DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)

Administration on Aging (AoA) and Centers for Medicare & Medicaid
Services (CMS)

Catalogue of Federal Domestic Assistance (CFDA) #s: AoA - 93.048 and
CMS - 93.779

**FY 2003 Program Announcement and Application Instructions (AoA-03-05
and CMS--2185-N)**

I. BACKGROUND AND PROGRAM DESCRIPTION

A. Background

1.  [Summary.]{.underline} The Administration on Aging (AoA) and the
    Centers for Medicare & Medicaid Services (CMS), announced in the
    March 29, 2003 *Federal Register* that they will jointly hold a
    competition for grants to be awarded as cooperative agreements for
    projects that support the development of state Aging and Disability
    Resource Center (Resource Center) programs. The word "grant," as
    used in this solicitation, refers to a cooperative agreement.
    Resource Center programs will provide citizen-centered "one-stop
    shop" entry points into the long term support system and will be
    based in local communities accessible to people who may require long
    term support. Resource Centers will serve individuals who need long
    term support, their family caregivers, and those planning for future
    long term support needs. They will also serve as a resource for
    health and long term support professionals and others who provide
    services to the elderly and to people with disabilities. The
    accompanying materials comprise the [application kit]{.underline}
    for preparing and submitting a grant proposal to compete for these
    project awards.

2.  [Statutory Authority.]{.underline} The statutory authority for
    grants under this program announcement is contained in section 411
    of the Older Americans Act and section 1110 of the Social Security
    Act.

3.  [Application Due Date.]{.underline} The *deadline date* for the
    submission of applications under this program announcement is July
    28, 2003. Potential applicants are encouraged to submit a letter of
    intent to apply for a grant no later than June 19, 2003. AoA and CMS
    will conduct an Applicant's Teleconference. Information regarding
    the time and call-in number for this open teleconference call will
    be available on the AoA Web site at
    [http://www.aoa.gov](http://www.aoa.gov/) and on the CMS Web site at
    http://www.cms.hhs.gov/newfreedom/default.asp. Additionally, AoA and
    CMS staff will be available for questions and answers on an on-going
    basis. All "Questions and Answers" resulting from inquires from the
    field will be posted on these two websites.

4.  [Project Funding, Duration and Match.]{.underline} AoA and CMS plan
    to fund up to 16 projects nationwide for a period of up to 3 years.
    The maximum total Federal award for the entire 3-year project period
    is \$800,000. We reserve the right to disqualify applications
    submitted in excess of the maximum award (\$800,000) and to return
    such applications without review to the applicant.

> Grantees are required to make a non-financial or cash recipient
> contribution (match) of five percent (5%) of the total grant award.
> Non-financial recipient contributions may include the value of goods
> and/or services contributed by the Grantee (e.g., salary and fringe
> benefits of staff devoting a percentage of their time to the grant not
> otherwise included in the budget or derived from Federal funds).
> Recipient contributions must be included in the applicant's budget in
> Item 15 (Estimated Funding) on Standard Form 424A and described in the
> budget narrative/justification section of the application. The
> non-financial match requirement may also be satisfied if a third party
> participating in the grant makes an "in-kind contribution," provided
> that the Grantee's contribution and/or the third-party in-kind
> contribution equals five percent (5%) of the total grant award
> (including all direct and indirect costs). Third-party "in-kind
> contributions" may include the value of the time spent by citizen task
> force members (using appropriate cost allocation methods to the extent
> that non-Federal funds are involved) who specifically contribute to
> the design, development, and implementation of the grant. While the
> five percent (5%) recipient contribution is not included as a
> screening criteria, it is a requirement that a five percent (5%) match
> of the total award be included in all funded projects.
>
> All funds will be awarded by 9/30/2003. Applicants are required to
> submit one project budget (SF424A) and budget justification. However,
> AoA and CMS are both providing funding for this program. As a result,
> successful applicants may receive an award from each agency that, when
> combined, will total the Federal award for the project. AoA and CMS
> reserve the right to request a revised budget to reflect these
> determinations.
>
> These grants will be issued as cooperative agreements because AoA and
> CMS anticipate having substantial involvement with the recipients
> during performance of funded activities. This involvement may include
> collaboration, participation, or intervention in the funded
> activities. AoA and CMS will also be involved in the development and
> implementation of the funded projects by way of conducting a joint
> review of the applications and providing technical assistance,
> training, guidance, and oversight throughout the project period. More
> specifically, applications may be submitted to AoA and CMS through the
> AoA "single point of application" address listed in this solicitation.
> AoA will ensure that all appropriate parties in both AoA and CMS
> receive the application. AoA and CMS will make final decisions on the
> grant awards jointly. AoA and CMS project officers will jointly
> perform the day-to-day Federal responsibilities. Grantees will be
> expected to keep in contact with AoA and CMS project officer staff on
> a regular basis. Grantees will also be expected to share all
> significant products that result from their projects with AoA and CMS.

5\. [Eligible Applicants.]{.underline} Only a state agency or
instrumentality of a state may apply for a Resource Center grant. The
applicant agency must have the support and active participation of the
Single State Agency on Aging and the Single State Medicaid Agency. Only
one application per state will be funded. \"State\" refers to the
definition provided under 45 CFR 74.2. Executive Order 12372 is not
applicable to these grant applications.

6\. [Target Groups]{.underline}. Resource Centers supported under this
program must, at a minimum, include the elderly population and at least
one of the following major target groups by the first quarter of the
second year: (a) individuals with physical disabilities, (b) individuals
with serious mental illness, and/or (c) individuals with mental
retardation/developmental disabilities. States may elect to develop
distinct entry points for different target groups as long as they are a
coordinated part of the single state Resource Center program.
Individuals with traumatic brain injury may be classified by the state
in the target group that best conforms with the state's service delivery
system and historical practice. The same principle applies to any other
condition that often spans target group boundaries. For the definition
of "elderly" in this solicitation we use age 60 and above as specified
in the Older Americans Act.

7\. [Further Information.]{.underline} Contact: Kari Benson, AoA, (202)
357-3461, kari.benson@aoa.gov or Mary Guy (410) 786-2772,
RealChoiceFY03@cms.hhs.gov.

B. Program Description

1.  **[Background]{.underline}.** The AoA/CMS Resource Center grants
    program reflects and supports the values of individual choice,
    independence, and community living inherent in President Bush's
    *Freedom Initiative*, including the President's "Money Follows the
    Person Initiative to Rebalance Long term Support Systems." The
    grants awarded under this program will be another tool the Federal
    government is making available to help states tear down barriers to
    community living and redirect their systems of support to be more
    consumer-driven and more supportive of home and community-based
    service options.

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2.  **[Goal and Vision.]{.underline}** The goal of the Aging and
    Disability Resource Center Program is to empower individuals to make
    informed choices and to streamline access to long term support. Long
    term support refers to a wide range of in-home, community-based, and
    institutional services and programs that are designed to help
    individuals with disabilities.

