telephone number
(Required), fax number, and email address (Required) of the person to
contact on

matters related to this application.

9\. **Type of Applicant:** (Required) Select the applicant organization
"type" from the following drop down list.

A. State Government B. County Government C. City or Township Government
D. Special District Government E. Regional Organization F. U.S.
Territory or Possession G. Independent School District H. Public/State
Controlled Institution of Higher Education I. Indian/Native American
Tribal Government (Federally Recognized) J. Indian/Native American
Tribal Government (Other than Federally Recognized) K. Indian/Native
American Tribally Designated Organization L. Public/Indian Housing
Authority M. Nonprofit with 501C3 IRS Status (Other than Institution of
Higher Education) N. Nonprofit without 501C3 IRS Status (Other than
Institution of Higher Education) O. Private Institution of Higher
Education P. Individual Q. For-Profit Organization (Other than Small
Business) R. Small Business S. Hispanic-serving Institution T.
Historically Black Colleges and Universities (HBCUs) U. Tribally
Controlled Colleges and Universities (TCCUs) V. Alaska Native and Native
Hawaiian Serving Institutions W. Non-domestic (non-US) Entity X. Other
(specify)

[]{.mark}

10\. **Name Of Federal Agency**: (Required) Enter U.S. Administration on
Aging

[]{.mark}

11\. **Catalog Of Federal Domestic Assistance Number/Title:** The CFDA
number can be found on page one of the Program Announcement.

[]{.mark}

12\. **Funding Opportunity Number/Title:** (Required) The Funding
Opportunity Number and title of the opportunity can be found on page one
of the program announcement.

[]{.mark}

13\. **Competition Identification Number/Title:** Leave this field
blank.

[]{.mark}

14\. **Areas Affected By Project:** List the largest political entity
affected (cities, counties, state etc).

15\. **Descriptive Title of Applicant's Project:** (Required) Enter a
brief descriptive title of the project.

16\. **Congressional Districts Of**: (Required) 16a. Enter the
applicant's Congressional District, and 16b. Enter all district(s)
affected by the program or project. Enter in the format: 2 characters
State Abbreviation -- 3 characters District Number, e.g., CA-005 for
California 5th district, CA-012 for California 12^th^ district, NC-103
for North Carolina's 103rd district. • If all congressional districts in
a state are affected, enter "all" for the district number, e.g., MD-all
for all congressional districts in Maryland. • If nationwide, i.e. all
districts within all states are affected, enter US-all.

17\. **Proposed Project Start and End Dates**: (Required) Enter the
proposed start date and end date of the project.

18\. **Estimated Funding:** (Required) Enter the amount requested or to
be contributed during the first funding/budget period by each
contributor. Value of in-kind contributions should be included on
appropriate lines, as applicable. If the action will result in a dollar
change to an existing award, indicate only the amount of the change. For
decreases, enclose the amounts in parentheses.

**NOTE:** Applicants should review cost sharing or matching principles
contained in Subpart C of 45 CFR Part 74 or 45 CFR Part 92 before
completing Item 18 and the Budget Information Sections A, B and C noted
below.

All budget information entered under item 18 should cover the upcoming
budget period. For sub-item 18a, enter the federal funds being
requested. Sub-items 18b-18e is considered matching funds. The dollar
amounts entered in sub-items 18b-18f must total at least 1/3^rd^ of the
amount of federal funds being requested (the amount in 18a). For a full
explanation of AoA's match requirements, see the information in the box
below. For sub-item 18f, enter only the amount, if any, that is going to
be used as part of the required match.

