# OMB Approval No. 0985-0018

> Expiration 3/31/2007

# 

# 

# Senior Medicare Patrol Projects

# Program Announcement and Grant Application Instructions

# 

# 

# U.S. Administration on Aging 

**2006**

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

**Administration on Aging (AoA)**

**AoA Center : Center for Wellness and Community-Based Services**

######## Funding Opportunity Title: Senior Medicare Patrol Projects

**Announcement Type: Initial**

**Funding Opportunity Number: HHS-2006-AoA-MP-0603**

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

**Key Dates: The deadline date for receipt of applications is April 28,
2006**

**Executive Summary:**

AoA funds sixty-four Senior Medicare Patrol (SMP) Projects which recruit
retired professionals as volunteers to educate older consumers in their
communities about Medicare, Medicaid, and other health care fraud, error
and abuse prevention. Currently SMPs operate in 49 states, the District
of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands. AoA plans to
award one project grant in each of the eligible states listed in this
announcement. States not listed are currently served by SMP projects
awarded in 2005. Applicants for the 2006 award must provide a plan for
statewide SMP program coverage and for serving isolated and
hard-to-reach, populations within their state.

Up to twenty-eight cooperative agreements will be funded at a federal
share of up to \$180,000 per year and a project period of up to three
years, contingent upon the availability of federal funds. The award is a
cooperative agreement because the Administration on Aging will be
substantially involved in the development and execution of the
activities of the projects and will describe training, technical
assistance and support to be provided to the projects. The cooperative
agreement will provide the program requirements and measures of program
success, as well as describe the training, technical assistance and
support to be provided by AoA and the National Consumer Protection
Technical Resource Center. Applicants (with the exception of Guam and
the U.S. Virgin Islands) must cover at least 25 % of the project's total
cost with non-Federal resources.

Public and/or nonprofit agencies and organizations, including
faith-based and community-based organizations, and federally recognized
tribes are eligible to apply under this program announcement. However,
to be considered for funding, applicants must be experienced in
providing outreach and education or assistance to older persons.
Applicants should ideally be well-established, known presences in their
respective professional communities, and must provide a comprehensive
plan to provide program services statewide.

**I. FUNDING OPPORTUNITY DESCRIPTION**

**[Program History]{.underline}**

The DHHS Office of Inspector General estimates that Medicare loses
billions of dollars each year due to errors, fraud, and abuse. These
losses are due, to a considerable extent, to the many ways in which the
funds are disbursed as well as to the sheer magnitude of health care
expenditures. Both factors increase the probability of errors while
opening wider opportunities for fraud and abuse. While the vast majority
of health care providers are honest, those operating unscrupulously,
intent on obtaining vital health care dollars illegally, have done so
based on the perception that the risks of detection have lessened over
the years.

In 1995, the AoA became a partner in a government-led effort to fight
error, fraud and abuse in the Medicare and Medicaid programs through the
implementation of a health care integrity program designed to coordinate
federal, state, local, and private resources to target those areas most
plagued by program abuses. This partnership includes three agencies
within the U.S. Department of Health and Human Services: the Office of
Inspector General (OIG); the Centers for Medicare & Medicaid Services
(CMS); and the AoA, as well as the U.S. Department of Justice, state and
area agencies on aging, long-term care ombudsmen, state Medicaid fraud
control units, state attorney general offices, state Medicaid agencies,
insurance counseling programs, health departments, and a number of other
local entities.

Beginning in 1997, the AoA established twelve local demonstration
projects designed to recruit and train retired professionals, such as
doctors, nurses, teachers, lawyers, accountants, and others to identify
and report error, fraud, and abuse. Implemented through the Omnibus
Consolidated Appropriation Act of 1997 (Public Law. 104-208), Senate
Report 104-368 noted that "senior citizens are our best front line
defense against these losses, but they often don't have the information
and experience needed" to recognize and accurately report cases of
error, fraud , and abuse. The Report further noted that "thousands of
retired accountants, health professionals, investigators, teachers, and
others ... with appropriate training could serve as volunteer expert
resources and educators for seniors in their communities." Accordingly,
these projects have worked to test different models designed to train
retirees in local communities to serve as both volunteer resources and
educators for other Medicare beneficiaries, and to build and strengthen
community coalitions of older Americans and service providers.

**SMP Program Today**

In 2005, the SMP Program has expanded to include 64 project grants in
virtually all states, the District of Columbia, Puerto Rico, Guam and
the U.S. Virgin Islands. These projects, funded through grants provided
under Title II and Title IV of the Older Americans Act, have made great
progress in recruiting and training retired professional and other
senior citizens on Medicare and Medicaid error, fraud and abuse. These
volunteers work in their communities, senior centers and elsewhere to
educate Medicare and Medicaid beneficiaries, family members, and
caregivers to actively protect themselves against fraudulent, wasteful
and abusive health care practices by reviewing their Medicare benefit
statements and reporting suspected errors.

SMP projects actively work to disseminate SMP fraud prevention and
identification

information through the media, outreach campaigns, community events and
many

other means. Through these efforts, beneficiaries contact the projects
with inquiries and complaints regarding Medicare, Medicaid and other
health care or related consumer issues. Another key role of the SMP
project is to address such inquiries and complaints, either by resolving
matters directly or by referrals to appropriate entities. SMP projects
refer numerous beneficiary complaints to state and national fraud
control /consumer protection entities, including Medicare contractors,
state Medicaid fraud control units, state attorneys general, the OIG,
and CMS. Tracking and reporting of beneficiary complaints and follow-up
on savings or other outcomes achieved through these efforts is also a
key function of the SMP project.

The AoA also receives Health Care Fraud and Abuse Control (HCFAC)
funding as authorized by the Health Insurance Portability and
Accountability Act (HIPAA) of 1996. The HCFAC funds, which are received
from the Medicare Trust Fund, are used to support infrastructure,
technical assistance, and other SMP program support and
capacity-building activities designed to enhance program effectiveness.
The National Consumer Protection Technical Resource Center (the Center),
an AoA grantee, provides training, support, information and technical
assistance to SMP projects and is also supported through the HCFAC
funding. Now that the SMP program has achieved national status, both in
state coverage and technical assistance, HCFAC funding has also been
used to support SMP projects' efforts to increase program capacity
needed to better fulfill the SMP mission.

In 2004, AoA announced a new competitive grant program to support SMP
project efforts to advance collaborative and innovative approaches for
integration of Medicare and Medicaid fraud awareness and prevention
activities within states and communities. Fourteen grants were awarded
that support the SMP projects' efforts to integrate the SMP program into
other areas of health care fraud awareness. Models developed by these
integration grantees, with focus on Medicaid, home health care and fraud
related to the new prescription drug benefits of the Medicare
Modernization Act (MMA), will be disseminated by AoA and the Center.
Applicants under this announcement should reflect awareness of
integration strategies and discuss how they will adapt models
appropriate to their state and target populations in SMP project plans.

