# OMB Approval No. 0985-0018

> Expiration 05/31/2010

# 

# 

# *Nursing Home Diversion Modernization Grants*

# 

# 

# 

# Program Announcement and Grant Application Instructions

# 

# U.S. Administration on Aging

*2007*

**TABLE OF CONTENTS**

**Overview
Information.................................................................1**

**SECTION I. FUNDING OPPORTUNITY DESCRIPTION........................\...
.. 2**

1.  **Statutory
    Authority...............................................................\...
    2**

2.  **Purpose and
    Vision...............................................................\...
    2**

3.  **Background...........................................................................2**

4.  **Relevant Sections of the Older Americans
    Act................................ 4**

5.  **Description of FY2007 Funding
    Opportunity................................. 5**

**SECTION II. AWARD
INFORMATION................................................\... 7**

1.  **Award
    Size............................................................................
    8**

**SECTION III. ELIGIBILITY
INFORMATION.......................................... 8**

1.  **Eligible
    Applicants..................................................................
    8**

2.  **Cost Sharing or
    Matching..........................................................8**

3.  **Application Screening
    Criteria.................................................\... 8**

**SECTION IV. Application and Submission Information.............. 9**

1.  **Address to Request Application
    Package....................................\... 9**

2.  **Content and Form of Application
    Submission..............................\... 10**

3.  **Submission Dates and
    Times...................................................... 14**

4.  **Intergovernmental
    Review......................................................\...
    14**

5.  **Funding
    Restrictions................................................................
    14**

6.  **Other Submission
    Requirements................................................. 15**

**SECTION V. Application Review Information............................
15**

1.  **Criteria..............................................................................\...
    15**

2.  **Review and Selection
    Process..................................................... 16**

**SECTION Vi. Award Administration Information......................16**

1.  **Award
    Notices.....................................................................\...
    16**

2.  **Administrative and National Policy
    Requirements...........................17**

3.  **Reporting..............................................................................17**

**SECTION VII.** **Agency
Contacts...................................................\... 17**

**SECTION viii. Other
Information................................................ 17**

1.  **Application
    Elements...............................................................
    17**

2.  **The Paperwork Reduction Act of 1995 (P.L.
    104-13).....................\.... 18**

**AttachmentS**

> **Attachment A: Standards for a Nursing Home Diversion
> Program\...\...\...\...\...\.....A-1**

A.  **Service Elements**

    a.  **Flexible Services that Follow the Needs of Individuals and
        their Family Caregivers**

    b.  **Targeting Individuals at High Risk of Nursing Home Placement**

    c.  **Consumer-Directed Service Options Including Cash and
        Counseling**

    d.  **Targeting Individuals at High Risk of Medicaid Spend Down**

    e.  **Complementing Informal Caregiving and Individual Resources**

    ```{=html}
    <!-- -->
    ```
    A.  **System Elements**

        a.  **Single Entry Points of Access to All Publicly Supported
            Long Term Care Programs**

        b.  **Mechanisms to Promote and Support**

> **Consumer Directed Service Options**

c.  **Quality Assurance**

d.  **Performance Measurement and Evaluation**

> **Attachment B: Instructions for completing the SF 424, Budget (SF
> 424A),**
>
> **Budget Narrative and Other Required
> Forms\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....A-8**
>
> **Attachment C: Budget Justification Format -- Sample Format with**
>
> **Examples\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...A-17**
>
> **Attachment D: Budget Justification -- Sample
> Format\...\...\...\...\...\...\...\...\...\...\...\...\.....A-20**
>
> **Attachment E: Project Work Plan - Sample
> Format\...\...\...\...\...\...\...\...\...\...\...\...\...\.....A-22**
>
> **Attachment F: Instructions for Completing the
> Summary/Abstract\...\...\...\...\...\...A-25**
>
> **Attachment G: "Survey on Ensuring Equal Opportunity for
> Applicants"\...\.....A-26**

**OVERVIEW INFORMATION**

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

**Administration on Aging (AoA)**
[http://www.aoa.gov](http://www.aoa.gov/)

**AoA Center for Planning and Policy Development**

######## Funding Opportunity Title: Nursing Home Diversion Modernization Grants 

**Announcement Type:** Initial

**Funding Opportunity Number:** HHS-2007-AoA-CD-0713

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

**Key Dates:** The deadline for submission of applications is August 24,
2007. The deadline for submission of letter of intent is July 20, 2007.
An open information teleconference for applicants of this solicitation
will be held July 11, 2007 at 3:00 p.m., EST. The toll-free
teleconference phone number will be (888) 381-5770, passcode: 9559261,
leader name: John Wren.

**Overview:** This Program Announcement provides an opportunity for
State Units on Aging (SUA), in partnership with Area Agencies on Aging
(AAA) and in collaboration with aging service provider organizations and
other long-term care stakeholders, to modernize their existing efforts
to help individuals who are not eligible for Medicaid to avoid nursing
home placement. This opportunity is designed specifically to help the
Aging Services Network to transform the way it uses existing funds under
the Older Americans Act and other sources to reflect the latest research
and best practices in the field and the new long-term care provisions in
the Older Americans Act.

A State Unit on Aging may propose a project within one or more Planning
and Service Areas (PSA). States with a single Planning and Service Area
(PSA) may propose a project targeted to a single county or region of the
state.

By the end of the grant project period (18 months), states must be
serving individuals in a manner that is more in line with the standards
described in Attachment A of this announcement than they do currently
with funds from any one of the following sources: Older Americans Act
Titles III-B and/or III-E, Alzheimer's Disease Demonstration Grants to
States (ADDGS), or any other program that can be used to serve
individuals who are not Medicaid eligible.

A state's application will be evaluated in part on the degree of
progress it proposes to make in aligning its existing nursing home
diversion efforts with the standards in Attachment A.

The specific requirements and fundable activities for this opportunity
are outlined in Section I.5.

Resources to assist applicants for this funding opportunity are
available on the [Nursing Home Diversion Modernization Grant
Announcement Resource
Page](http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc)
(<http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc>).

**SECTION I. FUNDING OPPORTUNITY DESCRIPTION**

1.  **Statutory Authority**

The statutory authority for grants under this program announcement is
contained in Title IV of the Older Americans Act (OAA) (42U.S.C. 3032),
as amended by the Older Americans Act Amendments of 2006, P.L. 109-365
(Catalog of Federal Domestic Assistance 93.048, Title IV Discretionary
Projects).

2.  **Purpose and Vision**

The Administration on Aging is providing this competitive grants
opportunity to assist State Units on Aging (SUA), in partnership with
Area Agencies on Aging (AAAs) and in collaboration with community aging
service providers and other key long-term care stakeholders, to
modernize and transform the funding they receive under the Older
Americans Act Title III-B and/or III-E, the Alzheimer's Disease
Demonstration Grants to States (ADDGS) program, or other non-Medicaid
revenue, into flexible, consumer-directed service dollars to support
nursing home diversion projects that reflect the standards described in
Attachment A of this announcement.