> AoA and CMS share a vision for the Resource Center program. The vision
> is to have Resource Centers in every community serving as highly
> **visible and trusted** places where people can turn for information
> on the full range of long term support options and a single point of
> entry to public long term support programs and benefits. The Centers
> will be a resource for both public and private-pay individuals. They
> will serve elderly persons, younger individuals with disabilities,
> family caregivers, as well as persons planning for future long term
> support needs. The Centers will also be a resource for health and long
> term support professionals and others who provide services to the
> elderly and to people with disabilities.
>
> AoA and CMS believe Resource Centers are a key component of an
> effectively managed, consumer-driven system of long term support. In
> many communities, long term support services are supported by numerous
> funding streams, administered by multiple agencies, and have complex,
> fragmented, and often duplicative intake, assessment, and eligibility
> functions. Figuring out how to obtain services is difficult both for
> persons who qualify for publicly-funded supports and for those who can
> pay privately. These barriers lead to institutional long term support
> as the default outcome. A single, coordinated system of information
> and access for all persons seeking long term support will minimize
> confusion, enhance individual choice and support informed
> decision-making. It will also improve the ability of state and local
> governments to manage resources and to monitor program quality through
> centralized data collection and evaluation. Resource Centers will
> enable policy makers and program administrators to more effectively
> respond to individual needs, address system problems, and limit the
> unnecessary use of high-cost services, including nursing home
> services.
>
> Making information and counseling available to private-pay individuals
> is a central element of the AoA/CMS Resource Center vision. Reaching
> people before they become Medicaid-eligible, and helping them to learn
> about low-cost options and programs such as private long term support
> insurance, can help individuals make better use of their own resources
> and help to prevent or delay spend-down to Medicaid.
>
> The AoA/CMS vision is for Resource Centers to:

-   Actively promote public awareness of both public and private long
    term support options, as well as awareness of the Resource Center,
    especially among underserved and hard-to-reach populations.

-   Provide information, and counseling as needed, on all available long
    term support options.

-   Help people assess their potential eligibility for public long term
    support programs and benefits.

-   Determine programmatic eligibility for public long term support
    programs and benefits, including level of care determinations for
    Medicaid nursing home and HCBS waiver programs.

-   Assist people with the Medicaid eligibility determination process
    (in collaboration or coordination with Medicaid eligibility
    determination staff).

-   Provide short-term assistance or case management to stabilize long
    term support individuals and their families in times of immediate
    need before they have been connected to ongoing support (e.g.,
    enrolled in a home and community-based waiver).

-   Provide information and referral to other programs and benefits that
    can help people remain in the community, such as disease prevention
    and health promotion programs, transportation services, and income
    support programs.

-   Help people plan for their future long term support needs.

-   Organize, simplify, and ensure "one-stop shopping" for access to all
    public long term support programs.

> Resource Centers may also provide on-going case management to public-
> and/or private-pay individuals.
>
> The operational configuration of Resource Centers will vary from state
> to state. In most states, Resource Centers will involve a state/local
> partnership, where the state will provide oversight and guidance, but
> may arrange for responsibility for the operation of Resource Center
> functions to be vested in local entities. In some communities, all
> Resource Center functions may be performed in a single location.
> However, in some localities, Resource Centers may be decentralized and
> have multiple sites and organizations involved in performing the
> information and access functions. Some communities may even have
> different access points for different populations, provided they
> perform all functions of a Resource Center. Regardless of the
> configuration, the functions of the Resource Center will be
> coordinated and standardized to ensure that all individuals are
> provided with uniform information and access to long term support.
>
> Resource Centers will create formal linkages between and among the
> major pathways to long term support, including preadmission screening
> programs for nursing home services, hospital discharge planning,
> physician services, and the various community agencies and
> organizations that serve the Resource Center's target populations.
> These linkages will ensure people have the information they need to
> make informed decisions about their support options as they pass
> through critical transition points in the health and long term support
> system.
>
> Resource Centers will gather and manage information from individuals
> in a way that ensures their confidentiality, but **limits repeated
> collection of the same information throughout their long term support
> careers.** The individual-level data will be used, in part, as the
> foundation of a **management information system** that will track
> client intake, needs assessment, service plans, utilization, and
> costs. The management information system will support on-going program
> analysis, planning, budgeting, quality assurance, program evaluation,
> and continuous improvement as well as state and local policy
> development.
>
> AoA and CMS recognize that not all states can immediately implement
> the ideal Resource Center described above. However, the vision
> indicates the latitude of design possibilities for Resource Centers
> and our long-range expectations. We believe implementation of the full
> vision can achieve success in meeting individual needs and preferences
> and in effectively managing public resources, while implementation of
> too few of the elements will limit the success of a Resource Center
> program.

**3. [Overview of the Program.]{.underline}** AoA and CMS will award
competitive grants to assist states to implement new, or significantly
expand existing, Resource Center programs. Building on previous state
efforts, Resource Centers will **move beyond information and assistance
and will assume the role of primary entry point into the long term
support system.** People who are eligible for Medicaid long term
support, including HCBS waiver services or Medicaid funded nursing home
services, will access those programs through the Resource Centers.

> Several states have initiated groundbreaking programs that have proven
> successful in informing and empowering individuals by bringing long
> term support services to individuals in one easy location. (For
> information on these programs, go to:
> <http://www.cms.hhs.gov/states/dis-aging.asp> or
> http://[www.hcbs.org](http://www.hcbs.org/).) Potential applicants are
> also encouraged to read, **[Navigating the Long term Care Maze: New
> Approaches to Information and Assistance in Three
> States]{.underline}** at:
> <http://research.aarp.org/health/2001_12_maze.html>.
>
> AoA and CMS will jointly review grant applications and issue grants to
> a lead state agency that will be responsible for administering the
> Resource Center program in the state. Regardless of which state agency
> is the lead agency, planning and implementation must substantially
> involve both the Single State Agency on Aging and the Single State
> Medicaid Agency.
>
> Applicants that received a grant award in fiscal year 2001 and fiscal
> year2002 under "Systems Change Grants for Community Living" for access
> and educational activities may be eligible for additional funding
> under this initiative. However, the new proposal must significantly
> expand the scope of work consistent with the Resource Center program
> vision.
>
> Grantees will be required to collaborate with AoA and CMS to develop a
> minimum data set and processes for data collection. Evaluation and
> analysis of these data will result in increased understanding of
> outcomes and strategies that are effective in serving people with a
> disability.

4\. **[Involvement of Stakeholders, and Public-Private
Partnerships.]{.underline}** States must meaningfully involve
stakeholders in the planning, implementation, and evaluation of their
Resource Center program. In addition, we encourage the development of
public-private partnerships that make the most effective use of each
partner's expertise. Examples of organizations that should be involved
include: Alzheimer's Association chapters, Area Agencies on Aging,
advocacy groups and organizations, community service providers, State
Health Insurance Assistance Programs (SHIPs), Long term Care Ombudsmen
Programs, Developmental Disabilities Councils, State Mental Health
Planning Councils, Independent Living Centers, State Assistive
Technology Act Projects (AT Act Projects), housing authorities,
volunteer groups, employers, faith-based service providers, private
philanthropic organizations, and other community-based organizations.