Semiannually, data is collected on the activities and results of the
program. Results documented since the program's inception reveal that
Senior Medicare Patrol Projects have:

-   Trained over 52,066 volunteers;

-   Educated over 2.2 million beneficiaries;

-   Conducted over 137,903 media events;

-   Resolved or referred over 14,598 complaints as a result of
    educational efforts; and

-   Recouped over \$104.1 million in Medicare, Medicaid or other
    savings.

> **[Project Objectives and Activities]{.underline}**

The purpose of this competition is to provide the opportunity to fund
one (1) Senior Medicare Patrol Project in each of 26 eligible states,
Guam and the US Virgin Islands for a project period of up to three (3)
years. Projects must recruit and train volunteers to conduct health care
fraud control outreach and education. Applicants under this announcement
are required to address the five 2006 Senior Medicare Patrol Program
Objectives, including:

-   *Foster National and Statewide Program Coverage.* Applicants must
    provide a comprehensive plan with appropriate strategies to achieve
    statewide coverage. Statewide program coverage is defined for this
    purpose as service to each county within the state. In the case of
    U.S. territories, coverage of all local jurisdictions is required.
    The plan is required of all applicants, whether they be statewide
    entities, regional, area or local organizations. Types and levels of
    service shall be specified as well as the strategies or approaches
    by which statewide coverage will be achieved and enhanced. Examples
    of appropriate strategies that may be used to ensure statewide
    program coverage include collaboration, formal partnering,
    sub-granting or contracting with other area, regional or statewide
    organizations, toll-free lines, web sites and web-based strategies,
    and statewide media and outreach plans. Program performance measures
    will reflect program coverage by county or jurisdiction.

-   *Improve beneficiary education and inquiry resolution for other
    areas of health care fraud.* Applicants will be required to
    coordinate with the Center to obtain and adapt successful models for
    integrating Medicaid, home health care, prescription drug, and
    durable medical equipment fraud awareness into their project plans.
    Partnerships at the state and local levels should be sought that
    expand the project's network into these areas of health care and
    consumer fraud, and provide information, expertise and support for
    SMP development efforts in these areas. Grantee cooperative
    agreements will reflect this objective.

-   *Foster national program visibility and consistency.* AoA will
    continue to work with the Center and SMP projects to achieve this
    objective on a national basis. Consistency in SMP project
    management, tracking and reporting of inquiries and complaints will
    be improved through a SMP-wide standardized process and web-based
    system for receiving, managing, referring and/or resolving
    beneficiary inquiries, complaints or systemic problems. All projects
    will be trained in this complaints management system, once
    developed. Educational standards and successful implementation of
    the SMP management, tracking and reporting system will be reflected
    in SMP grantee cooperative agreements.

-   *Improve the efficiency of the SMP Program while increasing results
    for both operational and quality measures.* The following desired
    program results will be reflected in SMP performance measures, SMP
    cooperative agreements, and tracked in project semi-annual reports:

    -   Increase the numbers of elderly individuals educated;

    -   Increase inquiries and the rate of inquiry resolution; and

    -   Increase savings.

> Applicant plans for project priorities, workplan and activities should
> reflect systems that will enhance and measure these program results.

-   *Target training and education to isolated and hard -to -reach*
    *populations*. Applicants are required to identify specific target
    populations within the state that are traditionally underserved due
    to isolation, ethnic, cultural or language barriers, or other
    factors. Applicants will provide a plan to identify underserved
    elders and reach them through innovative and collaborative methods.
    To achieve this each comprehensive plan will specify the target
    population and discuss how barriers to this population will be
    overcome. Outreach strategies and measures of increased access of
    the target population must be included in the plan. Applicants must
    include signed letters of collaboration from organizations
    representing the target population that specifies their commitment,
    role, and activities of the applicant in addressing this objective.

To advance the above objectives, applications are sought from consortia
of state, area or local, public or nonprofit agencies and organizations,
including federally financed tribes, faith-based organizations and
community organizations, with a demonstrated capacity to utilize
effective models for the recruitment, training, support, and retention
of retired persons who, with appropriate training, could provide
volunteer service as expert resources and educators for older persons in
their communities. Applicants must demonstrate that they have enlisted
the assistance of appropriate community-based organizations in the
preparation of the application and that these organizations are included
in the project's plans for statewide implementation. All applicants
should demonstrate their capacity and experience in using quantitative
performance outcome information to support their activity and management
decisions.

Projects should utilize best practice models and test innovative
approaches for recruiting retirees fully capable of teaching and
educating Medicare and Medicaid beneficiaries to better monitor payments
on their behalf and recommend actions to address identified
discrepancies. In every case, applicants should propose activities that
will effectively employ the unique skills, varied experiences, good
will, and availability of retired professionals in assisting older
persons to become more educated about their health care expenditures
under Medicare and Medicaid. As beneficiaries, citizens, and taxpayers,
older persons can and should have the knowledge necessary to assess
their health care bills, statements, and other documents accurately and
to identify and report suspected instances of error, fraud, and abuse.
Examples of practices deserving their careful scrutiny include: billing
for services not rendered; overcharging for services performed; waiving
patient coinsurance; accepting or paying kickbacks for patient
referrals; offers of motorized and durable medical equipment; and
providing inappropriate or unnecessary services.

The applicant must provide a detailed plan for the management and
operation of the "Senior Medicare Patrol Project." This includes:

-   developing a systematic plan for project start-up;

-   providing a comprehensive plan for statewide program coverage that
    identifies collaborations and innovations designed to reach the
    targeted populations;

-   involving a variety of community-based, local, state and
    federally-financed aging network services organizations;

-   developing formal partnerships, collaborations and other
    arrangements as needed to address SMP Program Objectives;

-   researching the demographics of the population to be served, and
    identifying barriers to program access;

-   developing outreach strategies specifically designed to overcome
    these barriers and reach the target population;

-   identifying a specific strategy for recruiting, training, and
    maintaining a pool of SMP volunteers, including seniors with
    language and other skills and abilities to help reach minority
    communities;

-   developing a training plan for staff, volunteers, and target
    populations tailored to the specific information required by each
    group to achieve program objectives;

-   developing outreach strategies and priority areas for fraud
    education based on assessment of trends, issues and cases identified
    within the statewide service area; and

-   developing a plan to evaluate project performance, including
    collection and reporting of information measuring project progress
    in addressing SMP program objectives.