This opportunity supports the new long-term care provisions in the 2006
Older Americans Act and is intended to support States' long-term care
rebalancing efforts. It is designed to complement the CMS "Money Follows
the Person Initiative" by strengthening the capacity of states to reach
older adults [before]{.underline} they enter a nursing home and spend
down to Medicaid. AoA's long-range vision is to have nursing home
diversion programs consistent with the standards in Attachment A to be a
key component of every state's system of long-term care.

These competitive grants offer community aging services provider
organizations an opportunity to work with State and Area Agencies on
Aging to modernize service delivery through the use of flexible funding
as well as the provision of services to individuals who are using
consumer-directed models of care. Participating in these projects will
help providers develop strategies they can use to tailor their services
to the individualized needs and preferences of older individuals and
their family caregivers. It will also give providers an opportunity to
better position themselves to serve the growing number of individuals
who will be purchasing their services in the private pay market.

3.  **Background**

The Older Americans Act authorizes the Aging Services Network at all
levels to promote the development of comprehensive and coordinated
systems of long-term care that enable seniors to remain in their own
homes and communities for as long as possible. Consistent with the
flexibility provided under the Act, the Network has carried out this
statutory responsibility in a variety of ways, using different
strategies and approaches that reflect varying state and local
conditions, policies and practices. Additionally, the state-of-the-art
in helping seniors to remain at home has evolved over time, with the
development of new approaches and techniques for identifying and serving
people who are at risk of nursing home placement, including nursing home
preadmission screening programs. While many of these strategies have
focused on Medicaid-eligible individuals, at least eight states have
supplemented their OAA programs with state revenue funds to establish
nursing home diversion programs specifically designed to help
individuals who are not Medicaid eligible.

There also has been considerable progress in developing flexible service
models and per capita budgeting techniques that allow programs to manage
their resources in a way that enables them to better respond to the
individualized needs of consumers, and that give consumers greater
control over the types of care they receive and the manner in which they
receive it. Most notable among consumer-directed approaches is Cash and
Counseling, in which individuals have a budget to use for purchasing
needed goods and services. Cash and Counseling, originally tested in 3
states, is now being widely replicated in Medicaid. Consumer directed
approaches similar to Cash and Counseling are also being used in Older
Americans Act Programs, particularly in the National Family Caregiver
Support Program, and in the ADDGS program.

The new long-term care provisions in the OAA create an opportunity for
the Aging Services Network to strengthen its role in shaping state and
local systems of care on behalf of older people and their family
caregivers. The new OAA provisions complement the changes occurring in
Medicaid, including the Deficit Reduction Act of 2005, which reflect
peoples' overwhelming desire to receive their care at home, as well as
the importance of going beyond Medicaid in charting the future of
long-term care. The OAA now authorizes all levels of the Network to
actively promote the development of consumer-centered systems of
long-term care, and emphasizes the Network's use of a three-pronged
strategy for advancing needed changes in our system of care. The three
elements of the strategy include:

-   Empowering individuals to make informed decisions about their care
    options through Aging and Disability Resource Centers (ADRCs);

-   Enabling older people to live healthier lives through the use of
    Evidence-Based Disease and Disability Prevention Programs; and,

-   Helping seniors to avoid unnecessary nursing home placement and
    spend down through the use of flexible, consumer-directed models of
    care.

AoA, in collaboration with a variety of Federal partners and several
private foundations, has already launched programs to support the first
two components of the strategy (i.e., ADRCs and Evidence-Based
Prevention Programs). This grant opportunity is designed to support the
initial implementation of the third component related to the Aging
Services Network's role in helping individuals who are not Medicaid
eligible to avoid unnecessary nursing home placement.

4.  **Relevant Sections of the Older Americans Act**

Title II of the Older Americans Act now authorizes the Assistant
Secretary for Aging to "promote the development and implementation of
comprehensive, coordinated systems at Federal, State, and local levels
that enable older individuals to receive long-term care in home and
community-based settings, in a manner responsive to the needs and
preferences of older individuals and their family caregivers."

Title II goes on to authorize the Assistant Secretary to: "facilitate,
in coordination with the Administrator of the Centers for Medicare and
Medicaid Services, and other heads of Federal entities as appropriate,
the provision of long-term care in home and community-based settings,
including the provision of such care through self-directed models that:

\(A\) provide for the assessment of the needs and preferences of an
individual at risk for institutional placement to help such individual
avoid unnecessary institutional placement and depletion of income and
assets to qualify for benefits under the Medicaid program under title
XIX of the Social Security Act (42 U.S.C et seq.);

\(B\) respond to the needs and preference of such individual and provide
the option-

\(i\) for the individual to direct and control the receipt of support
services provided; or

\(ii\) as appropriate, for a person who was appointed by an individual,
or is legally acting on the individual's behalf, in order to represent
or advise the individual in financial or service coordination matters
(referred to in this paragraph as a 'representative' of the individual),
to direct and control the receipt of those services; and

\(C\) assist an older individual (or, as appropriate, a representative
of the individual) to develop a plan for long-term support, including
selecting, budgeting for, and purchasing home and community-based
long-term care and supportive services."

To complement this new authority, new definitions have been added to
Title I of the Act, including:

"The term **'self-directed care'** means an approach to providing
services (including programs, benefits, supports, and technology) under
this Act intended to assist an individual with activities of daily
living, in which:

\(A\) such services (including the amount, duration, scope, provider,
and location of such services) are planned, budgeted, and purchased
under the direction and control of such individual;

\(B\) such individual is provided with such information and assistance
as are necessary and appropriate to enable such individual to make
informed decisions about the individual's care options;

\(C\) the needs, capabilities, and preferences of such individual with
respect to such services, and such individual's ability to direct and
control the individual's receipt of such services, are assessed by the
area agency on aging (or other agency designated by the area a agency on
aging) involved;

\(D\) based on the assessment made under subparagraph (C), the area
agency on aging (or other agency designated by the area agency on aging)
develops together with such individual and the individual's family
caregiver (as defined in paragraph (18)(B)), or legal representative:

\(i\) a plan of services for such individual that specifies which
services such individual will be responsible for directing;

\(ii\) a determination of the role of family members (and others whose
participation is sought by such individual) in providing services under
such plan; and

\(iii\) a budget for such services; and

\(E\) the area agency on aging or State agency provides for oversight of
such individual's self-directed receipt of services, including steps to
ensure the quality of services provided and the appropriate use of funds
under this Act."

5.  **Description of FY2007 Funding Opportunity**

Under this announcement, AoA will award competitive grants in the form
of Cooperative Agreements to assist State Units on Aging (SUA), working
in partnership with one or more Area Agencies on Aging (AAA) and in
collaboration with aging service provider organizations and other
long-term care stakeholders, to modernize existing efforts to help
individuals who are not eligible for Medicaid to avoid unnecessary
nursing home placement by bringing these efforts in line with the
standards described in Attachment A of this announcement.

A State Unit on Aging may propose a project within one or more Planning
and Service Areas (PSA). States with a single Planning and Service Area
(PSA) may propose a project targeted to a single county or region of the
state.