Applicant states must establish or designate an Advisory Board to assist
in the development and implementation of their Resource Center program.
(Advisory boards established under the Real Choice Systems Change
Program may be used for this purpose in an existing or modified form.)
The Advisory Board will advise the lead state agency on: (a) the design
and operations of Resource Centers, (b) stakeholder input, (c) the
state's progress toward achieving the goal and vision described in this
announcement, and (d) other program and policy development issues
related to the state's Resource Center program.

The lead state agency will have ultimate authority over the program and
its Advisory Board. The Advisory Board must be composed of (a)
individuals representing all populations served by the state's Resource
Center program including individuals who have a disability or a chronic
condition requiring long term support, (b) representatives from
organizations that provide services to the individuals served by the
program, and (c) representatives of the government and non-governmental
agencies that are impacted by the program.

Under this grant program, grantees must meet the provisions for consumer
task force participation that apply to the overall Real Choice Systems
Change Grants for Community Living as administered by CMS. Congress
expressed its preference that Real Choice Systems Change Grants
applications "be developed jointly by the State and the Consumer Task
Force" (H. Conf. Rep. No. 106-1033 at 150 and H. Conf. Rep. No. 107-342
at 101, adopting S. Rep. No. 107-84 at 17). "The task force should be
composed of individuals with disabilities from diverse backgrounds
(including the elderly), representatives from organizations that provide
services to individuals with disabilities, consumers of long-term
services and supports, and those who advocate on behalf of such
individuals" (H. Conf. Rep. No. 106-1033 at 150 and H. Conf. Rep. No.
107-342 at 101, adopting S. Rep. No. 107-84 at 17). In its report
accompanying, the "Consolidated Appropriations Resolution, 2003," Pub.
L. No. 108﷓7, the conferees stated that they "continue to strongly
support the Real Choice Systems Change grants and expect CMS to provide
expanded technical assistance for the consumer task forces involved with
the program by contracting with a consortium of consumer controlled
organizations for people with disabilities," H.R. Conf. Rep. 108-10 at
1107. Applicants may elect to use or expand existing Real Choice
Consumer Task Forces to meet the consumer involvement provisions of this
solicitation.

5.  **[Award Size]{.underline}.** As noted above, AoA and CMS plan to
    fund up to 16 grants totaling up to \$800,000 each for a 3-year
    period. Applicants are encouraged to develop project budgets that
    reflect annual Federal funding of about \$250,000 for each project
    year. Grantees are required to make a non-financial or cash
    recipient contribution (match) of five percent (5%) of the total
    grant award. AoA and CMS are both providing funding for this grants
    program.

A key consideration for AoA and CMS is that the size of the award will
correlate with the significance of the proposed endeavors, rather than
with the size of the state. AoA and CMS reserve the right to offer a
funding level that differs from the requested amount and to negotiate
with the applicant with regard to the scope and intensity of effort that
would be appropriate and commensurate with the final funding level. AoA
and CMS also reserve the right to select alternates from the pool of
applicants.

Significance will be measured in terms of the **breadth of the
initiative** (i.e., the potential number of people affected and the
number of populations served) and the **degree of enduring change in the
system** (i.e., the \"intensity\" or depth of the improvement, including
the range of long term support information and access functions that are
effectively integrated and/or coordinated). States that have systems
that already include major elements of Resource Centers may apply but
may be successful only to the extent that further progress is to be
demonstrated (e.g., by adding additional Resource Center functions
specified in this solicitation, expanding geographical coverage,
expanding target group coverage, etc.).

**6. [Use of Funds]{.underline}.** Applicants must demonstrate that the
grant (a) establishes new capacity or significantly enhances existing
capabilities; (b) does not duplicate existing work or supplant existing
funding; and (c) devotes all funding under the new proposal to endeavors
that advance the goal and vision of the Resource Center Program.

[Design activities]{.underline} may include, but are not limited to:

-   Obtaining and analyzing stakeholder input.

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-   Conducting a feasibility and planning study.

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-   Developing an Advance Planning Document (APD).

-   Completing a fiscal impact analysis.

> [Implementation activities]{.underline} may include, but are not
> limited to:

-   Hiring or contracting for staff dedicated to the administration and
    operation of the Resource Center Program (this does not include
    using these grant funds to pay for staff to perform functions that
    are mandated and reimbursable under other funding sources.)

-   Purchasing computers and computer software used specifically for the
    operation and administration of the center, as well as collecting,
    analyzing, reporting, and disseminating Resource Center data.

-   Performing public awareness and outreach activities to inform
    individuals of the information and assistance offered at the
    Resource Center.

-   Initial and continuous training, particularly for staff that
    directly serve individuals.

-   Evaluation activities.

####### 7. [Resource Center Design Issues:]{.underline} A state's Resource Center program must provide information and assistance to both public- and private-pay individuals and must include both public and private programs in its information and assistance functions. A state's Resource Center program must also serve as the entry point to publicly administered long term supports for individuals who are eligible for, or appear to be eligible for, those publicly supported programs. By the end of the third year, an eligible Resource Center must, at a minimum, perform the following functions of "Awareness, Assistance, and Access": 

> **Awareness and Information**

-   Public Education.

-   Information on Long term support Options.

> **Assistance**

-   Long term Support Options Counseling.

-   Benefits Counseling

-   Employment options counseling for people who are interested in, or
    may be interested in, such counseling. Grantees would be expected to
    coordinate with other sources funding employment counseling in their
    state, such as the Social Security Administration and/or the
    Department of Labor, to ensure access and prevent duplication.

-   Referral to other programs and benefits that can help people remain
    in the community, including programs that can assist a person in
    obtaining and sustaining paid employment.

-   Crisis Intervention.

-   Helping people to plan for their future long term support needs.

> **Access**

-   Eligibility Screening.

-   Assistance in gaining access to long term support service that may
    be paid with private funds.

-   Comprehensive assessment of long term support needs and care
    planning.

-   Programmatic Eligibility Determination for long term support
    services (see Section II for a definition of Long term Support
    Services).

-   Medicaid Financial Eligibility Determination that is either
    integrated or so closely coordinated with the Resource Center that
    each individual applicant experiences a seamless interaction.

-   One-Stop Access to all public programs for community and
    institutional long term support services administered by the state
    under Medicaid, and those portions of Older Americans Act programs
    that the state has determined will be devoted to long term support
    services (see definition), and any other publicly funded services
    which the state determines should be accessed through the Resource
    Center.

> For a description of these functions, see the Definitions, under
> Section II, below.
>
> Grantees must have at least one Resource Center operational at the
> community level within 12 months of receipt of grant funds that, at a
> minimum, is providing information and counseling on long term support
> options, and has a plan in place (that has been approved by the lead
> state agency) describing how it will put in place the following
> functions within 24 months of the State's receipt of grant funds:
> Eligibility Screening, Programmatic Eligibility Determination, and
> Coordination with Medicaid Financial Eligibility Determination. In the
> first quarter of the second year the State's Resource Center program
> must include, in addition to the elderly, at least one additional
> major target groups identified in this solicitation. By the end of the
> 3-year grant period, the Resource Center must be performing all
> required functions.