**[Statutory Authority:]{.underline}**

The statutory authority for grants under this program announcement is
contained in Title IV and Title II, of the Older Americans Act, (42
U.S.C. 3001 et seq.), as amended by the Older Americans Act Amendments
of 2000 (P.L. 106-501) and the HIPAA of 1996 (P.L.104-191).

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

Award Type: Cooperative Agreement

Estimated Federal Funds Available: \$4.6 million

Individual Annual Award Ceiling: \$180,000

Estimated Number of Awards: up to 28

Project Start Date: July 1, 2006

Estimated Length of Project: three years

The award is a cooperative agreement because the Administration on Aging
will be substantially involved in the development and execution of the
activities of the projects. The cooperative agreement will describe
training, technical assistance and support to be provided the projects.
The cooperative agreement will also specify project performance criteria
and measures relative to the SMP Program Objectives. The AoA project
officer for the SMP project grant will provide technical assistance and
support on grant management and implementation issues, including
execution of the cooperative agreement.

The Administration on Aging, primarily through services of the Center,
will provide technical assistance and support to the project in
volunteer recruitment and management, ensuring currency in Medicare and
Medicaid program information, fraud prevention and identification
techniques, outreach strategies, complaint management, tracking and
reporting, and strategies for reaching targeted populations.

The Administration on Aging will conduct at least one national
conference and one regional meeting in alternate years for the purpose
of providing technical assistance and training to SMP projects. Grantee
participation in these conferences is specified as part of the
cooperative agreement.

The SMP grantee and the Administration on Aging will work cooperatively
to determine the priority activities to be completed by the project and
develop the work plan for each year of the project. Within 45 days of
the award and 45 days of each continuation award, the project will agree
upon and adhere to a work plan that details expectations for major
activities, products, and reports during the current budget period. The
work plan will include specific steps and a timetable for implementing
statewide program coverage. The plan will also specify actions to expand
program access to target populations. The work plan will also include
staff assignments, work locations, and other areas that require
Administration on Aging consultation, review, and/or prior approval.
Either the Administration on Aging or the project can propose a revision
of the final work plan at any time.

The Administration on Aging (AoA) will define project performance
criteria and expectations, and will monitor, evaluate and support the
projects' efforts in achieving performance goals. AoA will provide
mentoring, on-line training and other technical support through its
National Consumer Protection Technical Resource Center (the Center).
Grantees are encouraged to contact the Center to receive project
toolkits and mentoring to assist in training the new project director.
The project will provide program performance output, outcome and
activity data semiannually utilizing the performance instrument
developed by the HHS Office of the Inspector General (OIG). The
Administration on Aging will evaluate grantee performance data, and
provide support and technical assistance, in coordination with the
Center, to assist projects in improving performance.

The Administration on Aging will assist the project leadership in
understanding the strategic goals and objectives, policy perspectives
and priorities of the Assistant Secretary for Aging and the Department
of Health and Human Services by sharing such information via e-mail,
conference calls, briefings and other consultations. The Administration
on Aging will also share information with the project about other SMP
projects, including integration grants, and other federally sponsored
projects and activities relevant to the interests of SMP projects.

The Administration on Aging, will, if possible, be represented at
meetings of the project's steering/advisory/policy committee. AoA should
also be advised in advance of major media, outreach or other project
events, and be offered the opportunity to attend, as appropriate.

**III. ELIGIBILITY INFORMATION**

**1. Eligible Applicants**

Through this competition, AoA plans to fund one project in each of the
following 26 states and two territories: Alabama, California,
Connecticut, Hawaii, Iowa, Illinois, Indiana, Louisiana, Maryland,
Minnesota, Missouri, Mississippi, North Carolina, North Dakota,
Nebraska, New Hampshire, Nevada, New York, Pennsylvania, Rhode Island,
South Carolina, South Dakota, Utah, Vermont, Wisconsin, Wyoming, Guam
and the US Virgin Islands. The competition is limited to public/private
non-profit organizations (proof of non-profit status is required)
located within the 28 eligible jurisdictions specified above.
Faith-based organizations and federally-financed tribes are encouraged
to apply.

The AoA is currently funding SMP projects in the remaining states, the
District of Columbia, and Puerto Rico, having awarded grants to these
entities in 2005.

**2. Cost Sharing or Matching**

Under this Older Americans Act (OAA) program, AoA will fund no more than
75% of the project's total cost, which means the applicant must cover at
least 25% of the project's total cost with non-federal resources. In
other words, for every three (3) dollars received in federal funding,
the applicant must contribute at least one (1) dollar in non-federal
resources toward the project's total cost (i.e., the amount on line 18g
of the SF 424). This "three-to-one" ratio is reflected in the formula
included under Item 18 in Attachment A. You can use this formula to
calculate your minimum required match. A common error applicants make is
to match 25% of the federal share, rather than 25% of the project's
total cost.

In accordance with 48 USC 1469a (d), matching requirements are waived
for grantee applicants from Guam and the U.S. Virgin Islands. Match is
not one of the responsiveness criteria but is a scored evaluation
criteria as noted in Section V., subsection (d).

**3. Application Screening Criteria**

All applications will be screened to assure a level playing field for
all applicants. Applications that fail to meet the screening criteria
described below will **[not]{.underline}** be reviewed and will receive
**[no]{.underline}** further consideration.

In order for an application to be reviewed, it must meet the following
screening requirements:

1.  Applications must be submitted electronically via
    [www.grants.gov](http://www.grants.gov/) by midnight April 28, 2006.
    All other hard copy submissions for which approval has been
    requested and received (per Section IV(6)) must be received in AoA
    by 5:30 PM Eastern time on April 28, 2006.

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

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

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IV. **APPLICATION AND SUBMISSION INFORMATION**

All applicants are required to submit electronically through
[http://www.grants.gov](http://www.grants.gov/) by midnight April 28,
2006.

EXCEPTIONS TO THIS REQUIREMENT MAY ONLY BY MADE BY THE AOA GRANTS
OFFICE; STEPHEN DANIELS (202-357-3464). EXCEPTIONS MAY ONLY BE MADE TO
ALLOW FOR CATASTROPIC EVENTS SUCH AS TORNADOES, FLOODS, ETC.

PLEASE NOTE THAT APPLICANTS ARE RESPONSIBLE FOR MAILING OR HAND
DELIVERING APPLICATIONS TO AOA IN SUFFICIENT TIME TO BE RECEIVED BY 5:30
PM EASTERN TIME APRIL 28, 2006.