By the end of the grant project period (18 months), states must be
serving individuals in a manner that is more in line with the standards
described in Attachment A than they currently do with funds from any one
of the following sources: Older Americans Act Titles III-B and/or III-E,
Alzheimer's Disease Demonstration Grants to States (ADDGS), or any other
program that can be used to serve individuals who are not eligible for
Medicaid.

States may focus its grant activities on one or more of the elements
contained in the nursing home diversion standards described in
Attachment A. These standards include both service elements and system
elements.

The **service elements** in Attachment A are designed to ensure that the
program reaches its intended target population, and that the needs and
preferences of consumers and their family caregivers are fully
considered in the design and implementation of the program. The service
elements include:

-   Flexible dollars to ensure that services can be tailored to the
    individualized needs of consumers and their family caregivers,
    rather than being tied to a particular service or set of services;

-   Targeting criteria to ensure the program actually serves individuals
    who are most at risk of nursing home placement.

-   Giving clients the option of using the Cash and Counseling model.

-   Ensuring that the program is used to complement and support -- and
    not to supplant -- the on-going efforts of family caregivers and the
    use of an individual's personal and financial resources - in helping
    that individual to remain at home.

-   Targeting criteria to ensure that publicly funded services are
    directed at individuals who are at risk of Medicaid spend down.

The **systems elements** in Attachment A are designed to ensure the
effective and efficient administration of a nursing home diversion
program and include:

-   Using "Single Entry Point" systems that provides access to all
    publicly supported long-term care services and supports to perform,
    at a minimum, the functions of client screening, assessment, care
    planning, and targeting individuals at risk of nursing home
    placement and spend down to Medicaid;

-   Having the infrastructure necessary to support the Cash and
    Counseling model;

-   Having a quality assurance program that can be used by program staff
    and administrators to continually improve the way the program is
    serving its clients.

-   Evaluating the program so that administrators, funders and the
    public will know if the program is meeting its goals and objectives.

A state's application under this announcement will be evaluated in part
on the degree of progress it proposes to make in aligning its existing
funds with the standards in Attachment A. Whatever activities a State
chooses to pursue under this grant announcement, by the end of the
18-month project period, the state's project [must at a
minimum]{.underline} be:

-   Providing consumers with flexible service options, not limited to
    any particular service or package of services, with funds from any
    of the following: OAA Titles III-B and/or III-E, ADDGS, and any
    other programs that serve individuals who are not eligible for
    Medicaid;

-   Effectively targeting these flexible services to individuals who are
    at risk of nursing home placement and spend down to Medicaid;

-   Using a Single Entry Point system that provides access to all
    publicly supported long-term care services and supports to perform
    the functions of client screening, assessment, care planning, and
    the targeting of services to individuals who are at risk of nursing
    home placement and spend-down to Medicaid.

Applicants for a grant under this announcement must provide specific
information on the type and range of activities they will pursue using
these grant funds, and how these activities contribute to the State's
overall rebalancing efforts. Priority will be given to States able to
demonstrate real potential for achieving:

-   A significant degree of progress in transforming existing funding
    under the OAA and/or other non-Medicaid programs to conform with the
    standards described in Attachment A, compared to how these dollars
    are currently being used;

-   The ability to begin serving individuals using the transformed
    dollars before the end of the project period;

-   A project that is fully coordinated with other state-administered
    long-term care programs, especially Medicaid, and with a state's
    overall long-term care rebalancing efforts; and,

-   The potential for the changes resulting from the project to be
    sustained beyond the grant period and incorporated into the state's
    overall system of long-term care.

Grant funds under this announcement can be used for, but are not limited
to, the following activities:

-   Provision of direct services and supports to individuals and their
    family caregivers;

-   Case management and support broker services;

-   Developing or refining a program's targeting criteria and tools;

-   Developing systems to support a "cash and counseling" component of
    the nursing home diversion program;

-   Developing a fiscal management and accounting system, including per
    capital budgeting and accounting methods that supports flexible
    funding and consumer-directed models of care, and,

-   Designing and implementing evaluation and quality assurance systems
    and protocols.

As part of its diversion program, states may propose to direct a
[limited]{.underline} amount of its diversion activities on
transitioning individuals who are not eligible for Medicaid out of acute
care and other facility settings into the community if such individuals
otherwise would have remained in, or would have been sent to, a nursing
facility for a long-term stay.

**Activities proposed under this announcement should not duplicate
activities that are supported under other funding sources.** Applicants
should note in their Project Narrative if activities developed under
this funding opportunity are supported with other funding and if so, how
the multiple funding sources will support, and not duplicate, efforts.
In addition, applicants for this opportunity should not propose to use a
significant amount of funding in the development of single point of
entry programs, since AoA and CMS have provided other funding
opportunities for this activity, including Real Choices System
Transformation and Aging and Disability Resource Center grants. .

Additional information important in the development of proposals for
this grant opportunity can be found in Section IV.2.C Project Narrative
and in Section V. Application Review Information.

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

The total amount of federal funds available for this new funding
opportunity is expected to be up to \$5,000,000. AoA plans to fund up to
10 to 12 States for a period of 18 months. The average grant amount is
anticipated to be approximately \$400,000. Applicants are encouraged to
develop project budgets that reflect federal funding at a maximum of
\$500,000. AoA reserves the right to offer a funding level that differs
from the requested amount. Funding will be allocated in total at time of
award. Grantees are required to provide a 25% match of the total project
cost.

All funds will be awarded by September 30, 2007. Applicants are required
to submit one project budget (SF424A) and one budget justification.

These grants will be issued as Cooperative Agreements because AoA
anticipates having substantial involvement with the recipients during
performance of funded activities. This involvement may include:

> ▪ Assisting the project leadership in understanding the strategic
> goals and objectives, policy perspectives, and priorities of the AoA
> by sharing such information on an ongoing basis via e-mail, conference
> calls, briefings, and other consultations;

-   Providing technical assistance and support on grant management and
    implementation issues, including execution of the cooperative
    agreement;

-   Defining project performance criteria and expectations; and,

-   Monitoring, evaluating and supporting the projects' efforts in
    achieving performance goals.

1.  **Award Size**

As noted above, AoA plans to award up to 10 to 12 grants with a maximum
award of \$500,000. A key consideration for AoA is how the award
correlates with the significance of proposed endeavors, rather than the
size of the State. Significance will be measured in terms of the
progress a state proposed to make in modernizing and transforming Older
Americans Act (OAA) Title IIIB, IIIE funding, the Alzheimer's Disease
Demonstration Grant (ADDGS) funds, and/or other non-Medicaid state
revenue, into flexible service dollars targeted at individuals at risk
of nursing home placement and spend down to Medicaid consistent with the
Standards described in Attachment A in this announcement.

**SECTION III. ELIGIBILITY INFORMATION**

1.  **Eligible Applicants**

Only a State Unit on Aging (SUA) may apply for a Nursing Home Diversion
Modernization Grant.

2.  **Cost Sharing or Matching**

[]{.mark}

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. 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. Please note, applications with a match
greater than the minimum required will **[not]{.underline}** receive
additional consideration under the review. Match is not one of the
responsiveness criteria as noted in Section III.3, *Application
Screening Criteria*.