Resource Centers must have a management information system that supports
the functions proposed under this program. The system should allow for
the tracking of client intake, needs assessment, care plans,
utilization, and costs. The data must be in a transmittable form. CMS
and AoA will provide technical assistance to successful applicants in
order to assist in creating measures and methods of collection of data.
It is recognized that Resource Centers will build upon existing state
and local information systems. In order to achieve the functional
capacity envisioned for Resource Centers in the time available, it will
often be necessary to enhance the information system related to the
Resource Center without completing a redesign and implementation of the
whole state or local information system. In that case, experience gained
on the Resource Center information system may be helpful in informing
the redesign of the larger system when the necessary funds, time, and
consensus are in place.

> Finally, grantees will be required to evaluate the effectiveness of
> their Resource Center programs in making progress toward the goal and
> vision outlined in this Announcement. The evaluation design should
> include measurable performance goals and support quality assurance and
> continuous program improvement.

**8. [Measurable Performance Goals.]{.underline}** Grantees must
establish measurable performance goals for their programs, along with
indicators that can be used to track progress on the performance goals.
The measurable performance goals and indicators should be incorporated
into the design of the program's evaluation, and be used to measure the
success of the Resource Center program over the long run. The goals and
indicators must be developed with input from the stakeholders and the
advisory board specified for these grants.

> At a minimum, grantees must establish performance goals and indicators
> related to their Resource Center program's: (a**) Visibility** -
> extent to which the public is aware of the existence and functions of
> the Resource Center, (b) **Trust** on the part of the public in the
> objectivity, reliability, and comprehensiveness of the information and
> assistance available at the Resource Center, (c) **Ease of Access**
> (e.g., reduction in the amount of time and level of frustration and
> confusion individuals and their families experience in trying to
> access long term support), and (d) **Responsiveness** to the needs,
> preferences, unique circumstances, and feedback of individuals as it
> relates to the functions performed by the Resource Center. Grantees
> must also establish performance goals and indicators related to the
> program's **Efficiency** and **Effectiveness** (e.g., reduction in the
> number of intake, screening, and eligibility determination processes,
> diversion of people to more appropriate, less costly forms of support,
> improved ability to match each person's preferences with appropriate
> services and settings, ability to rebalance the state's long term
> support system, ability to implement methods that enable money to
> follow the person. etc.)

## II. DEFINITIONS

> **[Aged (or Elderly Person)]{.underline}:** As defined in the Older
> Americans Act, "an individual who is 60 years of age or older."
>
> **[Benefits Counseling:]{.underline}** The provision of information
> and assistance designed to help people learn about and, if desired,
> apply for public and private benefits to which they are entitled,
> including but not limited to, private insurance (such as Medigap
> policies), SSI, Food Stamps, Medicare, Medicaid and private pension
> benefits. For purposes of this program, Benefits Counseling funded
> under the Older Americans Act that is provided to individuals who need
> help in order to remain in the community, is included in this
> definition.
>
> **[Coordination With Medicaid Financial Eligibility
> Determination:]{.underline}** The determination of financial
> eligibility for Medicaid may take place either at the Resource Center
> or off-site. Regardless of where it takes place, the Resource Center
> must assure that the process is coordinated or integrated with the
> functions of the Center so that it takes place in an expeditious
> manner that avoids duplication of effort for individuals, their
> families and agency workers. The result of this coordination should be
> a seamless system of long term support as experienced by the
> individual.
>
> **[Counseling and Referral to Help People Remain in the
> Community:]{.underline}** The provision of comprehensive and accurate
> information on services and programs that can help people to remain at
> home and in the community. These include (a) direct services (such as
> home and community-based waiver programs, home health, personal care,
> case management), (b) generic community sources of help (such as
> nutrition programs, prescription drug programs, health promotion and
> disease prevention programs, transportation services, home repair
> programs, real property tax relief), and public or private insurance
> (such as long term care insurance, Medicare, SSDI, and SSI). For
> purposes of this program, counseling and referral activities designed
> to help individuals to remain in the community that are funded under
> the Older Americans Act are included in this definition.
>
> **[Eligibility Screening:]{.underline}** Is a non-binding inquiry into
> an individual's income and assets, as necessary, and other
> circumstances in order to determine probable eligibility for programs,
> services, and benefits, including Medicaid. This screening should be
> provided to all individuals who may be eligible for publicly funded
> programs.
>
> **[Crisis Intervention]{.underline}**: The systemic capability to
> respond to situations of immediate jeopardy to the health or welfare
> of an individual, by means of remedy, removal from danger, protective
> services, or other timely safety measure.
>
> **[Information on Long term Support Options:]{.underline}** The
> information available must be comprehensive, objective, up-to-date,
> citizen-friendly, and cover the full range of available options,
> including in-home, community-based, and institutional services
> (including nursing home services). The information must cover options
> that people will use immediately (such as Medicaid services) to
> long-range options (such as private long term care insurance). The
> information must also cover programs and services that support family
> caregivers, as well as any special options in the state to maintain
> independence or direct one's own long term support services.
>
> **[Long term Support Services]{.underline}**: Long term support refers
> to a wide range of in-home, community-based, and institutional
> services and programs that are designed to help individuals with
> disabilities or chronic conditions with activities of daily living or
> instrumental activities of daily living. Public long term support
> services are those administered by a governmental entity. For purposes
> of this program, long term support services under Medicaid include
> home health, personal care, targeted case management, home and
> community-based waivers under section 1915(c) of the Social Security
> Act, nursing facility services, and Intermediate Care Facilities for
> the Mentally Retarded (ICFs-MR). Long term support services under the
> Older Americans Act include personal care and other in-home services
> similar to those provided under section 1915(c) of the Social Security
> Act. Long term support services under state-only programs include home
> health and personal care. Finally, for purposes of this program, the
> state may include in the definition of long term support services any
> other publicly-funded service which the state determines should be
> accessed through the assessment process of the Resource Center.
>
> **[Long term Support Options Counseling:]{.underline}** Resource
> Centers will help people make informed decisions by assisting
> individuals and their families in understanding how their strengths,
> needs, preferences, and unique situations translate into possible
> support strategies, plans, and tactics, based on the options available
> in the community. The counseling includes helping individuals assess
> their needs and resources, the assessment of the needs of family
> caregivers, developing a plan, and assisting the individual/family in
> implementing their long term support choices. Counseling links
> individuals to other counseling programs and services, including
> Web-based information and counseling programs. For purposes of this
> program, Long term Support Options Counseling activities funded under
> the Older Americans Act are included in this definition.
>
> **[One-Stop Access to Public Programs]{.underline}:** The
> organizational ability and authority to provide intake, full access,
> and comprehensive point of entry to publicly supported long term
> support services for individuals who are eligible for, or appear to be
> eligible for, publicly supported long term support services, as those
> services are defined under Section II. A single program performs these
> functions, along with information and assistance, through a simple,
> convenient, single contact point. The program may involve more than
> one entry point (or "site) at the community level (e.g., different
> access points for different populations) so long as (a) each access
> point is authorized and performs all functions of a single point of
> entry, (b) the process of access experienced by individuals is uniform
> across all entry points, and (c) individuals do not access long term
> support services through admission points that do not perform all
> functions of a single point of entry. One-stop access to public
> programs also ensures that individuals have the information they need
> to make informed decisions and that individuals reliant on public
> support are not admitted to service by alternate means or by direct
> admission through an individual provider of services.
>
> **[Programmatic Eligibility Determination:]{.underline}** A
> determination of the publicly supported benefits or services to which
> a person is eligible, **based on non-financial criteria**. This may
> require a formal assessment to determine the full scope of the
> individual's needs. It may include a functional assessment of the
> individual's current health conditions and provide a situational
> assessment of the client's environment, available resources, and
> current support. For Medicaid services, this function includes the
> "Level of Care" determination process.
>
> **[Public Education and Outreach:]{.underline}** Activities related to
> ensuring that all potential users of long term support (and their
> families) are aware of both public and private long term support
> options, as well as awareness of the Resource Center, especially among
> underserved and hard-to-reach populations.
>
> **[State:]{.underline}** Refers to the definition provided under 45
> CFR 74.2 any of the several States of the United States, the District
> of Columbia, the Commonwealth of Puerto Rico, any territory or
> possession of the United States, or any agency or instrumentality of a
> State exclusive of local governments.