## 1. Address to Request Application Package 

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

Applicants with prior approval may write for materials to:

U.S. Department of Health and Human Services

Administration on Aging

Barbara Lewis

Center for Wellness and Community Based Services

Washington, D.C. 20201

Or by calling: 202-357-3532

Or e-mailing: Barbara.Lewis@aoa.hhs.gov

Please note, AoA is requiring applications for this announcement to be
submitted electronically through
[www.grants.gov](http://www.grants.gov/). The Grants.gov registration
process can take several days. If your organization is not currently
registered with [www.grants.gov](http://www.grants.gov/), please begin
this process immediately. **For assistance with
[www.grants.gov](http://www.grants.gov/), please contact Arthur Miller
at AoA's Grants.gov helpdesk at 202-357-3438.** At
[www.grants.gov](http://www.grants.gov/), you will be able to download a
copy of the application packet, complete it off-line, and then upload
and submit the application via the Grants.gov website.

Applications submitted via [www.grants.gov](http://www.grants.gov/) :

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

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

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

-   You may submit all documents electronically, including all
    information included on the SF 424 and all necessary assurances and
    certifications.

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

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

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

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

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

##  

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

-   Summary/Abstract

-   Problem Statement

-   Goal(s) and Objective(s)

-   Proposed Intervention

-   Special Target Populations and Organizations

-   Outcomes

-   Project Management

-   Evaluation

-   Dissemination

-   Organizational Capability

> The Project Narrative is the most important part of the application,
> since it will be used as the primary basis to determine whether or not
> your project meets the minimum requirements for grants under Title IV
> of the Older Americans Act. The Project Narrative should provide a
> **clear and concise** description of your project. AoA recommends that
> your project narrative include the following components:
>
> **Summary/Abstract.** This section should include a one page-300 words
> maximum - description of the proposed project, including: the goal,
> priority area(s), target population, activities, products and
> measurable outcomes. Detailed instructions for completing the
> summary/abstract are included in Attachment E of this document.
>
> **Problem Statement.** This section should describe, in both
> quantitative and qualitative terms, the nature and scope of the
> particular problem or issue the proposed intervention is designed to
> address, including how the project will potentially affect the
> targeted elderly population and/or their caregivers (including
> specific subgroups within those populations), and possibly the health
> care and social services systems (e.g., the use of health care and/or
> nursing home services.)
>
> **Goals and Objectives.** This section should consist of a description
> of the project's goal(s) and major objectives in terms of the priority
> area(s). Unless the project involves multiple, complex interventions,
> we recommend you have only one overall goal.
>
> **Proposed Intervention.** This section should provide a clear and
> concise description of the intervention you are proposing to use to
> address the problem described in the "Problem Statement". You should
> also describe the rationale for using the particular intervention,
> including factors such as: "lessons learned" for similar projects
> previously tested in your community, or in other areas of the country;
> factors in the larger environment that have created the "right
> conditions" for the intervention (e.g., existing social, economic or
> political factors that you'll be able to take advantage of, etc.).
> Also note any major barriers you anticipate encountering, and how your
> project will be able to overcome those barriers. Be sure to describe
> the role and makeup of strategic partnerships you plan to involve in
> implementing the intervention, including other organizations, funders,
> and/or consumer groups.
>
> **Special Target Populations and Organizations.** This section should
> describe how you plan to systematically involve community-based
> organizations experienced with the target population in the planning
> and implementation of the proposed statewide project. Specifically,
> your application should discuss proposed strategies for targeting
> minority and hard-to-reach populations, including low-income, rural,
> isolated, and limited English-speaking individuals. (Suggested length:
> one to two pages.)
>
> **Outcomes**. This section of the project narrative must clearly
> identify the [measurable]{.underline} outcome(s) that will result from
> the project. (NOTE: AoA will not fund any project that does not
> include measurable outcomes). This section should also describe how
> the project's findings might benefit the field at large, (e.g., how
> the findings could help other organizations throughout the nation to
> address the same or similar problems.) List measurable outcomes in the
> attached Work Plan Grid (Attachment D) under "Measurable Outcomes" in
> addition to any discussion included in the narrative along with a
> description of how the project might benefit the field at large.
> (Suggested Length: one to two pages.)
>
> A "measurable outcome" is an observable end-result that describes how
> a particular intervention benefits consumers. Examples of outcomes
> include: Measurable increase of Medicare beneficiary awareness
> regarding health care error, fraud and abuse, as well as beneficiary
> behaviors that result in increased detection and reporting of errors,
> fraud and abuse. Examples of other outcomes measured by the OIG
> semiannually include number of volunteers conducting activities to
> educate beneficiaries, number of beneficiaries educated, number of
> complaints that resulted in some action, and savings attributable to
> the project. A measurable outcome is not a measurable "output", such
> as: the number of clients served; the number of training sessions
> held; or the number of service units provided.
>
> You should keep the focus of this section on describing
> [what]{.underline} outcome(s) will be produced by the project. You
> should use the Evaluation section noted below to describe
> [how]{.underline} the outcome(s) will be measured and reported. Your
> application will be scored on the clarity and nature of your proposed
> outcomes, not on the number of outcomes cited.
>
> **Project Management**. This section should include a clear
> delineation of the roles and responsibilities of project staff,
> consultants and partner organizations, and how they will contribute to
> achieving the project's objectives and outcomes. It should specify who
> would have day-to-day responsibility for key tasks such as: leadership
> of project; monitoring the project's on-going progress, preparation of
> reports; communications with other partners and AoA. It should also
> describe the approach that will be used to monitor and track progress
> on the project's tasks and objectives. (Suggested Length: one to two
> pages.)
>
> **Evaluation**. This section should describe the method(s), techniques
> and tools that will be used to: 1) measure the success of the proposed
> intervention, products and practices in achieving anticipated
> outcomes; and 2) document project "lessons learned" (both positive and
> negative) that will be useful to other SMP projects interested in
> replicating the intervention. This section should also include a
> self-assessment of prior performance data and a plan for addressing
> those areas identified for improvement. (Suggested Length: one to two
> pages.)
>
> **Dissemination.** This section should describe the method that will
> be used to disseminate the project's successful products and practices
> in a timely manner and in easily understandable formats, to other SMP
> projects who might be interested in using these as models to improve
> practice, service delivery, program and partnership development.
> (Suggested Length: one to two pages.)

## Organizational Capability Statement. Each application should include an organizational capability statement and vitae for key project personnel. The organizational capability statement should describe how the applicant agency (or the particular division of a larger agency which will have responsibility for this project) is organized, the nature and scope of its work and/or the capabilities it possesses. This description should cover capabilities of the applicant agency not included in the program narrative, such as any current or previous relevant experience and/or the record of the project team in preparing cogent and useful reports, publications, and other products. If appropriate, include an organization chart showing the relationship of the project to the current organization. Please attach short vitae for key project staff only. Neither vitas nor an organizational chart will count towards the narrative page limit. Also include information about any contractual organization(s) that will have a significant role(s) in implementing project and achieving project goals. 