There are three types of match: 1.) non-federal cash; 2.) non-federal
non-cash (i.e., in-kind); and 3.) program income. In general, costs
borne by the applicant and cash contributions of any and all third
parties involved in the project, including sub-grantees, contractors and
consultants, are considered [cash matching funds]{.underline}.
Generally, most contributions from third parties will be non-cash (i.e.,
in-kind) matching funds. Examples of [non-cash (in-kind)
match]{.underline} include: volunteered time and use of facilities to
hold meetings or conduct project activities. A third form of non-federal
match is projected [program income]{.underline} derived from activities
of the project such as participant fees and sale of publications. [Only
program income that is to be used as part of the required match should
be shown on Line 15.]{.underline}

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. **If indirect costs are to be included in the
application, a copy of the approved indirect cost agreement must be
included with the application.**

[]{.mark}

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> []{.mark}

[]{.mark}

19\. **Is Application Subject to Review by State Under Executive Order
12372 Process?** Check c. Program is not covered by E.O. 12372

20\. **Is the Applicant Delinquent on any Federal Debt?** (Required)
This question applies to the applicant organization, not the person who
signs as the authorized representative. If yes, include an explanation
on the continuation sheet.

21\. **Authorized Representative**: (Required) To be signed and dated by
the authorized representative of the applicant organization. Enter the
name (First and last name required) title (Required), telephone number
(Required), fax number, and email address (Required) of the person
authorized to sign for the applicant. A copy of the governing body's
authorization for you to sign this application as the official
representative must be on file in the applicant's office. (Certain
Federal agencies may require that this authorization be submitted as
part of the application.)

**b. Standard Form 424A**

[]{.mark}

+-----------------------------------------------------------------------+
| > 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. You should only consider and respond to the budget      |
| > items for which guidance is provided below. Unless otherwise        |
| > indicated, the SF 424A should reflect a one year budget.            |
+-----------------------------------------------------------------------+

##### 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 Narrative/Justification Requirement            |
|                                                                       |
| > You must submit a separate budget narrative 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 Narrative.** 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.
>
> []{.mark}
>
> [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.
>
> []{.mark}

##### 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. Certification Regarding Lobbying

> 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.

[]{.mark}

[]{.mark}

######### 

**Attachment B: 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   |      | \$5  | \$45 | Project Supervisor (name) = |
| sonnel** | 0,000 |      | ,000 | ,000 | .3FTE @ \$50,000/yr =       |
|          |       |      |      |      | \$15,000                    |
|          |       |      |      |      |                             |
|          |       |      |      |      | Project Director (name) =   |
|          |       |      |      |      | 1FTE @ \$30,000 = \$30,000  |
+----------+-------+------+------+------+-----------------------------+
| **Fringe | \$1   | 0    | 0    | \$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              |
+----------+-------+------+------+------+-----------------------------+
| **       | \$    | 0    | \$   | \$3  | Travel to Annual Grantee    |
| Travel** | 3,000 |      | 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 B: Budget Justification, Page 2 - Sample Format with EXAMPLES

+-----+-----+------+------+------+-----------------------------------+
| **  | **  | #    | *    | ##   | ### Justification                 |
| Obj | Fed | #### | *Non | ## * |                                   |
| ect | era |  Non | -Fed | [TOT |                                   |
| C   | l** | -Fed | eral | AL]{ |                                   |
| las |     | eral | I    | .und |                                   |
| s** | #   |      | n-Ki | erli |                                   |
|     |  Fu | ##   | nd** | ne}* |                                   |
| **C | nds | ###  |      |      |                                   |
| ate |     | Cash |      |      |                                   |
| gor |     |      |      |      |                                   |
| y** |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| *   | 0   | 0    | 0    | 0    | No equipment requested            |
| *Eq |     |      |      |      |                                   |
| uip |     |      |      |      |                                   |
| men |     |      |      |      |                                   |
| t** |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| **S | \   |      | \$2  | \$3  | Laptop computer for use in client |
| upp | $1, |      | ,000 | ,500 | intakes = \$1,340                 |
| lie | 500 |      |      |      |                                   |
| s** |     |      |      |      | Consumable supplies (paper, pens, |
|     |     |      |      |      | etc.)                             |
|     |     |      |      |      |                                   |
|     |     |      |      |      | \$100/mo x 12 months = \$1,200    |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Copying \$80/mo x 12 months = \$  |
|     |     |      |      |      | 960                               |
+-----+-----+------+------+------+-----------------------------------+
| **C | \$2 | \$50 | 0    | \    | Contracts to A,B,C direct service |
| ont | 00, | ,000 |      | $250 | providers (name providers)        |
| rac | 000 |      |      | ,000 |                                   |
| tua |     |      |      |      | adult day care contractor =       |
| l** |     |      |      |      | \$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 |     |      |      |      |                                   |
| B:  |     |      |      |      |                                   |
| Bud |     |      |      |      |                                   |
| get |     |      |      |      |                                   |
| Ju  |     |      |      |      |                                   |
| sti |     |      |      |      |                                   |
| fic |     |      |      |      |                                   |
| ati |     |      |      |      |                                   |
| on, |     |      |      |      |                                   |
| P   |     |      |      |      |                                   |
| age |     |      |      |      |                                   |
| 3   |     |      |      |      |                                   |
| --  |     |      |      |      |                                   |
| Sam |     |      |      |      |                                   |
| ple |     |      |      |      |                                   |
| For |     |      |      |      |                                   |
| mat |     |      |      |      |                                   |
| w   |     |      |      |      |                                   |
| ith |     |      |      |      |                                   |
| EX  |     |      |      |      |                                   |
| AMP |     |      |      |      |                                   |
| LES |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| **O | \$  | \$8  | \$19 | \$37 | Local conference registration fee |
| the | 10, | ,000 | ,800 | ,800 | (name conference) = \$ 200        |
| r** | 000 |      |      |      |                                   |
|     |     |      |      |      | 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** |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| ##  | \$2 | \$60 | \$27 | \    |                                   |
| ### | 65, | ,800 | ,767 | $354 |                                   |
|  TO | 700 |      |      | ,267 |                                   |
| TAL |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+

