I. State Information 

Chief Executive Officer’s Funding Agreements, Assurances Non-Construction Programs and 

Certifications (Form 03)

Fiscal Year 2016/17

U.S. Department of Health and Human Services 

Substance Abuse and Mental Health Services Administrations

Funding Agreements 

as required by

Community Mental Health Services Block Grant Program

as authorized by

Title XIX, Part B, Subpart I and Subpart III of the Public Health Service Act 

and

Tile 42, Chapter 6A, Subchapter XVII of the United States Code

Title XIX, Part B, Subpart I of the Public Health Service Act

Section Title Chapter

Section 1911 Formula Grants to States 42 USC § 300x

Section 1912 State Plan for Comprehensive Community Mental Health Services for Certain 

Individuals

42 USC § 300x-1

Section 1913 Certain Agreements 42 USC § 300x-2

Section 1914 State Mental Health Planning Council 42 USC § 300x-3

Section 1915 Additional Provisions 42 USC § 300x-4

Section 1916 Restrictions on Use of Payments 42 USC § 300x-5

Section 1917 Application for Grant 42 USC § 300x-6

Title XIX, Part B, Subpart III of the Public Health Service Act

Section 1941 Opportunity for Public Comment on State Plans 42 USC § 300x-51

Section 1942 Requirement of Reports and Audits by States 42 USC § 300x-52

Section 1943 Additional Requirements 42 USC § 300x-53

Section 1946 Prohibition Regarding Receipt of Funds 42 USC § 300x-56

Section 1947 Nondiscrimination 42 USC § 300x-57

Section 1953 Continuation of Certain Programs 42 USC § 300x-63

Section 1955 Services Provided by Nongovernmental Organizations 42 USC § 300x-65

Section 1956 Services for Individuals with Co-Occurring Disorders 42 USC § 300x-66

I hereby certify that the state or territory will comply with Title XIX, Part B, Subpart I and Subpart III of 

the Public Health Service (PHS) Act, as amended, and summarized above, except for those sections in 

the PHS Act that do not apply or for which a which a waiver has been granted or may be granted by the 

Secretary for the period covered by this agreement.

State: 

Name of Chief Executive Officer (CEO) or Designee: 

Signature of CEO or Designee1: 

Title: 

Date Signed: 

mm/dd/yyyy

1 If the agreement is signed by an authorized designee, a copy of the designation must be attached.
ASSURANCES - NON-CONSTRUCTION PROGRAMS

Note: Certain of these assurances may not be applicable to your project or program. If you 

have questions, please contact the awarding agency. Further, certain Federal awarding 

agencies may require applicants to certify to additional assurances. If such is the case, 

you will be notified.

As the duly authorized representative of the applicant I certify that the applicant:

1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and 

financial capability (including funds sufficient to pay the non-Federal share of project costs) 

to ensure proper planning, management and completion of the project described in this 

application.

2. Will give the awarding agency, the Comptroller General of the United States, and if 

appropriate, the State, through any authorized representative, access to and the right to 

examine all records, books, papers, or documents related to the award; and will establish a 

proper accounting system in accordance with generally accepted accounting standard or 

agency directives.

3. Will establish safeguards to prohibit employees from using their positions for a purpose that 

constitutes or presents the appearance of personal or organizational conflict of interest, or 

personal gain. 

4. Will initiate and complete the work within the applicable time frame after receipt of approval 

of the awarding agency.

5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. §§4728-4763) 

relating to prescribed standards for merit systems for programs funded under one of the 

nineteen statutes or regulations specified in Appendix A of OPM’s Standard for a Merit 

System of Personnel Administration (5 C.F.R. 900, Subpart F).

6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not 

limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits 

discrimination on the basis of race, color or national origin; (b) Title IX of the Education 

Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and 1685- 1686), which 

prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of

1973, as amended (29 U.S.C. §§794), which prohibits discrimination on the basis of 

handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101-6107), 

which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment 

Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug 

abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and 

Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the 

basis of alcohol abuse or alcoholism; (g) §§523 and 527 of the Public Health Service Act of 

1912 (42 U.S.C. §§290 dd-3 and 290 ee-3), as amended, relating to confidentiality of 

alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42

U.S.C. §§3601 et seq.), as amended, relating to non- discrimination in the sale, rental or 

financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) 

under which application for Federal assistance is being made; and (j) the requirements 

of any other nondiscrimination statute(s) which may apply to the application.