> **Work Plan**. The Project Work Plan should reflect and be consistent
> with the Project Narrative and Budget. It should include a statement
> of the project's overall goal, anticipated outcome(s), key objectives,
> and the major tasks / action steps that will be pursued to achieve the
> goal and outcome(s). For each major task / action step, the work plan
> should identify the timeframes (including start- and end-dates), and
> the lead person/partner or collaborator responsible for completing the
> task. The work plan must clearly identify the actions and timetable to
> implement statewide program coverage. Please use the sample work plan
> format included in Attachment D. (Suggested Length and Format: use the
> sample grid; alternatively, not more than two pages preferably
> presented in bulleted format.)
>
> **Letters of Commitment from Key Participating Organizations and
> Agencies.**
>
> Include confirmation of the commitments to the project (should it be
> funded) made by [key]{.underline} collaborating organizations and
> agencies in this part of the application. Any organization that is
> specifically named to have a significant role in carrying out the
> project should be considered an essential collaborator. The signed
> letters of collaboration must specify the commitment, role, and
> resources/activities that will be provided in support of the
> applicant. Strategies to reach targeted populations must be documented
> with letters of commitment that detail the specific role/function in
> support of the project's effort that will be played by the
> collaborating organization. The organization's expertise, experience,
> and access to the targeted population(s) should also be described in
> the letter of commitment.
>
> For applications submitted electronically via Grants.gov, signed
> letters of commitment should be scanned and included as attachments.
> Applicants unable to scan the signed letters of commitment may fax
> them to the AoA Grants Management Office at 202-357-3466 by the
> application submission deadline. The Program Announcement number
> should appear at the top of each page faxed.

**3. Submission Dates and Times**

> The deadline for the submission of applications under this program
> announcement is April 28 , 2006. Applications must be: submitted
> electronically by midnight on this date; other hard copy submissions
> for which approval has been requested and received (per Section IV(6))
> must be received by 5:30 PM Eastern Time.
>
> Applications that fail to meet the application due date will be
> returned without review and will receive no further consideration.
>
> Applicants applying through Grants.gov will automatically receive a
> tracking number and date of receipt verification electronically once
> the application has been successfully received and validated in
> Grants.gov.
>
> Applicants who fill in the return address information on the
> confirmation of application receipt postcard, and submit with their
> application package, will receive confirmation of their application
> receipt from AoA.
>
> Applicants must ensure that a legibly dated U.S. Postal Service
> postmark or a legibly dated machine produced postmark of a commercial
> mail service is affixed to the envelope/package containing the
> application(s). To be acceptable as proof of a timely mailing, a
> postmark from a commercial mail service must include the logo/emblem
> of the commercial mail service company and must reflect the date the
> package was received by the commercial mail service company from the
> applicant. Private Metered postmarks shall not be acceptable as proof
> of timely mailing. Applicants are cautioned that express/overnight
> mail services do not always deliver as agreed.

**4. Intergovernmental Review**

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

**5. Funding Restrictions**

> The following activities are not fundable:

-   Construction and/or major rehabilitation of buildings

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

-   Continuation of existing projects without expansion or new and
    innovative

> approaches

**6. Other Submission Requirements**

> Electronic submissions must be sent to: http://www.grants.gov.
>
> Applicants submitting their application through
> [www.grants.gov](http://www.grants.gov/) must register in the Central
> Contractor Registry (CCR) database in order to be able to submit the
> application. One element of the CCR is the DUNS number (see section
> IV.2), which must be obtained separately from CCR registration.
> Information about CCR is available at
> <http://www.grants.gov/CCRRegister>. You must also register with a
> Credential Provider to receive a username and password to securely
> submit your grant application. Information is available at
> <http://www.grants.gov/CredentialProvider> .
>
> Applicants unable to submit their application via
> [www.grants.gov](http://www.grants.gov/) may request permission to
> submit a hard copy from the AoA Grants Management Officer Stephen
> Daniels, (202) 357-3464, AND E-MAIL ADDRESS:
> <Stephen.Daniels@aoa.hhs.gov>.
>
> If you mail or hand deliver your application, you must submit **one
> original application and two copies**, plus a completed application
> checklist to AoA. The application deadline for receipt of applications
> by mail or hand-delivered is 5:30 PM Eastern Time on April 28, 2006 to
> the below address:
>
> Department of Health and Human Services
>
> Administration on Aging
>
> Grants Management Division
>
> Washington, DC 20201
>
> Attention: Stephen Daniels
>
> It is the responsibility of all applicants using mail or hand delivery
> of materials to do so in sufficient time to be received by the
> deadline date of April 28, 2006 5: 30 PM Eastern time.

V.  **APPLICATION REVIEW INFORMATION**

**Criteria**

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

### Purpose and Need for Assistance - (20 points); 

### Approach/Method -- Workplan and Activities - (30 points);

### Outcomes/Evaluation/Dissemination - (30 points); and 

### Level of Effort - (20 points).

> a\. [Purpose and Need for Assistance]{.underline} [Weight: 20
> points]{.underline}

-   Does the proposed project clearly identify and adequately respond to
    the target population(s), and is it consistent with the SMP program
    objectives? (10 points)

-   Does the applicant substantiate how the project would address the
    current gaps in SMP project service to these population(s)? Is the
    problem identified for target populations consistent with the AoA
    program's purpose and objectives? (5 points)

-   Does the application adequately and appropriately describe and
    document the key problem(s)/condition(s) relevant to its purposes?
    Is the proposed

> project justified in terms of the most recent, relevant, and available
>
> information and knowledge? (5 points)
>
> b\. [Approach, Work Plan and Activities]{.underline} [Weight: 30
> points]{.underline}

-   Does the applicant present a well-thought out approach for statewide
    program coverage and experience with the target population? Has the
    applicant demonstrated a thorough familiarity with the objectives,
    work and accomplishments of the SMP program? Does the applicant
    clearly define its commitment to and plans to address the SMP
    program objectives? Does the project take into account barriers and
    opportunities that may impact on the project's success? Does the
    proposal include plans to explore models developed by other SMPs
    (including Integration Grantees) as well for sharing its own results
    with AoA, the Center and other SMP projects? (10 points)

-   Is the project work plan clear and comprehensive? Does it include
    sensible and feasible timeframes for the accomplishment of tasks
    presented? Does the work plan include specific objectives and tasks
    that are linked to measurable outcomes? Does the proposal include a
    clear and coherent management plan? Are the roles and
    responsibilities of project staff, consultants and partners clearly
    defined and linked to specific objectives and tasks? Are the
    qualifications of the project staff, consultants and/or partners,
    and the proposed level of effort, adequate to carryout the project?
    (10 points)