Attachment C: Budget Justification, Page 1 -- Sample Format

+-----+------+------+------+------+-----------------------------------+
| >   | *    | **N  | **N  | # T  | ### Justification                 |
|  ** | *Fed | on-F | on-F | OTAL |                                   |
| Obj | eral | eder | eder |      |                                   |
| ect | Fun  | al** | al** |      |                                   |
| >   | ds** |      |      |      |                                   |
|  Cl |      | **Ca | **I  |      |                                   |
| ass |      | sh** | n-Ki |      |                                   |
| > C |      |      | nd** |      |                                   |
| ate |      |      |      |      |                                   |
| gor |      |      |      |      |                                   |
| y** |      |      |      |      |                                   |
+-----+------+------+------+------+-----------------------------------+
| *   |      |      |      |      |                                   |
| *Pe |      |      |      |      |                                   |
| rso |      |      |      |      |                                   |
| nne |      |      |      |      |                                   |
| l** |      |      |      |      |                                   |
+-----+------+------+------+------+-----------------------------------+
| **  |      |      |      |      |                                   |
| Fri |      |      |      |      |                                   |
| nge |      |      |      |      |                                   |
| B   |      |      |      |      |                                   |
| ene |      |      |      |      |                                   |
| fit |      |      |      |      |                                   |
| s** |      |      |      |      |                                   |
+-----+------+------+------+------+-----------------------------------+
| *   |      |      |      |      |                                   |
| *Tr |      |      |      |      |                                   |
| ave |      |      |      |      |                                   |
| l** |      |      |      |      |                                   |
+-----+------+------+------+------+-----------------------------------+
| *   |      |      |      |      |                                   |
| *Eq |      |      |      |      |                                   |
| uip |      |      |      |      |                                   |
| men |      |      |      |      |                                   |
| t** |      |      |      |      |                                   |
+-----+------+------+------+------+-----------------------------------+

**Attachment C: 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 |      |      |    |      |                                   |
+------+------+------+----+------+-----------------------------------+

Attachment D: Project Work Plan, Page 1 -- Sample Format

  --------------- ------------------------------- ---------- ------------- -- -- -- -- -- -- -- -- -- -- --
  **Goal:**                                                                                              

  **Measurable                                                                                           
  Outcome(s):**                                                                                          

  **Major         **Key Tasks**                   **Lead     **Timeframe                                 
  Objectives**                                    Person**   (Start and                                  
                                                             End Date by                                 
                                                             Month)**                                    

  1\.                                                                                                    

                                                                                                         

                                                                                                         

                                                                                                         