3.  **Application Screening Criteria**

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

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

A.  Applications must be submitted electronically via
    [www.grants.gov](http://www.grants.gov/) by midnight of **August 24,
    2007**.

B.  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.

C.  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.

**SECTION IV. APPLICATION AND SUBMISSION INFORMATION**

## 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>.

Application materials are also available by writing to:

U.S. Department of Health and Human Services

Administration on Aging

Richard Nicholls

Center for Planning and Policy Development

Washington, D.C. 20201

Or by calling: 202-357-0152

Or e-mailing: richard.nicholls@aoa.hhs.gov

Please note, AoA is requiring applications for this announcement to be
submitted electronically through
[www.grants.gov](http://www.grants.gov/). The Grants.gov registration
process can take several days. If your organization is not currently
registered with [www.grants.gov](http://www.grants.gov/), please begin
this process immediately. **For assistance with
[www.grants.gov](http://www.grants.gov/), please contact them at
[support@grants.gov](mailto:support@grants.gov?subject=Support) or
1-800-518-4726 between 7 a.m. and 9 p.m. Eastern Time.** 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.

How to apply for this opportunity via
[www.grants.gov](http://www.grants.gov/):

-   You may access the electronic application for this program on
    [www.Grants.gov](http://www.Grants.gov/). You must search the
    downloadable application page by the CFDA number 93.048**.** At the
    www.grants.gov website, you will find information about submitting
    an application electronically through the site, including the hours
    of operation. AoA strongly recommends that you do not wait until the
    application due date to begin the application process through
    [www.grants.gov](http://www.grants.gov/) because of the time delay.

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

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

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

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

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

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

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

[]{.mark}

A.  **Letter of Intent**

Applicants are requested, but not required, to submit a letter of intent
to apply for this funding opportunity to assist AoA in planning for the
application independent review process. The deadline for submission of
the letter of intent is July 20, 2007.

B.  **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**.**

C.  **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. AoA
will not accept applications with a Project Narrative that exceeds 20
pages. The Project Work Plan, Letters of Commitment, 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

-   Current Status of State's Long-Term Care Rebalancing and Nursing
    Home Diversion Efforts

-   Goal(s) and Objective(s)

-   Proposed Approach

-   Project Outcomes

-   Project Management

-   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 brief - no more than
265 words maximum - description of the proposed project, including: the
goal(s) and objectives, and a description of the specific types of
changes that will be made to existing programs as a result of the
proposed project. Detailed instructions for completing the
summary/abstract are included in Attachment F of this document.

**Current Status of Aging Network Nursing Home Diversion Efforts in the
State.** Applicants should provide a description of the current efforts,
or planned activities, in the State to divert both Medicaid and
non-Medicaid individuals from institutions, and the specific role that
the SUA and/or AAAs and community aging services provider organizations
play in those efforts. Explain how these diversion activities fit into
the state's overall long-term care system, including current system
reform efforts.

**Goals and Objectives.** This section should describe the proposed
project's goals and objectives as it relates to modernizing the use of
existing funding to bring it more in line with the standards described
in Attachment A.

**Proposed Approach.** Describe the overall approach you plan to use to
transform the way current service dollars are being used, and why you
think this approach will be successful. This must include a description
of how funds are currently being used in the geographic areas to be
covered by the proposed project, and how their use will be changed as a
result of the project.

Applicants are encouraged to provide as much detail -- and to be as
precise as possible \-- in describing both the "status quo" and the
changes that you plan to make in the way existing funds are being used.
This includes identifying the specific funds to be transformed, exactly
how they will be transformed into, and used as, flexible dollars, along
with a description of the involvement of Area Agencies on Aging,
services provider organizations and other stakeholders in the process.
For each element of a diversion program developed through this proposal,
there must be a description of current activities in this area, how
Aging Network and other stakeholders are involved, and how these
activities and the involvement of the various stakeholders will be
different by the end of the grant period.

Applicants must describe the targeting criteria they already have in
place, and/or plan to develop, to ensure they can effectively identify
and serve individuals by the end of this grant period who are in fact at
risk of nursing home placement and spend-down to Medicaid, consistent
with the standards in Attachment A.

Applicants must work with a single entry point system, and by the end of
the grant project period, that system must meet the definition of a
fully functional Single Point of Entry. (See the [Nursing Home Diversion
Modernization Grant Announcement Resource
Page](http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc)
(<http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc>).
Information should be included on existing single entry point access
systems in their state, and specifically how their program will
interface with, or in some cases add to, the chosen system. Ideally, the
single entry point systems will be performing preadmission screening and
will be using its preadmission screening program to identify individuals
to be served under this grant project. Applicants must also ensure the
single entry point is fully coordinated with State and local Medicaid
programs, and other publicly funded long-term care programs. Specific
letters of commitment should be included in the application as outlined
in the "Content and Form of Application Submission" section (Section
IV.2) of this announcement.

Applicants should specify and provide a rationale for selecting the
geographic location(s) where grant efforts will be carried-out in their
state. State Units on Aging, at a minimum, must implement program
elements in at least one Planning and Service Area (PSA) of their State
(or one county or region for states with a single PSA); and involve at
least one Area Agency on Aging, and describe the involvement of aging
services provider organizations and other stakeholders who will be
participating in the project, and the role they will play.

Proposals should include a description of existing and planned
Information Technology needed to support a Nursing Home Diversion
Modernization Grant project.

If proposals include the use of any dollars beyond OAA funding to serve
a population under the age of 60, or for transition activities, a
rationale and description of how these will be accomplished should be
included.

Applicants should demonstrate how their proposal fits with other Aging
Network and state activities, and how the proposed grant activities will
build on or add to the development of a full diversion program, as
described in Attachment A. Proposals should include any major barriers
anticipated, and how the project will be able to overcome those
barriers. The role and makeup of any strategic partnerships to be
involved in implementing the intervention, including other
organizations, funders, and/or consumers should also be described.
Applicants may wish to refer to the *State Readiness Assessment & Gap
Analysis for a Nursing Home Diversion Program* located on the [Nursing
Home Diversion Modernization Grant Announcement Resource
Page](http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc)
for assistance in preparing for this funding opportunity.

**Project Outcomes**. This section of the project narrative must clearly
identify the project outcomes to be accomplished by the end of the
18-month project period, based on the priority activities outlined in
Section I.5, 'Description of Funding Opportunity' and the standards
described in Attachment A. At a minimum, by the end of the 18-month
project period, the state's project must be:

-   Providing consumers with flexible service options, not limited to
    any particular service or package of services, using existing
    funding under OAA Title III-B and/or III-E, ADDGS, or other
    non-Medicaid programs;

-   Using targeting criteria that will allow the project to effectively
    identify and serve individuals who are at risk of nursing home
    placement and spend-down to Medicaid,

-   Using a Single Entry Point system to perform the functions of client
    screening, assessment, care planning, and the targeting of services
    to individuals who are at risk of nursing home placement and
    spend-down to Medicaid.