-   Has the applicant identified unmet needs for the Medicare/Medicaid
    error, fraud and abuse information among isolated, disadvantaged,
    and limited English-speaking populations, in addition to a
    well-defined collaboration strategy for reaching these groups? Are
    the proposed strategies cost- effective, appropriate to the areas
    and clients served? Has the applicant identified appropriate aging,
    federal, state and community-based organizations, and specified the
    roles of these partner organizations in

> implementing the project? (10 points)

c\. [Project Outcomes, Evaluation and Dissemination]{.underline}
[Weight: 30 points]{.underline}

-   Are the expected project outcomes directly linked to the five SMP
    program

> objectives? Are the benefits/results clear, realistic, and consistent
> with the purpose of the project? Are the proposed outcomes
> quantifiable and measurable, consistent with the definition of a
> project outcome contained in Section II of the Program Announcement?
> (10 points)

-   Does the project evaluation reflect a thoughtful and well-designed
    approach that will be able to successfully measure whether or not
    the project has achieved its proposed outcome(s)? Does the plan
    include the qualitative and/or quantitative methods necessary to
    reliably measure outcomes? Is the evaluation also designed to
    capture "lessons learned" from the overall effort that might be of
    use to others in the field of aging, especially those who might be
    interested in replicating the project? (10 points)

-   Will the dissemination plan get relevant and easy to use information
    in a timely manner to parties that might be interested in making use
    of its findings, particularly to those who might want to replicate
    the project? Is use of the SMP Technical Resource Center cited as a
    strategy for dissemination of project results?

> (10 points)

d\. [Level of Effort]{.underline}: [Weight: 20 points]{.underline}

-   Do the proposed project director(s), key staff and consultants have
    the

> background, experience, and other qualifications required to carry out
> their
>
> designated roles? Has the applicant demonstrated capacity and
>
> experience in using quantitative performance outcome information to
>
> support their activity and management decisions? (5 points)

-   Are letters from participating organizations included, as
    appropriate, and do they express the clear commitment and areas of

> responsibility of those organizations, consistent with the work plan
>
> description of their intended roles and contributions? Is each
> targeted
>
> population identified by the applicant supported by letters of
> commitment
>
> from appropriate organizations that specify their role in facilitating
> outreach
>
> and access to this population? (5 points)

-   Is the budget justified with respect to the adequacy and
    reasonableness of resources requested? Is the time commitment of the
    proposed director and

> other key project personnel sufficient to assure proper direction,
>
> management and timely completion of the project? Are budget line items
>
> clearly delineated and consistent with work plan objectives? Have
> state applicants included a 25% match of the projects total cost? (10
> points)

**2. Review and Selection Process**

> An independent review panel of at least three individuals will
> evaluate applications that pass the screening. These reviewers are
> experts in their field, and are drawn from academic institutions,
> non-profit organizations, state and local government, and federal
> government agencies other than AoA. Based on the specific programmatic
> considerations as outlined under section I, Funding Opportunity
> Description, the reviewers will comment on and score the applications,
> focusing their comments and scoring decisions on the criteria
> identified above.
>
> Final award decisions will be made by the Assistant Secretary for
> Aging (ASA). In making these decisions, the ASA will take into
> consideration: recommendations of the review panel; reviews for
> programmatic and grants management compliance; the reasonableness of
> the estimated cost to the government considering the available funding
> and anticipated results; and the likelihood that the proposed project
> will result in the benefits expected.

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

## VI. AWARD ADMINISTRATION INFORMATION 

###### 1. Award Notices 

> Successful applicants will receive an Approval letter through the U.S.
> Mail, and a Notice of Financial Assistance Award. The Notice of
> Financial Assistance Award is the authorizing document, and will be
> signed by the AoA grants officer, the AoA authorizing official, and
> the AoA budget office. Unsuccessful applicants will be notified in
> writing within 30 days.

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

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

**3. Reporting**

> An original and two copies of the SF-269 (Financial Status Report) and
> the AoA program progress report are due semi-annually. Awardees will
> receive a copy of the required program progress report form with their
> Notice of Financial Assistance Award. Final performance and SF-269
> reports are due 90 days after the end of the project period. For more
> information see DHHS / AoA Standard Terms and Conditions. Required
> reports can be mailed to the Office of Grants Management or sent
> electronically to the Grants Management Specialist designated in the
> Award Letter.

## 

## VII. AGENCY CONTACTS 

> [Project Officer:]{.underline}
>
> U.S. Department of Health and Human Services
>
> Administration on Aging
>
> Washington, DC 20201
>
> Attn: Barbara Lewis
>
> Telephone: (202) 357-3532, e-mail: <Barbara.Lewis@aoa.hhs.gov>
>
> [Grants Management Specialist:]{.underline}
>
> U.S. Department of Health and Human Services
>
> Administration on Aging
>
> Washington, DC 20201
>
> Attn: Stephen Daniels
>
> Telephone: (202) 357-3464, e-mail: <Stephen.Daniels@aoa.hhs.gov>

## VIII. OTHER INFORMATION

###### A. Order of Application Elements

a)  To expedite the processing of applications, we request that you
    arrange the components of your application in the following order:

> 1\. SF 424 -- Application for Federal Assistance.

2.  SF 424A -- Budget Information.

> 3\. Separate Budget Narrative/Justification (See Attachments for
> Sample Format).
>
> 4\. SF 424B -- Assurances. Note: Be sure to complete this form
> according to
>
> instructions and have it signed and dated by the authorized
> representative (see
>
> item 18d on the SF 424).
>
> 5\. Certification
>
> 6\. Proof of non-profit status
>
> 7\. Copy of the applicant\'s most recent indirect cost agreement, as
> necessary.
>
> 8\. Project Narrative with Work Plan (See Attachment for Sample Work
> Plan
>
> Format).
>
> 9\. Organizational Capability Statement and Vitae for Key Project
> Personnel.
>
> 10\. Letters of Commitment from Key Partners.
>
> 11\. "Survey on Ensuring Equal Opportunity for Applicants" (Optional
> non-profit applicants)
>
> **B. The Paperwork Reduction Act of 1995 (P.L. 104-13)**
>
> An agency may not conduct or sponsor, and a person is not required to
> respond to, a collection of information unless it displays a currently
> valid OMB control number.
>
> The project description and budget justification is approved under OMB
> control number 0985-0018 which expires on 3/31/07.
>
> Public reporting burden for this collection of information is
> estimated to average 10 hours per response, including the time for
> reviewing instructions, gathering and maintaining the data needed and
> reviewing the collection information.