  2\.                                                                                                    

                                                                                                         

                                                                                                         

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

Attachment D: Project Work Plan, Page 2 -- Sample Format

  -------------- ------------------------------- ---------- ------------- ------- ------- ------- ------- ------- ------- ------- ------- -------- -------- --------
  **Major        **Key Tasks**                   **Lead     **Timeframe                                                                                     
  Objectives**                                   Person**   (Start and                                                                                      
                                                            End Date by                                                                                     
                                                            Month)**                                                                                        

                                                            **1**         **2**   **3**   **4**   **5**   **6**   **7**   **8**   **9**   **10**   **11**   **12**

  3\.                                                                                                                                                       

                                                                                                                                                            

                                                                                                                                                            

                                                                                                                                                            

  4\.                                                                                                                                                       

                                                                                                                                                            

                                                                                                                                                            

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

Attachment D: Project Work Plan, Page 3 -- Sample Format

  -------------- ------------------------------- ---------- ------------- ------- ------- ------- ------- ------- ------- ------- ------- -------- -------- --------
  **Major        **Key Tasks**                   **Lead     **Timeframe                                                                                     
  Objectives**                                   Person**   (Start and                                                                                      
                                                            End Date by                                                                                     
                                                            Month)**                                                                                        

                                                            **1**         **2**   **3**   **4**   **5**   **6**   **7**   **8**   **9**   **10**   **11**   **12**

  5\.                                                                                                                                                       

                                                                                                                                                            

                                                                                                                                                            

                                                                                                                                                            

  6\.                                                                                                                                                       

                                                                                                                                                            

                                                                                                                                                            

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

NOTE: Please do note infer from this sample format that your work plan
must have 6 major objectives. If you need more pages, simply repeat this
format on additional pages.

**Attachment E:**

Instructions for Completing the Project Summary/Abstract

-   All applications for grant funding must include a Summary/Abstract
    that concisely describes the proposed project. It should be written
    for the general public.

```{=html}
<!-- -->
```
-   To ensure uniformity, please limit the length to no more than 265
    words on a single page with a font size of not less than 11,
    doubled-spaced.

-   The abstract must include the project's goal(s), objectives, overall
    approach (including target population and significant partnerships),
    anticipated outcomes, products, and duration. The following are very
    simple descriptions of these terms, and a sample Compendium
    abstract.

> **Goal(s)** -- broad, overall purpose, usually in a mission statement,
> i.e. what you want to do, where you want to be
>
> **Objective(s)** -- narrow, more specific, identifiable or measurable
> steps toward a goal. Part of the planning process or sequence (the
> "how"). Specific performances which will result in the attainment of a
> goal.
>
> **Outcomes -** measurable results of a project. Positive benefits or
> negative changes, or measurable characteristics that occur as a result
> of an organization's or program's activities. (outcomes are the
> end-point)

**Products --** materials, deliverables.

-   A model abstract/summary is provided below:

The grantee, Okoboji University, supports this three year Dementia
Disease demonstration (DD) project in collaboration with the local
Alzheimer's Association

and related Dementias groups. The [goal]{.underline} of the project is
to provide comprehensive, coordinated care to individuals with memory
concerns and to their caregivers. The approach is to expand the services
and to integrate the bio-psycho-social aspects of care. The
[objectives]{.underline} are: 1) to provide dementia specific care,
i.e., care management fully integrated into the services provided; 2) to
train staff, students and volunteers; 3) to establish a system
infrastructure to support services to individuals with early stage
dementia and to their caregivers; 4) to develop linkages with community
agencies; 5) to expand the assessment and intervention services; 6) to
evaluate the impact of the added services; 7) to disseminate project
information. The expected [outcomes]{.underline} of this DD project are:
patients will maintain as high a level of mental function and physical
functions (thru Yoga) as possible; caregivers will increase ability to
cope with changes; and pre and post -- project patient evaluation will
reflect positive results from expanded and integrated services. The
[products]{.underline} from this project are: a final report, including
evaluation results; a website; articles for publication; data on driver
assessment and in-home cognitive retraining; abstracts for national
conferences.