This section should describe the degree of progress anticipated,
compared to the status quo within a state and within the geographic area
where the project will be implemented, in transforming existing funding
under the OAA and other non-Medicaid programs to conform with the
standards described in Attachment A.

This section should also describe how, and to what extent, the changes
brought about by the project will be sustained beyond the grant period,
as well as the extent to which the changes will be incorporated into the
state's overall system of long-term care.

**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 SUA, AAA and 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.

## Organizational Capability Statement. Each application should include an organizational capability statement, organizational charts, and vitae for key project personnel. The organizational capability statement should describe the organization and capacity of the SUA, AAA (if applicable), community providers and other key participants, and how they will collaborate in this project. This statement should also describe any existing single entry point system/ADRC and its role in the proposed nursing home diversion program. The statement should cover capabilities of the SUA and AAA (not previously discussed in the narrative) related to current or previous experience with diversion or consumer directed programs. 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**. Applicants should provide a realistic timetable and work
plan that outlines the extent to which they will be able to complete
each activity within the project period as well as a description of how
each activity will be coordinated to support expansion of current state
diversion program development.

The Project Work Plan should reflect and be consistent with the Project
Narrative and Budget. It should include a statement of the project's
overall goal, anticipated outcome(s), key objectives, and the major
tasks / action steps that will be pursued to achieve the goal and
outcome(s). For each major task / action step, the work plan should
identify the timeframes involved (including start- and end-dates), and
the lead person responsible for completing the task. Please use the
Sample Work Plan format included in the Attachments.

[]{.mark}

**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. This should include at a minimum letters of
commitment from: 1) the State Medicaid Agency; 2) the collaborating
AAA(s); 3) community provider partners, and, 4) the Single Entry Point.
Any organization that is specifically named to have a significant role
in carrying out the project should be considered a key collaborator. For
applications submitted electronically via
[www.grants.gov](http://www.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 Office of
Grants Management at 202-357-3466 by the application submission
deadline.

3.  **Submission Dates and Times**

The deadline for the submission of applications under this program
announcement is August 24, 2007. Applications must be submitted
electronically by **[midnight EST]{.underline}**, August 24, 2007.

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

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

An open information teleconference for applicants of this solicitation
will be held July 11, 2007 at 3:00 p.m., EST. The toll-free
teleconference phone number will be (888) 381-5770, passcode: 9559261,
leader name: John Wren.

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**

> []{.mark}

The following activities are not fundable:

-   Construction and/or major rehabilitation of buildings;

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

-   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](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 are requested, but not required, to submit a letter of intent
to apply for this funding opportunity to assist AoA in planning for the
application independent review process. The deadline for submission of
the letter of intent is July 20, 2007.

**SECTION V. APPLICATION REVIEW INFORMATION**

The Review Criteria listed below will be used by an Independent Review
Panel to score each application for this funding opportunity. In
applying for this opportunity, applicants should therefore be sure to
adequately address all of the elements noted below.

1.  **Criteria**

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

A.  Demonstration of an accurate understanding of AoA's vision for
    Nursing Home Diversion Programs, including the key design elements
    described in Attachment A, and how nursing home diversion programs
    targeted at individuals who are not eligible for Medicaid fit into
    the larger long-term care policy environment, and state long-term
    care reform / rebalancing efforts -- [(5 Points)]{.underline};

B.  The degree of progress anticipated during the18 month project
    period, compared to the "status quo" in the State and in the
    geographic area where the project will be implemented, in
    transforming existing OAA and other non-Medicaid funding to reflect
    the standards described in Attachment A -- (25 Points);

C.  The likelihood that the project, based on the information provided
    in the application and consistent with the standards in Attachment
    A, will be able -- by the end of the 18 month grant period -- to be:

> 1\. Serving consumers with flexible service options that are not
> limited to any particular service or package of services with funds
> from OAA Title III-B and/or III-E, ADDGS, and/or other non-Medicaid
> programs;
>
> 2\. Using targeting criteria that allow the project to effectively
> identify and serve individuals who are at risk of nursing home
> placement and spend down to Medicaid; and,
>
> 3\. Using a Single Entry Point system that provides access to all
> publicly supported long-term care services and supports to perform the
> functions of client screening, assessment, care planning, and the
> targeting of services to individuals who are at risk of nursing home
> placement and spend-down to Medicaid -- (A total of 25 Points will be
> allocated to "C").

D.  The likelihood that the project will actually succeed in achieving
    all its goals and objectives, based on the proposed approach, the
    project work plan, the involvement of key stakeholders, and other
    information contained in the application - (25 Points);

E.  The likelihood, based on the information contained in the
    application, that the changes resulting from the project will be
    sustained beyond the grant period, as well as the degree to which
    the changes are likely to be incorporated into the state's overall
    system of long-term care - (20 Points).

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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. Based on the specific programmatic considerations as outlined
under Section I.5, '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;
geographic distribution; program diversity; 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.

## SECTION VI. AWARD ADMINISTRATION INFORMATION

###### 1. Award Notices 

Successful applicants will receive an Approval Letter, and a Notice of
Award. The Notice of Award is the authorizing document, and will be
signed by the AoA grants management officer, the AoA authorizing
official, and the AoA budget office. Unsuccessful applicants are
notified within 30 days of the final funding decision and will receive a
disapproval letter via U.S. mail.

###### 

###### 

###### 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 the Standard Terms and Conditions
implemented through the HHS Grants Policy Statement, October 1, 2006,
located at: <http://www.hhs.gov/grantsnet/adminis/gpd/index.htm>.

###### 3. Reporting 

The SF-269 (Financial Status Report) is due annually and the AoA program
progress report is due semi-annually. Final performance and SF-269
reports are due 90 days after the end of the project period.

## SECTION VII. AGENCY CONTACTS 

[Project Officers:]{.underline}

U.S. Department of Health and Human Services

Administration on Aging

Washington, DC 20201

Attn: Linda Velgouse

Telephone: (202) 357-3427, e-mail: <linda.velgouse@aoa.hhs.gov>

U.S. Department of Health and Human Services

Administration on Aging

Washington, DC 20201

Attn: Richard Nicholls

Telephone: (202) 357-0152, e-mail: <richard.nicholls@aoa.hhs.gov>

[Grants Management Officer:]{.underline}

U.S. Department of Health and Human Services

Administration on Aging

Washington, DC 20201

Attn: Stephen Daniels

Telephone: (202) 357-3464, e-mail:
[s­tephen.daniels@aoa.hhs.gov](mailto:s%1Ftephen.daniels@aoa.hhs.gov)

## SECTION VIII. OTHER INFORMATION

###### Application Elements

A.  SF 424 -- Application for Federal Assistance.

B.  SF 424A -- Budget Information.

C.  Separate Budget Narrative/Justification (See Attachments for Sample
    Format).

D.  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).

E.  Certification

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

G.  Project Narrative with Work Plan (See Attachment for Sample Work
    Plan Format).

H.  Organizational Capability Statement and Vitae for Key Project
    Personnel.

I.  Letters of Commitment from Key Partners.

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1.  **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 05/31/2010.