**ATTACHMENTS**

**Attachment A:**

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

**Attachment B:**

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

**Attachment C:**

**Budget Justification -- Sample Format**

**Attachment D:**

**Project Work Plan - Sample Format**

**Attachment E:**

**Instructions for Completing the Summary/Abstract**

**Attachment F:**

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

#  Attachment A

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

  -----------------------------------------------------------------------
  This section provides step-by-step instructions for completing the four
  (4) standard federal forms required as part of your grant application,
  including special instructions for completing Standard Budget Forms 424
  and 424A. Standard Forms 424 and 424A are used for a wide variety of
  federal grant programs, and federal agencies have the discretion to
  require some or all of the information on these forms. AoA does not
  require all the information on these Standard Forms. Accordingly,
  please use the instructions below in lieu of the standard instructions
  attached to SF 424 and 424A to complete these forms. Please note that
  in FY 2006, a new version of the SF 424 is being used for new grants.

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

###### a. Standard Form 424

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

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

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

• New . • Continuation • Revision

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

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

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

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

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

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

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

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

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

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

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

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

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

matters related to this application.

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

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

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

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

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

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

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

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

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

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

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

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

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

There are three types of match: 1.) non-federal cash; 2.) non-federal
non-cash (i.e., in-kind); and 3.) program income. In general, costs
borne by the applicant and cash contributions of any and all third
parties involved in the project, including sub-grantees, contractors and
consultants, are considered [cash matching funds]{.underline}.
Generally, most contributions from third parties will be non-cash (i.e.,
in-kind) matching funds. Examples of [non-cash (in-kind)
match]{.underline} include: volunteered time and use of facilities to
hold meetings or conduct project activities. A third form of non-federal
match is projected [program income]{.underline} derived from activities
of the project such as participant fees and sale of publications. [Only
program income that is to be used as part of the required match should
be shown on Line 18.]{.underline}

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

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

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

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

**b. Standard Form 424A**

+-----------------------------------------------------------------------+
| > NOTE: Standard Form 424A is designed to accommodate applications    |
| > for multiple grant programs; thus, for purposes of this AoA         |
| > program, many of the budget item columns and rows are not           |
| > applicable. You should only consider and respond to the budget      |
| > items for which guidance is provided below. Unless otherwise        |
| > indicated, the SF 424A should reflect a one year budget.            |
+-----------------------------------------------------------------------+

##### Section A ‑ Budget Summary

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

##### Section B ‑ Budget Categories

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

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

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

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

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

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

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

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

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

###### d. Certification Regarding Lobbying

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

###### e. Other Application Components

**Survey on Ensuring Equal Opportunity for Applicants**

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

**Proof of Non-Profit Status**

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

## Indirect Cost Agreement

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

**Attachment B: Budget Narrative, Page 1 -- Sample Format with
EXAMPLES**

+----------+-------+------+------+------+-----------------------------+
| >        | **Fe  | **N  | **N  | # T  | ### Justification           |
| **Object | deral | on-F | on-F | OTAL |                             |
| > Class  | Fu    | eder | eder |      |                             |
| > Ca     | nds** | al** | al** |      |                             |
| tegory** |       |      |      |      |                             |
|          |       | **Ca | **I  |      |                             |
|          |       | sh** | n-Ki |      |                             |
|          |       |      | nd** |      |                             |
+----------+-------+------+------+------+-----------------------------+
| **Per    | \$4   |      | \$5  | \$45 | Project Supervisor (name) = |
| sonnel** | 0,000 |      | ,000 | ,000 | .3FTE @ \$50,000/yr =       |
|          |       |      |      |      | \$15,000                    |
|          |       |      |      |      |                             |
|          |       |      |      |      | Project Director (name) =   |
|          |       |      |      |      | 1FTE @ \$30,000 = \$30,000  |
+----------+-------+------+------+------+-----------------------------+
| **Fringe | \$1   | 0    | 0    | \$12 | Fringes on Supervisor and   |
| Be       | 2,600 |      |      | ,600 | Director @ 28% of salary.   |
| nefits** |       |      |      |      |                             |
|          |       |      |      |      | FICA (7.65%) = \$3,442      |
|          |       |      |      |      |                             |
|          |       |      |      |      | Health (12%) = \$5,400      |
|          |       |      |      |      |                             |
|          |       |      |      |      | Dental (5%) = \$2,250       |
|          |       |      |      |      |                             |
|          |       |      |      |      | Life (2%) = \$ 900          |
|          |       |      |      |      |                             |
|          |       |      |      |      | Workers Comp Insurance      |
|          |       |      |      |      | (.75%) = \$ 338             |
|          |       |      |      |      |                             |
|          |       |      |      |      | Unemployment Insurance      |
|          |       |      |      |      | (.6%) = \$ 270              |
+----------+-------+------+------+------+-----------------------------+
| **       | \$    | 0    | \$   | \$3  | Travel to Annual Grantee    |
| Travel** | 3,000 |      | 967  | ,967 | Meeting:                    |
|          |       |      |      |      |                             |
|          |       |      |      |      | Airfare: 1 RT x 2 people x  |
|          |       |      |      |      | \$750/RT = \$1,500          |
|          |       |      |      |      |                             |
|          |       |      |      |      | Lodging: 3 nights x 2       |
|          |       |      |      |      | people x \$100/night = \$   |
|          |       |      |      |      | 600                         |
|          |       |      |      |      |                             |
|          |       |      |      |      | Per Diem: 4 days x 2 people |
|          |       |      |      |      | x \$40/day = \$ 320         |
|          |       |      |      |      |                             |
|          |       |      |      |      | Out-of-Town Project Site    |
|          |       |      |      |      | Visits                      |
|          |       |      |      |      |                             |
|          |       |      |      |      | Car mileage: 3 trips x 2    |
|          |       |      |      |      | people x 350 miles/trip     |
|          |       |      |      |      |                             |
|          |       |      |      |      | x \$ .365/mile = \$ 767     |
|          |       |      |      |      |                             |
|          |       |      |      |      | Lodging: 3 trips x 2 people |
|          |       |      |      |      | x 1 night/ trip             |
|          |       |      |      |      |                             |
|          |       |      |      |      | x \$50/night = \$300        |
|          |       |      |      |      |                             |
|          |       |      |      |      | Per Diem: 3 trips x 2       |
|          |       |      |      |      | people x 2days/trip         |
|          |       |      |      |      |                             |
|          |       |      |      |      | x \$40/day = \$480          |
+----------+-------+------+------+------+-----------------------------+