**III. INSTRUCTIONS FOR COMPLETING THE PROJECT NARRATIVE**

## A. Required Format and Length. 

## 

## The Project Narrative must be double-spaced, on single-sided 8 ½" x 11" plain white paper with 1" margins on both sides, and a font size of not less than 11. The maximum length allowed for the project narrative is 25 pages. We will [not accept]{.underline} applications with a Project Narrative that exceeds 25 pages. NOTE: 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 25-page limit, but all of the other sections noted below are included in the 25-page limit.

Beginning with the page for the project summary description, pages must
be numbered sequentially. Please do not use covers or tabs. **Do not
include extraneous materials** such as agency promotion brochures,
slides, tapes, film clips, and appendices, etc. It is not feasible to
include such items in the review process. They will be discarded if
submitted as part of the application. The application should not be
bound. A staple is recommended.

**B. Standard Components.**

1.  **[Executive Summary.]{.underline}** This section should include a
    clear and concise summary of your proposal including: the project's
    goal and objectives; the proposed intervention; target
    population(s); and anticipated outcomes. (Length: **not to exceed
    one page**.)

2.  **[Problem Statement.]{.underline}** The applicant must provide a
    general description of its long term support system, including a
    description of how the current system limits or facilitates
    individual choice and access for both public- and private-pay
    individuals in the applicant's target population. The applicant
    should describe current efforts to address information and access
    issues and problems.

3.  **[Target Population(s)]{.underline}** This section should describe
    the target group(s) to be served and the rationale for focus on the
    specified group(s).

4.  **[Proposed Intervention.]{.underline}** Describe your overall
    approach to advancing the vision and goals outlined in this
    Announcement, including your plans to streamline, coordinate, and/or
    integrate existing intake, screening, assessment, eligibility
    determination, and counseling services, and how the project will
    ensure that targeted populations will utilize the Resource Center to
    access the long term support system. This section must address
    coordination with both the Medicaid Level of Care determination
    process for Nursing Home and other long term support, and the
    Medicaid eligibility process. You must include a description of the
    management information system that will be used and/or developed to
    support the functions and goals of your Resource Center program.
    Your process for selecting local entities to carry out Resource
    Center functions at the community level should also be described.
    You should note any major barriers you anticipate encountering, and
    how your project will be able to overcome those barriers. This
    section should also include how the project will improve
    collaboration between health support and human service agencies
    (including housing) agencies at the state and local level.

5.  **[Involvement of Key Stakeholders]{.underline}**. Describe the role
    and makeup of the Advisory Committee and any strategic partnerships
    you plan to involve in implementing the intervention, including
    other agencies, organizations, funders, and/or citizen groups.
    Describe how the Resource Center will coordinate with the State
    Health Insurance Assistance Program.

6.  **[Performance Goals and Indicators.]{.underline}** Provide a
    description of the initial measurable performance goals and
    indicators you plan to use to measure the success of your program
    over the long run, including those related to the program's
    visibility**,** trust, ease of access, responsiveness, efficiency,
    and cost-effectiveness. Also describe how you plan to refine your
    performance goals and indicators over the course of the project
    period, if you plan to do so.

7\. **[Evaluation]{.underline}**. Describe the approach, methods, and
data that will be used to evaluate the program's progress toward
achieving its policy goals and objectives, and its measurable
performance goals.

8\. **[Dissemination.]{.underline}** 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.

9\. **[Project Management]{.underline}**. This section should include a
clear delineation of the roles and responsibilities of the involved
agencies, project staff, consultants and partner organizations, and how
they will contribute to achieving the project's objectives. It should
specify who would have day-to-day responsibility for project leadership
and the key tasks associated with designing, establishing, and operating
a Resource Center program. It should also describe the approach that
will be used to track progress on the project's tasks and objectives.

10\. [**Work Plan**.]{.underline} 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(s) and objectives, and
the major tasks / action steps that will be undertaken to achieve the
goal and objectives. 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.
(See Attachment C for a sample work plan grid you can use for this
purpose.

11\. **[Organizational Capability Statement and Vitae for Key Project
Personnel.]{.underline}** Each application should include an
organizational capability statement and vitae for key project personnel.
The organizational capability statement should assure and demonstrate
that the lead state agency for the Resource Center Program has the
capacity to implement the full Resource Center Goal and Vision described
in section I.B. of this announcement. Likewise, local entities
designated to implement the operational Resource Centers at the
community level should demonstrate that they have this capacity. 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.

12\. **[Sustainability]{.underline}:** Applicants must describe in the
application the steps the State has taken (or will take) to ensure its
Resource Center project will be sustained beyond the grant period.

13\. **[Letters of Commitment From Key Participating Organizations and
Agencies.]{.underline}** Include confirmation of the commitments to the
project (should it be funded) made by key 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.

## IV. APPLICATION SCREENING CRITERIA

######## Screening Criteria

> All applications will be screened to assure a level playing field for
> all applicants. Applications that fail to meet the three 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 postmarked by midnight, July 28, 2003, or
    hand-delivered by 5:30 p.m. Eastern Time, on July 28, 2003, or
    submitted electronically by midnight, July 28, 2003.

> Electronic submissions must be sent to: http://www.aoa.gov/egrants.
> NOTE: For electronic submissions, the required signature form must be
> postmarked by midnight, July 28, 2003, or hand-delivered by 5:30 p.m.,
> Eastern Time, on July 28, 2003.
>
> Paper submissions must be mailed to:
>
> Department of Health and Human Services
>
> Administration on Aging
>
> Grants Management Division
>
> Washington, DC 20201
>
> Attention: Margaret A. Tolson

Paper submissions should be hand-delivered to:

> Department of Health and Human Services
>
> Administration on Aging
>
> Grants Management Division
>
> One Massachusetts Avenue, NW, Room 4604
>
> Washington, DC 20001
>
> Attention: Margaret A. Tolson

2.  The Project Narrative section of the Application must be
    double-spaced, on single-sided 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 25 pages. NOTE:
    The Project Work Plan, Letters of Cooperation, and Vitae of Key
    Project Personnel **[are not counted]{.underline}** as part of the
    Project Narrative for purposes of the 25-page limit.