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:**

**Standards for a Nursing Home Diversion Program**

**Attachment B:**

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

**Attachment C:**

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

**Attachment D:**

**Budget Justification -- Sample Format**

**Attachment E:**

**Project Work Plan - Sample Format**

**Attachment F:**

**Instructions for Completing the Summary/Abstract**

**Attachment G:**

# "Survey on Ensuring Equal Opportunity for Applicants" 

# Attachment A

# Standards for Nursing Home Diversion Program

Consistent with the new long-term care provisions in the OAA and the
latest research and best practices from the field, AoA has identified
standards for a Nursing Home Diversion Program. These standards include
nine key elements. These elements are described in this Attachment and
include both service elements and systems elements.

The **service elements** are designed to ensure that the program reaches
its intended target population, and that the needs and preferences of
consumers and their family caregivers are fully considered in the design
and implementation of the program. The **systems elements** of a Nursing
Home Diversion Program are designed to ensure the effective and
efficient administration of the program.

Consistent with the principle of local flexibility that has been a
hallmark of the Older Americans Act, AoA will allow states to exercise
considerable freedom in designing and implementing the service and
system elements of a Nursing Home Diversion Program, including how to
best phase in the implementation of the various elements over time. We
expect and encourage states to demonstrate creativity and ingenuity in
using the latest research and best practices to design their diversion
programs. We believe this approach will help to advance the state-of-the
art by providing states with an opportunity to learn from one another as
they develop and/or refine and implement their Nursing Home Diversion
Programs.

The following standards describe the key design elements of a
state-of-the-art Nursing Home Diversion Program targeted at individuals
who are not eligible for Medicaid.

A.  **Service Elements:**

***a. Flexible Service Dollars that Follow the Needs of Individuals and
their Family Caregivers***

The funding used to support a nursing home diversion program should be
flexible, so that it can be fully responsive to the individualized needs
and preferences of consumers, as well as those of their family
caregivers. This includes the capacity to respond rapidly to the often
changing needs and circumstances facing at risk consumers and their
family caregivers. A fully flexible, consumer-responsive program means
that the funding is not tied to any particular service, or package of
services, nor to any particular type, or types, of providers.
Additionally, certain fiscal management techniques, such as per-capita
and unit rate budgeting, help support the delivery of flexible service
models and consumer-directed approaches.

Flexible funding used to support nursing home diversion programs should
not be used to pay for services and supports covered by another funding
source, although it can be used to pay for such services on a short
term, emergency basis if it is necessary to help an individual to stay
at home, as long as the diversion program is later reimbursed for the
cost of those services by the appropriate program.

Research on systems change efforts, such as those undertaken by CMS Real
Choice Systems Change grantees, suggests that the most effective systems
change efforts undertaken to-date by states include mechanisms to change
long-term service systems from being provider and service driven to
systems that are consumer-driven, and that it is critical that states
concentrate on efforts and best practices that focus on consumer's needs
rather than service silos. (See *Unlocking the Code of Effective Systems
Change* located on the [Nursing Home Diversion Modernization Grant
Resource
Page](http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc).

***b. Targeting Individuals at High Risk of Nursing Home Placement***

Targeting individuals at high risk of nursing home placement is an
essential element of any nursing home diversion program. The earliest
nursing home diversion programs used targeting criteria that focused on
a person's functional status, such as the number of impairments in
activities of daily living. Since these early efforts, the
state-of-the-art has advanced considerably. Today, the more advanced
nursing home diversion programs use multiple targeting criteria that go
beyond functional status to include factors that relate to the
individual's health and cognitive status and the status of their
informal support system.

A Nursing Home Diversion Program should use multiple risk factors in its
targeting criteria to ensure that the program has a high likelihood of
reaching individuals who are, in fact, at high-risk of
institutionalization. At a minimum, at least four domains must be
addressed by these risk factors:

-   ***Functional status*** which includes ability to perform activities
    of daily living and instrumental activities of daily living.

-   ***Health status*** which includes diagnoses (e.g., diabetes,
    fall-related fractures) and medical/skilled care needs (e.g.,
    nursing, therapies) and can be evidenced by a hospitalization or a
    prior nursing facility stay and the use of medications.

-   ***Cognitive/emotional status*,** which includes cognitive
    impairments, impairments in decision-making ability, inability to
    make decisions to avoid injury in emergency situations, etc.

-   ***Informal support system status,** which may include* the existing
    capacity of informal caregivers to assist in the provision of
    support, as well as the lack of informal support.

Many States are already using some of these risk factors in their
existing eligibility criteria for public programs. Additional
information is located on the [Nursing Home Diversion Modernization
Grant Announcement Resource
Page](http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc).

***c. Giving Consumers the Option to Use a Consumer Directed Model***

A Nursing Home Diversion Program should give consumers and their family
caregivers the maximum degree of control possible, or desired, over
decisions affecting the types of services and supports they receive, as
well as the manner in which the services and supports are provided. AoA
believes all consumers receiving long-term care from public programs
should be offered -- as a matter of choice - the option of controlling
their own services through a Cash and Counseling model. Obviously, if
the consumer does not want, or is not able to participate in, a Cash and
Counseling model, then a traditional form of care would be provided.
Under Cash and Counseling, individuals, or their representatives, manage
a flexible budget, employ and pay workers, including family and friends,
and purchase needed goods and services based on their specific needs and
preferences. This model is reflected in the definition of "self-directed
care" that was added to Title I of the OAA as a result of the 2006
Amendments.

The Cash and Counseling Demonstration provides clear evidence on the
importance of using consumer-directed models of care. The evaluation of
this three state demonstration, which was targeted at Medicaid clients
who were at high-risk of nursing home placement, found that consumers
who self-directed their services had better quality care, greatly
improved quality of life, better health outcomes, and decreased
utilization of more expensive services such as nursing home care.
Additional information can be found at
<http://www.cashandcounseling.org/index.html> and is included on the
[Nursing Home Diversion Modernization Grant Announcement Resource
Page](http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc).

***d. Targeting Individuals at High Risk of Medicaid Spend Down***

To help ensure the effective use publicly funded services under a
Nursing Home Diversion Program, the project should use criteria that can
identify and target publicly funded services at individuals who can
successfully be diverted from Medicaid spend down. In order to
effectively target individuals who are at risk of Medicaid spend down,
states will have to figure out an approach to understanding how an
individual's income and assets relate to the state's Medicaid financial
eligibility criteria, and then use that information to determine the
person's risk of spending down. A number of states have developed
different approaches to assess the risk of Medicaid spend down.
Minnesota, for example, in its Alternative Care Program determines how
long it may take an individual to spend down if he/she were to enter a
nursing facility, taking into account the combination of income and
assets. Another example is Connecticut which uses an asset test, but not
an income limit for their State-funded HCBS program. Connecticut's asset
limit is \$19,908 for individuals and \$29,862 for couples. Another
approach used by some states is to set specific levels for income and
assets at a specified amount above the current Medicaid financial
eligibility levels.

Additional information is located on the [Nursing Home Diversion
Modernization Grant Announcement Resource
Page](http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc).