Attachment B: Budget Narrative, Page 2 - Sample Format with EXAMPLES

+-----+-----+------+------+------+-----------------------------------+
| **  | **  | #    | *    | ##   | ### Justification                 |
| Obj | Fed | #### | *Non | ## * |                                   |
| ect | era |  Non | -Fed | [TOT |                                   |
| C   | l** | -Fed | eral | AL]{ |                                   |
| las |     | eral | I    | .und |                                   |
| s** | #   |      | n-Ki | erli |                                   |
|     |  Fu | ##   | nd** | ne}* |                                   |
| **C | nds | ###  |      |      |                                   |
| ate |     | Cash |      |      |                                   |
| gor |     |      |      |      |                                   |
| y** |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| *   | 0   | 0    | 0    | 0    | No equipment requested            |
| *Eq |     |      |      |      |                                   |
| uip |     |      |      |      |                                   |
| men |     |      |      |      |                                   |
| t** |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| **S | \   |      | \$2  | \$3  | Laptop computer for use in client |
| upp | $1, |      | ,000 | ,500 | intakes = \$1,340                 |
| lie | 500 |      |      |      |                                   |
| s** |     |      |      |      | Consumable supplies (paper, pens, |
|     |     |      |      |      | etc.)                             |
|     |     |      |      |      |                                   |
|     |     |      |      |      | \$100/mo x 12 months = \$1,200    |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Copying \$80/mo x 12 months = \$  |
|     |     |      |      |      | 960                               |
+-----+-----+------+------+------+-----------------------------------+
| **C | \$2 | \$50 | 0    | \    | Contracts to A,B,C direct service |
| ont | 00, | ,000 |      | $250 | providers (name providers)        |
| rac | 000 |      |      | ,000 |                                   |
| tua |     |      |      |      | adult day care contractor =       |
| l** |     |      |      |      | \$75,000                          |
|     |     |      |      |      |                                   |
|     |     |      |      |      | respite care contractor in home=  |
|     |     |      |      |      | \$75,000                          |
|     |     |      |      |      |                                   |
|     |     |      |      |      | respite care contractor-NF =      |
|     |     |      |      |      | \$50,000                          |
|     |     |      |      |      |                                   |
|     |     |      |      |      | personal care/companion provider  |
|     |     |      |      |      | = \$50,000                        |
|     |     |      |      |      |                                   |
|     |     |      |      |      | See detailed budget justification |
|     |     |      |      |      | for each provider (and then       |
|     |     |      |      |      | provide it!)                      |
+-----+-----+------+------+------+-----------------------------------+

+-----+-----+------+------+------+-----------------------------------+
| A   |     |      |      |      |                                   |
| tta |     |      |      |      |                                   |
| chm |     |      |      |      |                                   |
| ent |     |      |      |      |                                   |
| B:  |     |      |      |      |                                   |
| Bud |     |      |      |      |                                   |
| get |     |      |      |      |                                   |
| N   |     |      |      |      |                                   |
| arr |     |      |      |      |                                   |
| ati |     |      |      |      |                                   |
| ve, |     |      |      |      |                                   |
| P   |     |      |      |      |                                   |
| age |     |      |      |      |                                   |
| 3   |     |      |      |      |                                   |
| --  |     |      |      |      |                                   |
| Sam |     |      |      |      |                                   |
| ple |     |      |      |      |                                   |
| For |     |      |      |      |                                   |
| mat |     |      |      |      |                                   |
| w   |     |      |      |      |                                   |
| ith |     |      |      |      |                                   |
| EX  |     |      |      |      |                                   |
| AMP |     |      |      |      |                                   |
| LES |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| **O | \$  | \$8  | \$19 | \$37 | Local conference registration fee |
| the | 10, | ,000 | ,800 | ,800 | (name conference) = \$ 200        |
| r** | 000 |      |      |      |                                   |
|     |     |      |      |      | Printing brochures (50,000 @ \$   |
|     |     |      |      |      | .05 ea) = \$ 2,500                |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Video production = \$19,800       |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Video Reproduction = \$ 3,500     |
|     |     |      |      |      |                                   |
|     |     |      |      |      | NF Respite Training Manual        |
|     |     |      |      |      | reproduction                      |
|     |     |      |      |      |                                   |
|     |     |      |      |      | \$3/manual x \$2000 manuals = \$  |
|     |     |      |      |      | 6,000                             |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Postage \$150/mo x 12 months = \$ |
|     |     |      |      |      | 1,800                             |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Caregiver Forum meeting room      |
|     |     |      |      |      | rentals                           |
|     |     |      |      |      |                                   |
|     |     |      |      |      | \$200/day x 12 forums = \$ 2,400  |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Respite Training Scholarships =   |
|     |     |      |      |      | \$1,600                           |
+-----+-----+------+------+------+-----------------------------------+
| *   | 0   | 0    | 0    | 0    | None                              |
| *In |     |      |      |      |                                   |
| dir |     |      |      |      |                                   |
| ect |     |      |      |      |                                   |
| Cha |     |      |      |      |                                   |
| rge |     |      |      |      |                                   |
| s** |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| ##  | \$2 | \$60 | \$27 | \    |                                   |
| ### | 65, | ,800 | ,767 | $354 |                                   |
|  TO | 700 |      |      | ,267 |                                   |
| TAL |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+

Attachment C: Budget Narrative -- Page 1 -- Sample Format

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

**Attachment C: Budget Narrative -- Page 2 -- Sample Format**

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

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

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

  **Measurable                                                                                           
  Outcome(s):**                                                                                          

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

  1\.                                                                                                    

                                                                                                         

                                                                                                         

                                                                                                         

  2\.                                                                                                    

                                                                                                         

                                                                                                         

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

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

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

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

  3\.                                                                                                                                                       

                                                                                                                                                            

                                                                                                                                                            

                                                                                                                                                            

  4\.                                                                                                                                                       

                                                                                                                                                            

                                                                                                                                                            

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

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

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

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

  5\.                                                                                                                                                       

                                                                                                                                                            

                                                                                                                                                            

                                                                                                                                                            

  6\.                                                                                                                                                       

                                                                                                                                                            

                                                                                                                                                            

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

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

**Attachment E**

Instructions for Completing the Project Summary/Abstract

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

```{=html}
<!-- -->
```
-   To ensure uniformity, please limit the length to no more than 300
    words on a single page with a font size of not less than 11,
    doubled-spaced.

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

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

**Products --** materials, deliverables.

-   A model abstract/summary is provided below:

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

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

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

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

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

Yes No

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

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

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

Less Than \$150,000

\$150,000 - \$299,999

\$300,000 - \$499,999

\$500,000 - \$999,999

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

\$5,000,000 or more

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

Yes No

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

Yes No

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

> Yes No

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

Yes No

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

Yes No

# Survey Instructions on Ensuring Equal Opportunity for Applicants

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

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

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

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

4\. Self-identify.

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

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

7.  Self-explanatory.

8.  Self-explanatory.

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please write to:** U.S. Department of Education, Washington, D.C.
2202-4651.

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

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