If you elect to mail or hand-deliver your application, you must submit
**one original application and two copies**, a completed application
checklist, and a copy of the application on a computer diskette to AoA.
The Checklist is included the Attachments. To expedite the processing of
applications, we request that you arrange the components of your
application in the following order:

1\. SF 424 [Note]{.underline}: The original copy of the application
[must]{.underline} have an original signature in item 18d on the SF 424.

2.  SF 424A.

3.  Separate Budget Justification (See Attachments for Sample Format).

4\. SF 424B 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\. SF CD-511.

6\. Copy of the applicant\'s most recent indirect cost agreement, as
necessary.

7\. Project Narrative with Work Plan (See Attachments for Sample Work
Plan Format.)

8\. Organizational Capability Statement and Vitae for Key Project
Personnel.

9.  Letters of Commitment From Key Partners.

10\. Completed Application Package Checklist

**Doing Business with AoA**

We have provided a number of resources to assist interested patrons in
doing business electronically.

**How to Obtain a D-U-N-S Number**

Electronic Government or eGovernment is one of the Presidential
Management Initiatives. The United States government is moving toward
providing the public the ability to conduct all business with the
government electronically.

One recent requirement is that all grant applications obtain a **D-U-N-S
number** from Dun and Bradstreet. This number will be a requirement if
the applicant applies on-line. 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.

To obtain a number, please use this link:

https://www.dnb.com/product/eupdate/requestOptions

## [FOR FURTHER INFORMATION CONTACT:]{.underline} U.S. Department of Health and Human Services, Administration on Aging, Office of Grants Management, Washington, D.C. 20001, telephone: (202) 357-3440. 

**V. APPLICATION REVIEW PROCESS AND EVALUATION CRITERIA**

######## Review 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 and CMS. Based on the specific
> programmatic considerations set forth above, the reviewers will
> comment on and score the applications, focusing their comments and
> scoring decisions on the criteria below. Applications are scored by
> assigning a maximum of 100 points across the seven evaluation criteria
> described below. AoA and CMS reserve the right to take into account
> geographic distribution and program diversity, in addition to the
> reviewer scores, in making the final award decisions.

**B. Evaluation Criteria**

1\. [Problem Statement / Need for Assistance]{.underline} [Weight: 5
points]{.underline}

Does the applicant demonstrate an understanding of: (i) the state's
current long term support system and (ii) how the system currently
limits or facilitates individual choice and access for both public- and
private-pay individuals in the applicant's target population? Does the
applicant adequately: (i) analyze the strengths and challenges of the
current system as it related to information and access; (ii) highlight
current strengths that the Resource Center will be building on and what
challenges must be overcome for it to succeed; and (iii) discuss any and
all ongoing effort to address information and access problems and
issues?

2\. [Approach, Work Plan and Activities]{.underline} [Weight: 25
points]{.underline}

> **Target Population/Goals/Objectives:** Are the target groups to be
> substantially served by the Resource Center clearly described and
> include the elderly? Has the applicant evidenced clear goals and
> objectives that are related in a meaningful way to the problems of
> citizen access and choice of long term support? Are the goals and
> objectives reasonable and likely to be effective in accomplishing the
> purpose of the grant?
>
> **Methods of Addressing the Problem**: Has the applicant clearly
> described a coherent approach that would successfully address the
> existing systemic problems in the areas of information, choice and
> access? Is it likely that the approach described will achieve the
> goals of the program?
>
> **Coordination and Linkages**: Has the applicant demonstrated that the
> initiatives proposed (i) complement other programs designed to create
> individual choice and access to long term support; (ii) utilize
> existing programs and services in a coordinated way through the
> Resource Center to improve long term support options; (iii) coordinate
> significant programs -- including Medicaid, the Older Americans Act,
> and state-only programs -- supporting efforts by individuals to access
> long term support options; and (iv) reflect a commitment from partners
> and include a description of their involvement and specific
> undertakings?
>
> **Work Plan and Timeline**: Has the applicant included a work plan
> that documents reasonable benchmarks, measurable outcomes, milestones,
> timeframes, and identifies the responsible parties to accomplish the
> goals of the project?

3\. [Formative Learning and Information Management]{.underline} [Weight:
10 points]{.underline}

> **Evaluation, Formative Learning and Management Information System**:
> Has the applicant outlined proposed data collection and management
> strategies, consistent with the Resource Center vision, for (i)
> supporting program management and tracking progress on the program
> goals and objectives and (ii) incorporating feedback into the
> project's ongoing operations, in a way that will improve program
> quality, promote individual choice, and limit repetitive provision of
> information by individuals?

4\. [Capabilities]{.underline} [Weight: 10 points]{.underline}

> **Organization, Management, and Qualifications**: Has the applicant:
> (i) provided evidence that key project staff, stakeholders and
> partners are qualified and possess the experience and skills to
> design, implement, and evaluate the program within the available time
> frames; (ii) provided information to show that key project staff who
> will be working at the community level have direct professional
> experiences serving populations targeted by the program; (iii)
> addressed any significant circumstances that would affect the ability
> of the applicant to recruit and hire staff for the project (e.g.,
> identified whether there are any current hiring freezes or other
> obstacles that would affect staffing) and, if so, identified methods
> by which such obstacles will be overcome?

5\. [Significance and Sustainability]{.underline} [Weight: 15
points]{.underline}

> **Enduring Systems Change**: Has the applicant demonstrated that the
> state seeks to implement enduring and effective systems changes and
> develop relationships among stakeholders that will advance the goal
> and vision of Resource Centers and help people of relevant ages with a
> disability to reside in the most integrated setting and exercise
> meaningful choice and control over where they reside and have access
> to community living and support services that are delivered in a
> manner that is consistent with the individual priorities and
> preferences and ensures the continuity of services?
>
> **Populations Impacted**: Is the program likely to have a meaningful
> impact on the targeted populations?
>
> **Sustainability**: Has the state taken steps to ensure that the
> Resource Center endures after the grant period?

6\. [Stakeholder Input and Partnerships]{.underline}: [Weight: 15
points]{.underline}

Has the applicant provided a plan to meaningfully involve individuals
and other public and private partners in all stages of the problem
analysis, planning, implementation, monitoring and evaluation
activities? Does the plan document citizen involvement in the Advisory
Board and detail how coordinated public/private efforts will ensure the
utilization of Resource Centers as the single entry-point for long term
support for the target population?