***e. Complementing Informal Caregiving and Individual Resources***

Since its inception, Older Americans Act funding has been designed to
fill gaps in services, not to fully fund the cost of all the services
and supports needed by older individuals and their family caregivers.
Consistent with this philosophy and approach, a Nursing Home Diversion
Program should complement other resources being deployed to support the
consumer's desire to remain at home. Of particular importance here are
the personal and financial resources of the individual and their family,
including the time and effort of family caregivers. The research shows
that these "private contributions" make up the vast majority of the care
received by frail elderly people living in the community.

It is expected that states will develop a standard approach to
determining the amount of publicly funded services and/or supports to
provide to an individual based on their needs, and that the approach
will involve a method for identifying and factoring into the
determination the "private contributions" that are being made by the
individual and their informal supports to the "cost" of the overall care
plan. AoA recognizes that states will use different approaches to
identifying and factoring in the "private contributions" of individuals
and their informal supports. For example, the level of "private
contribution" could be determined based on the self-declaration of the
individual and/or their informal caregivers and documented during the
development of formal care plans. States are encouraged to consider
approaches where they use care plans to document these "private
contributions" and avoid approaches that involve the "exchange of money"
(and the administrative costs associated with such exchanges) that often
occur under traditional "cost sharing" methods.

Linking the amount of publicly supported services and/or supports that
an individual receives to the "private contributions" of those
individuals and their informal caregivers should in no way preclude
states from developing and operating Nursing Home Diversion Programs
that serve individuals who are willing and able to pay for the full cost
of their formal care. AoA strongly encourages states to develop Nursing
Home Diversion Programs that not only serve individuals who need some
form of public support to cover the cost of their care, but that also
serve the growing number of individuals who are willing and able to pay
for the full cost of their care. For example, many states already have
programs that can assist such individuals by helping them to assess
their needs and then locate and/or help them to arrange for services
that they directly purchase with their own resources.

Additional information is located on the [Nursing Home Diversion
Modernization Grant Announcement Resource
Page](http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc).

B.  **System Elements**

***a. Using Single Entry Point Programs to Ensure Streamlined Access for
Consumers***

Single entry point systems perform functions that are essential to
nursing home diversion activities. For example, integrating access with
Medicaid through a single entry point system is essential to ensure that
those individuals who are screened by the entry point and found to be
not eligible for Medicaid are seamlessly linked to the Nursing Home
Division Program for non-Medicaid eligible individuals. Accordingly, to
be effective, a "single entry point" system must provide access to
[all]{.underline} publicly supported long-term care programs, including
all forms of Medicaid long-term care, and perform, at a minimum, the
following functions for all those programs:

-   Screening individuals to identify those most likely to benefit from
    the program, including performing preadmission nursing home
    screening which is a key component of any well developed system of
    long-term care;

-   Assessing the needs of the targeted individuals and their family
    caregivers;

-   Working with the individual and their informal caregivers to
    developing care plans;

-   Determining an individuals' functional and financial eligibility for
    Medicaid and other publicly supported services; and,

-   Linking consumers to needed services.

Single entry point systems that provide streamlined access to all
publicly funded long-term care programs can enable policy makers and
program administrators to more effectively respond to individual needs,
address system problems, and limit the unnecessary use of high-cost
services, including institutional care.[^1] The AoA/CMS funded Aging and
Disability Resource Centers (ADRC) Program includes a "single point of
entry" component that covers all publicly supported long-term care
programs. For more detailed information on the components of a fully
functional single point of entry system, additional information is
located on the [Nursing Home Diversion Modernization Grant Announcement
Resource
Page](http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc).

***b. Infrastructure to Support Consumer Directed Service Approaches***

The reauthorized OAA supports the Cash & Counseling model as an
important element of a Nursing Home Diversion Program. The Cash &
Counseling model requires state and local programs to have the capacity
to offer consumers the option of managing their own budgets, hiring
their own workers, and purchasing necessary goods and services. This
includes fiscal management services and specialized care managers or
support brokers. Fiscal management services involve payroll functions
including paying taxes and insurance for the workers hired by consumers
participating in the program. Support brokers are specially trained to
counsel and assist consumers in directing their own care. Some of the
functions of the support broker and/or fiscal management services
include:

-   Training and assisting participants/representatives on recruiting,
    hiring, training, managing, evaluating and dismissing workers;

-   Assisting participant/representative in developing an individual
    back-up plan;

-   Processing payroll for directly hired workers in accordance with
    Federal, State and local tax, labor and worker compensation laws for
    domestic service employees and government or vendor fiscal/employer
    agents operating under Section 3504 of the IRS code[^2]; and,

-   Processing and making payments for goods and services in accordance
    with the participant's approved spending plan.

Consumer involvement at all levels of program development and
implementation is essential for a consumer directed program. It ensures
that the program can respond to the needs and preferences of consumers
over time, including providing varying levels of assistance when
necessary.

A full description of the operational systems and supports that a state
needs to offer Cash and Counseling can be found on the website of the
National Program Office for the Cash and Counseling Program at
[www.cashandcounseling.org](http://www.cashandcounseling.org/).

Based on the success of the original Cash and Counseling demonstration
in the states of Florida, New Jersey and Arkansas, the Administration on
Aging, CMS and the Office of the Assistant Secretary for Planning and
Evaluation have joined with the Robert Wood Johnson Foundation and the
Retirement Research Foundation to support the replication of the Cash
and Counseling Program in 12 additional states. Like the original
states, these projects are focused on offering the Cash and Counseling
model to Medicaid eligible individuals. Additional states are using
Independence Plus Waivers and new provisions in the DRA that now give
every state Medicaid program the authority to offer the Cash and
Counseling model as a state plan option.

A Nursing Home Diversion Program should build on and leverage the
capacity being developed under these existing Cash and Counseling
programs, including the infrastructures they are developing for carrying
out the necessary fiscal management and support broker functions noted
above. More information on consumer direction can be found on
[http://www.hcbs.org](http://www.hcbs.org/) and on the [Nursing Home
Diversion Modernization Grant Announcement Resource
Page](http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc).

***c. Quality Assurance***

Any effective long-term care program must have a well defined quality
assurance program. Nursing Home Diversion Programs should adopt the CMS
Quality Framework, or a similar quality assurance program, as the basis
for development of the quality assurance component of their Programs. A
well developed quality assurance program enhances a state's capacity to
determine if its long-term programs are operating as they were designed,
and that the critical quality assurance processes of discovery,
remediation, and systems improvement occur in a structured and routine
manner.

Quality can assume several dimensions in community-based systems. The
basic measures included in the CMS Quality Framework are:

-   Participant access to services;

-   Participant-centered service planning and delivery;

-   Provider capacity and capabilities;

-   Participant safeguards;

-   Participant rights and responsibilities;

-   Participant outcomes and satisfaction; and,

-   Systems performance.

Measuring quality, or discovery, includes identifying specific elements
within chosen domains, specifying a clear and discrete indicator(s) to
measure the element, and having a system to collect, analyze and report
the data.