**Applicant's (Organization) Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Applicant's DUNS Number:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Grant Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_CFDA
Number: \_\_\_\_\_\_\_\_\_\_\_\_\_**

1\. Does the applicant have 501(c)(3) status?

Yes No

2\. How many full-time equivalent employees does the applicant have?
*(Check only one box).*

> 3 or Fewer 15-50
>
> 4-5 51-100
>
> 6-14 over 100

3\. What is the size of the applicant's annual budget? *(Check only one
box.)*

Less Than \$150,000

\$150,000 - \$299,999

\$300,000 - \$499,999

\$500,000 - \$999,999

\$1,000,000 - \$4,999,999

\$5,000,000 or more

4\. Is the applicant a faith-based/religious\
organization?

Yes No

5\. Is the applicant a non-religious community-based organization?

Yes No

6\. Is the applicant an intermediary that will manage the grant on
behalf of other organizations?

> Yes No

7\. Has the applicant ever received a government grant or contract
(Federal, State, or local )?

Yes No

8\. Is the applicant a local affiliate of a national\
organization?

Yes No

# Survey Instructions on Ensuring Equal Opportunity for Applicants

**Provide the applicant's (organization) name and DUNS number and the
grant name and CFDA number.**

1\. 501(c)(3) status is a legal designation provided on application to
the Internal Revenue Service by eligible organizations. Some grant
programs may require nonprofit applicants to have 501(c)(3) status.
Other grant programs do not.

2\. For example, two part-time employees who each work half-time equal
one full-time equivalent employee. If the applicant is a local affiliate
of a national organization, the responses to survey questions 2 and 3
should reflect the staff and budget size of the local affiliate.

3\. Annual budget means the amount of money your organization spends
each year on all of its activities.

4\. Self-identify.

5\. An organization is considered a community-based organization if its
headquarters/service location shares the same zip code as the clients
you serve.

6\. An "intermediary" is an organization that enables a group of small
organizations to receive and manage government funds by administering
the grant on their behalf.

7.  Self-explanatory.

8.  Self-explanatory.

**Paperwork Burden Statement**

According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless such
collection displays a valid OMB control number. The valid OMB control
number for this information collection is 1890-0014. The time required
to complete this information collection is estimated to average five (5)
minutes per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review
the information collection. **If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form,
please write to:** U.S. Department of Education, Washington, D.C.
2202-4651.

**If you have comments or concerns regarding the status of your
individual submission of this form, write directly to:** Joyce I. Mays,
Application Control Center, U.S. Department of Education, 7^th^ and D
Streets, SW, ROB-3, Room 3671, Washington, D.C. 20202-4725

> OMB No. 1890-0014 Exp. 1/31/20

ATTACHMENT G:

Alzheimer's Demonstration Program

DATA COLLECTION PROTOCOL

The data collection protocol has been designed to maximize the utility
of the data for informing policy and practice and minimize the data
collection burden on participating grantees. AoA will work with grantees
to efficiently implement the data collection requirements in an effort
to minimize disruption to existing data collection efforts states may
already have underway. All required data elements must be collected and
documented in a manner that produces data that are consistent across all
the grantee programs. Consistent reporting will maximize the utility of
the data for identifying the successes of each individual grantee as
well as the entire demonstration.

## [Type of Data to be Collected]{.underline} {#type-of-data-to-be-collected .unnumbered}

Three types of data will be collected for the evaluation of Alzheimer's
Demonstration Grants to States Program (ADDGS). Data will be collected
pertaining to

-   Client (Person with dementia or caregiver) characteristics

-   Services Expenditures

-   Accomplishments and Collaborations

The following icons provide:

1.  Four Excel spreadsheets that contain the specific data elements to
    be collected;

2.  Definition of terms used for the purpose of ADDGS data collection;

3.  Template forms, which are [provided as a reference only]{.underline}
    so applicants can determine how best to incorporate ADDGS data
    collection requirements with existing service intake tools and
    protocols. Please note: use of these forms is not required, they are
    offered only for informational purposes.

![](media/image1.wmf) ![](media/image2.wmf) ![](media/image3.wmf)