7\. [Budget and Resources]{.underline}: [Weight: 20 points]{.underline}

Has the applicant proposed: (i) a reasonable and detailed budget; (ii)
budgeted costs that are reasonable in relation to the project's
objectives, design and significance; (iii) a budget that follows the
requirements stated in the program announcement and specifically does
not use grant funds to supplant existing funds; and (iv) included the
required five percent (5%) non-financial or cash recipient contribution

# IV. INSTRUCTIONS FOR COMPLETING STANDARD FORMS

  -----------------------------------------------------------------------
  This section provides step-by-step instructions for completing the four
  (4) standard Federal forms required by 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 and CMS do not require all the information on these Standard Forms.
  Accordingly, please use the instructions below in lieu of the standard
  instructions attached to SF 424 and 424A to complete these forms.
  Please note that single-sided copies of all required forms must be used
  in submitting your application.

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

###### A. Standard Form 424

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

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

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

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

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

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

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

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

[Item 9]{.underline}. Enter - Administration on Aging and Centers for
Medicare & Medicaid

Services.

[Item 10]{.underline}. Enter the AoA CFDA \# 93.048 in the box provided.
Underneath of the box provided for Item 10, also list the CMS CFDA \#
93.779.

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

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

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

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

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

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

[Item 15]{.underline}. **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 15 and the Budget Information
Sections A, B and C noted below.

> All budget information entered under item 15 should cover the upcoming
> budget period. For sub-item 15a, enter the federal funds being
> requested. Sub-items 15b-15e are considered matching funds. The dollar
> amounts entered in sub-items 15b-15f must total at least 5 percent of
> the amount of federal funds being requested (the amount in 15a) in the
> form of a non-financial or cash recipient contribution (match).
>
> Non-financial recipient contributions may include the value of goods
> and/or services contributed by the Grantee (e.g., salary and fringe
> benefits of staff devoting a percentage of their time to the grant not
> otherwise included in the budget or derived from federal funds).
> Recipient contributions must be included in the applicant\'s budget on
> Standard Form 424A and described in the budget narrative/justification
> section of the application. The non-financial match requirement may
> also be satisfied if a third party participating in the grant makes an
> \"in-kind contribution,\" provided that the Grantee\'s contribution
> and/or the third-party in-kind contribution equals 5% of the total
> grant award. Third-party \"in-kind contributions\" may include the
> value of the time spent by citizen task force members (using
> appropriate cost allocation methods to the extent that non-Federal
> funds are involved) who specifically contribute to the design,
> development and implementation of the grant.

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 (HHS) 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
HHS requirements.

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

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

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

**B. Standard Form 424A**

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

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

##### 

##### Section A ‑ Budget Summary

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

##### Section B ‑ Budget Categories

Column 3: Enter the breakdown of how you plan to use the Federal funds
being

> requested by object class category (see instructions for each object
> class category below).

Column 4: Enter the breakdown of how you plan to use the non-Federal
share by object class category.

Column 5: Enter the total funds required for the project (the sum of
Columns 3 and 4) by object class category.

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

[Line 6a]{.underline}: [Personnel]{.underline}: Enter total costs of
salaries and wages of applicant/grantee staff. Do

> not include the costs of consultants; consultant costs should be
> included under 6h ‑ Other. [In the Justification]{.underline}:
> Identify the project director, if known. Specify the key staff, their
> titles, brief summary of project related duties, and the percent of
> their time commitments to the project in the budget justification.

[Line 6b]{.underline}: [Fringe Benefits]{.underline}: Enter the total
costs of fringe benefits unless treated as part of

> an approved indirect cost rate. [In the Justification]{.underline}:
> Provide a break‑down of amounts and percentages that comprise fringe
> benefit costs, such as health insurance, FICA, retirement insurance,
> etc.

[Line 6c]{.underline}: [Travel]{.underline}: Enter total costs of
[out‑of‑town travel]{.underline} (travel requiring per diem) for

> staff of the project. Do not enter costs for consultant\'s travel -
> this should be included in line 6h. [In the
> Justification]{.underline}: Include the total number of trips,
> destinations, purpose, length of stay, subsistence allowances and
> transportation costs (including mileage rates).

[Line 6d]{.underline}: [Equipment]{.underline}: Enter the total costs of
all equipment to be acquired by the project. For all grantees,
\"equipment\" is non‑expendable tangible personal property having a
useful life of more than two years 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 and CMS grants
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. [State governments should enter the amount of
> indirect costs determined in accordance with DHHS
> requirements]{.underline}

[Line 6k]{.underline}: [Total]{.underline}: Enter the total amounts of
Lines 6i and 6j.

[Line 7]{.underline}: [Program Income]{.underline}: As appropriate,
include the estimated amount of income, if any, you expect to be
generated from this project that you wish to designate as match (equal
to the amount shown for Item 15(f) on Form 424). **[Note]{.underline}:**
Any program income indicated at the bottom of Section B and for item
15(f) on the face sheet of Form 424 will be included as part of
non-Federal match and will be subject to the rules for documenting
completion of this pledge. If program income is expected, but is not
needed to achieve matching funds, **do** **not** include that portion
here or on Item 15(f) of the Form 424 face sheet. Any anticipated
program income that will not be applied as grantee match should be
described in the Level of Effort section of the Program Narrative.

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

[Line 12]{.underline}: Enter the amounts of non‑Federal resources that
will be used in carrying out the proposed project, by source (Applicant;
State; Other) and enter the total amount in Column (e). Do not include
program income unless it is used to meet the match requirement. Keep in
mind that if program income used to meet the match requirement and the
projected level of program income is not met, thereby decreasing the
level of match, the amount of Federal funds available to the grantee may
be reduced if the match falls below required levels.

[Section D ‑ Forecasted Cash Needs]{.underline} - Not applicable.

[Section E ‑ Budget Estimate of Federal Funds Needed for Balance of the
Project]{.underline}

[Line 20]{.underline}: Enter the additional funding amounts requested
for the second and third years of the project. Note that federal funding
for the three years cannot total more than \$800,000.

###### 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
and the Centers for Medicare and Medicaid Services. Please note that a
duly authorized representative of the applicant organization must
certify that the organization is in compliance with these assurances.

###### 

###### D. Standard Form CD-511 -- Certifications 

This form contains certifications that are required of the applicant
organization regarding (a) lobbying; (b) debarment, suspension, and
other responsibility matters; and (3) 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.