A system of continuous quality improvement - remediation and systems
improvement - results from examining and analyzing data to determine the
meaning and significance for the programs operation. This includes
sharing information with program administrators with responsibility and
authority for program quality and interventions necessary to affect
program improvements, using the information as a management tool to
identify issues that need attention and remediation, and using
subsequent measurements to gauge whether their interventions were
successful or whether additional changes are necessary.

Quality monitoring, assessment and improvement activities in consumer
directed systems must involve consumer evaluation and must be focused on
using data to enhance program quality. Quality monitoring systems might
include complaint hotlines and program performance indicators. Quality
assessment and improvement activities should involve mechanisms for
stakeholder input and program self-assessment.

Information on the CMS Quality Framework can be found at:
<http://www.cms.hhs.gov/HCBS/downloads/qualityframework.pdf>. In
addition, "A Guide to Quality in Consumer Directed Services" and other
information on quality in consumer directed systems can be found at
<http://www.cashandcounseling.org/index.html> and on the [Nursing Home
Diversion Modernization Grant Announcement Resource
Page](http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc).

***d. Performance Measurement and Evaluation***

A state's Nursing Home Diversion Program must include a performance
measurement program that can be used to continually track and evaluate
the program's performance in achieving its goals and objectives. States
must identify the relevant outcome and process evaluation factors they
plan to use for their nursing home diversion program. At a minimum,
states must plan for performance measurement and evaluation that
includes the following factors:

-   Change in consumer well being and quality of life;

-   Numbers of consumers diverted from nursing home care;

-   Numbers of consumers diverted from spending down to Medicaid;

-   Documentation of cost-savings (or cost-neutrality) to public
    programs, including Medicaid, as compared to institutional care;
    and,

-   Decrease in State's Medicaid nursing home expenditures.

The Performance Indicators being used in the Cash and Counseling
replication offer a good model for developing a performance measurement
and evaluation program. This can be accessed at
[www.cashandcounseling.org](http://www.cashandcounseling.org/) or on the
[Nursing Home Diversion Modernization Grant Announcement Resource
Page](http://www.aoa.gov/doingbus/fundopp/announcements/2007/NHDP_Resource_Page.doc).

**Attachment B**

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

+----------+-------+------+------+------+-----------------------------+
| >        | **Fe  | **N  | **N  | # T  | ### Justification           |
| **Object | deral | on-F | on-F | OTAL |                             |
| > Class  | Fu    | eder | eder |      |                             |
| > Ca     | nds** | al** | al** |      |                             |
| tegory** |       |      |      |      |                             |
|          |       | **Ca | **I  |      |                             |
|          |       | sh** | n-Ki |      |                             |
|          |       |      | nd** |      |                             |
+----------+-------+------+------+------+-----------------------------+
| **Per    | \$4   |      | \$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 C: Budget Justification, Page 2 - Sample Format with EXAMPLES

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

+-----+-----+------+------+------+-----------------------------------+
| A   |     |      |      |      |                                   |
| tta |     |      |      |      |                                   |
| chm |     |      |      |      |                                   |
| ent |     |      |      |      |                                   |
| C:  |     |      |      |      |                                   |
| Bud |     |      |      |      |                                   |
| get |     |      |      |      |                                   |
| Ju  |     |      |      |      |                                   |
| sti |     |      |      |      |                                   |
| fic |     |      |      |      |                                   |
| ati |     |      |      |      |                                   |
| on, |     |      |      |      |                                   |
| P   |     |      |      |      |                                   |
| age |     |      |      |      |                                   |
| 3   |     |      |      |      |                                   |
| --  |     |      |      |      |                                   |
| Sam |     |      |      |      |                                   |
| ple |     |      |      |      |                                   |
| For |     |      |      |      |                                   |
| mat |     |      |      |      |                                   |
| w   |     |      |      |      |                                   |
| ith |     |      |      |      |                                   |
| EX  |     |      |      |      |                                   |
| AMP |     |      |      |      |                                   |
| LES |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| **O | \$  | \$8  | \$19 | \$37 | Local conference registration fee |
| the | 10, | ,000 | ,800 | ,800 | (name conference) = \$ 200        |
| r** | 000 |      |      |      |                                   |
|     |     |      |      |      | Printing brochures (50,000 @ \$   |
|     |     |      |      |      | .05 ea) = \$ 2,500                |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Video production = \$19,800       |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Video Reproduction = \$ 3,500     |
|     |     |      |      |      |                                   |
|     |     |      |      |      | NF Respite Training Manual        |
|     |     |      |      |      | reproduction                      |
|     |     |      |      |      |                                   |
|     |     |      |      |      | \$3/manual x \$2000 manuals = \$  |
|     |     |      |      |      | 6,000                             |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Postage \$150/mo x 12 months = \$ |
|     |     |      |      |      | 1,800                             |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Caregiver Forum meeting room      |
|     |     |      |      |      | rentals                           |
|     |     |      |      |      |                                   |
|     |     |      |      |      | \$200/day x 12 forums = \$ 2,400  |
|     |     |      |      |      |                                   |
|     |     |      |      |      | Respite Training Scholarships =   |
|     |     |      |      |      | \$1,600                           |
+-----+-----+------+------+------+-----------------------------------+
| *   | 0   | 0    | 0    | 0    | None                              |
| *In |     |      |      |      |                                   |
| dir |     |      |      |      |                                   |
| ect |     |      |      |      |                                   |
| Cha |     |      |      |      |                                   |
| rge |     |      |      |      |                                   |
| s** |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+
| ##  | \$2 | \$58 | \$27 | \    |                                   |
| ### | 67, | ,000 | ,767 | $352 |                                   |
|  TO | 100 |      |      | ,267 |                                   |
| TAL |     |      |      |      |                                   |
+-----+-----+------+------+------+-----------------------------------+

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

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

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

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

Attachment E: 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**   **3**   **4**   **5**   **6**   **7**   **8**   **9**   **10**   **11**   **12**

  1\.                                                                                                                                                        

                                                                                                                                                             

                                                                                                                                                             

                                                                                                                                                             

  2\.                                                                                                                                                        

                                                                                                                                                             

                                                                                                                                                             

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

Attachment E: 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 E: 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 F**

Instructions for Completing the Project Summary/Abstract

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

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

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

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

**Products --** materials, deliverables.

-   A model abstract/summary is provided below:

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

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

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

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

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

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

Yes No

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

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

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

Less Than \$150,000

\$150,000 - \$299,999

\$300,000 - \$499,999

\$500,000 - \$999,999

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

\$5,000,000 or more

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

Yes No

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

Yes No

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

> Yes No

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

Yes No

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

Yes No

# Survey Instructions on Ensuring Equal Opportunity for Applicants

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

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

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

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

4\. Self-identify.

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

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

7.  Self-explanatory.

8.  Self-explanatory.

**Paperwork Burden Statement**

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

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

> OMB No. 1890-0014 Exp. 1/31/2006

[^1]: The Lewin Group (2006), The Aging and Disability Resource Center
    (ADRC) Initiative Interim Outcomes Report.
    [www.adrc-tae.org](http://www.adrc-tae.org/).

[^2]: Oregon is the exception to this, for historical reasons.