**ATTACHMENTS**

**Attachment A:**

**Sample Budget Justification Format with Examples**

**Attachment B:**

**Sample Budget Justification Format**

**Attachment C:**

**Sample Work Plan Format**

**Attachment D:**

**Application Package Checklist**

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

+------+------+------+------+------+----------------------------------+
| >    | *    | **N  | **N  | # T  | ### Justification                |
| **Ob | *Fed | on-F | on-F | OTAL |                                  |
| ject | eral | eder | eder |      |                                  |
| > C  | Fun  | al** | al** |      |                                  |
| lass | ds** |      |      |      |                                  |
| > Ca |      | **Ca | **I  |      |                                  |
| tego |      | sh** | n-Ki |      |                                  |
| ry** |      |      | nd** |      |                                  |
+------+------+------+------+------+----------------------------------+
| *    | \$40 |      | 0    | \$40 | Project Director (name) = 1FTE @ |
| *Per | ,000 |      |      | ,000 | \$40,000 = \$40,000              |
| sonn |      |      |      |      |                                  |
| el** |      |      |      |      |                                  |
+------+------+------+------+------+----------------------------------+
| **Fr | \$14 | 0    | 0    | \$14 | Fringes on Supervisor and        |
| inge | ,000 |      |      | ,000 | Director @ 28% of salary.        |
| Be   |      |      |      |      |                                  |
| nefi |      |      |      |      | FICA (7.65%) = \$3,825           |
| ts** |      |      |      |      |                                  |
|      |      |      |      |      | Health (12%) = \$6,000           |
|      |      |      |      |      |                                  |
|      |      |      |      |      | Dental (5% ) = \$2,500           |
|      |      |      |      |      |                                  |
|      |      |      |      |      | Life (2%) = \$1,000              |
|      |      |      |      |      |                                  |
|      |      |      |      |      | Workers Comp Insurance (.75%) =  |
|      |      |      |      |      | \$ 375                           |
|      |      |      |      |      |                                  |
|      |      |      |      |      | Unemployment Insurance (.6%) =   |
|      |      |      |      |      | \$ 300                           |
+------+------+------+------+------+----------------------------------+
| **   | 0    | 0    | \$   | \$   | Travel to Annual Grantee         |
| Trav |      |      | 1    | 1    | Meeting:                         |
| el** |      |      | ,984 | ,984 |                                  |
|      |      |      |      |      | Airfare: 1 RT x 1 person x       |
|      |      |      |      |      | \$750/RT = \$ 750                |
|      |      |      |      |      |                                  |
|      |      |      |      |      | Lodging: 3 nights x 1 person x   |
|      |      |      |      |      | \$100/night = \$ 300             |
|      |      |      |      |      |                                  |
|      |      |      |      |      | Per Diem: 4 days x 1 person x    |
|      |      |      |      |      | \$40/day = \$ 160                |
|      |      |      |      |      |                                  |
|      |      |      |      |      | Out-of-Town Project Site Visits  |
|      |      |      |      |      |                                  |
|      |      |      |      |      | Car mileage: 3 trips x 1person x |
|      |      |      |      |      | 350 miles /trip                  |
|      |      |      |      |      |                                  |
|      |      |      |      |      | x \$ .365/mile = \$ 384          |
|      |      |      |      |      |                                  |
|      |      |      |      |      | Lodging: 3 trips x 1 person x 1  |
|      |      |      |      |      | night/ trip x \$50/night = \$    |
|      |      |      |      |      | 150                              |
|      |      |      |      |      |                                  |
|      |      |      |      |      | Per Diem: 3 trips x 1 person x   |
|      |      |      |      |      | 2days/trip x \$40/day = \$ 240   |
+------+------+------+------+------+----------------------------------+

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

###### 

+-----+-----+------+------+------+-----------------------------------+
| **  | **  | ###  | *    | ##   | ### Justification                 |
| Obj | Fed | ## * | *Non | ## * |                                   |
| ect | era | Non- | -Fed | [TOT |                                   |
| C   | l** | Fede | eral | AL]{ |                                   |
| las |     | ral* | I    | .und |                                   |
| s** | #   |      | n-Ki | erli |                                   |
|     |  Fu | #### | nd** | ne}* |                                   |
| **C | nds | # *C |      |      |                                   |
| ate |     | ash* |      |      |                                   |
| gor |     |      |      |      |                                   |
| y** |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| *   | 0   | 0    | 0    | 0    | No equipment requested            |
| *Eq |     |      |      |      |                                   |
| uip |     |      |      |      |                                   |
| men |     |      |      |      |                                   |
| t** |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| **S | \   | 0    | \$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 | 0    | 0    | \    | Contracts to A,B,C direct service |
| ont | 00, |      |      | $200 | providers (name providers)        |
| rac | 200 |      |      | ,200 |                                   |
| tua |     |      |      |      | adult day care contractor =       |
| l** |     |      |      |      | \$75,000                          |
|     |     |      |      |      |                                   |
|     |     |      |      |      | respite care contractor in home=  |
|     |     |      |      |      | \$75,000                          |
|     |     |      |      |      |                                   |
|     |     |      |      |      | respite care contractor-NF =      |
|     |     |      |      |      | \$50,200                          |
|     |     |      |      |      |                                   |
|     |     |      |      |      | See detailed budget justification |
|     |     |      |      |      | for each provider (and then       |
|     |     |      |      |      | provide it!)                      |
+-----+-----+------+------+------+-----------------------------------+
| A   |     |      |      |      |                                   |
| tta |     |      |      |      |                                   |
| chm |     |      |      |      |                                   |
| ent |     |      |      |      |                                   |
| A:  |     |      |      |      |                                   |
| Bud |     |      |      |      |                                   |
| get |     |      |      |      |                                   |
| Ju  |     |      |      |      |                                   |
| sti |     |      |      |      |                                   |
| fic |     |      |      |      |                                   |
| ati |     |      |      |      |                                   |
| on, |     |      |      |      |                                   |
| P   |     |      |      |      |                                   |
| age |     |      |      |      |                                   |
| 3   |     |      |      |      |                                   |
| --  |     |      |      |      |                                   |
| Sam |     |      |      |      |                                   |
| ple |     |      |      |      |                                   |
| For |     |      |      |      |                                   |
| mat |     |      |      |      |                                   |
| w   |     |      |      |      |                                   |
| ith |     |      |      |      |                                   |
| EX  |     |      |      |      |                                   |
| AMP |     |      |      |      |                                   |
| LES |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| **O | \$  | \$9  | \$   | \$20 | Local conference registration fee |
| the | 10, | ,404 | 596  | ,000 | (name conference) = \$ 200        |
| r** | 000 |      |      |      |                                   |
|     |     |      |      |      | Printing brochures (50,000 @ \$   |
|     |     |      |      |      | .05 ea) = \$ 2,500                |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Video production = \$ 2,000       |
|     |     |      |      |      |                                   |
|     |     |      |      |      | 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 | \$   | \$   | \    |                                   |
| ### | 65, | 9    | 4    | $279 |                                   |
|  TO | 700 | ,404 | ,580 | ,684 |                                   |
| TAL |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+

Attachment B: 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 B: 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** |      |      |    |      |                                   |
+------+------+------+----+------+-----------------------------------+
| #    |      |      |    |      |                                   |
| #### |      |      |    |      |                                   |
|  *TO |      |      |    |      |                                   |
| TAL* |      |      |    |      |                                   |
+------+------+------+----+------+-----------------------------------+

Attachment C: 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 C: 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 C: 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 D:

####### Grant Application Package Checklist

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

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

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

-   SF 424.

-   SF 424A.

-   Budget Justification.

-   SF 424B.

-   SF CD-511. Be sure this form is completed according to the
    instructions, signed and dated by the authorized representative (see
    item 18d on SF 424).

-   A copy of the current indirect cost rate agreement approved by the
    Department of Health and Human Services or another Federal agency.

-   Project Narrative

-   Completed Grant Application Package Checklist