7. Will comply, or has already complied, with the requirements of Title II and III of the Uniform 

Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) 

which provide for fair and equitable treatment of persons displaced or whose property is 

acquired as a result of Federal or federally assisted programs. These requirements apply to
all interests in real property acquired for project purposes regardless of Federal 

participation in purchases.

8. Will comply with the provisions of the Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328) 

which limit the political activities of employees whose principal employment activities are 

funded in whole or in part with Federal funds.

9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. §§276a to 

276a-7), the Copeland Act (40 U.S.C. §276c and 18 U.S.C. §874), and the Contract Work 

Hours and Safety Standards Act (40 U.S.C. §§327- 333), regarding labor standards for 

federally assisted construction subagreements.

10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of 

the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a 

special flood hazard area to participate in the program and to purchase flood insurance if 

the total cost of insurable construction and acquisition is $10,000 or more.

11. Will comply with environmental standards which may be prescribed pursuant to the 

following: (a) institution of environmental quality control measures under the National 

Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b) 

notification of violating facilities pursuant to EO 11738; (c) protection of wetland pursuant to 

EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO

11988; (e) assurance of project consistency with the approved State management program 

developed under the Costal Zone Management Act of 1972 (16 U.S.C. §§1451 et seq.); (f) 

conformity of Federal actions to State (Clear Air) Implementation Plans under Section 

176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. §§7401 et seq.); (g) protection 

of underground sources of drinking water under the Safe Drinking Water Act of 1974, as 

amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered 

Species Act of 1973, as amended, (P.L. 93-205).

12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§1271 et seq.) related 

to protecting components or potential components of the national wild and scenic rivers 

system.

13. Will assist the awarding agency in assuring compliance with Section 106 of the National 

Historic Preservation Act of 1966, as amended (16 U.S.C. §470), EO 11593 (identification 

and protection of historic properties), and the Archaeological and Historic Preservation Act of 

1974 (16 U.S.C. §§ 469a-1 et seq.).

14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, 

development, and related activities supported by this award of assistance.

15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 

U.S.C. §§2131 et seq.) pertaining to the care, handling, and treatment of warm blooded 

animals held for research, teaching, or other activities supported by this award of 

assistance. 16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42

U.S.C. §§4801 et seq.) which prohibits the use of lead based paint in construction or 

rehabilitation of residence structures.

17. Will cause to be performed the required financial and compliance audits in accordance with 

the Single Audit Act of 1984.

18. Will comply with all applicable requirements of all other Federal laws, executive orders, 

regulations and policies governing this program.
LIST of CERTIFICATIONS

1. CERTIFICATION REGARDING LOBBYING

Title 31, United States Code, Section 1352, entitled "Limitation on use of appropriated 

funds to influence certain Federal contracting and financial transactions," generally 

prohibits recipients of Federal grants and cooperative agreements from using Federal 

(appropriated) funds for lobbying the Executive or Legislative Branches of the Federal 

Government in connection with a SPECIFIC grant or cooperative agreement. Section 

1352 also requires that each person who requests or receives a Federal grant or 

cooperative agreement must disclose lobbying undertaken with non-Federal (nonappropriated) funds. These requirements apply to grants and cooperative agreements 

EXCEEDING $100,000 in total costs (45 CFR Part 93). By signing and submitting this 

application, the applicant is providing certification set out in Appendix A to 45 CFR 

Part 93. 

2. CERTIFICATION REGARDING PROGRAM FRAUD CIVIL REMEDIES 

ACT (PFCRA)

The undersigned (authorized official signing for the applicant organization) certifies that 

the statements herein are true, complete, and accurate to the best of his or her knowledge, 

and that he or she is aware that any false, fictitious, or fraudulent statements or claims 

may subject him or her to criminal, civil, or administrative penalties. The undersigned 

agrees that the applicant organization will comply with the Department of Health and 

Human Services terms and conditions of award if a grant is awarded as a result of this 

application. 

3. CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE

Public Law 103-227, also known as the Pro-Children Act of 1994 (Act), requires that 

smoking not be permitted in any portion of any indoor facility owned or leased or 

contracted for by an entity and used routinely or regularly for the provision of health, 

day care, early childhood development services, education or library services to 

children under the age of 18, if the services are funded by Federal programs either 

directly or through State or local governments, by Federal grant, contract, loan, or loan 

guarantee. The law also applies to children’s services that are provided in indoor 

facilities that are constructed, operated, or maintained with such Federal funds. The law 

does not apply to children’s services provided in private residence, portions of facilities 

used for inpatient drug or alcohol treatment, service providers whose sole source of 

applicable Federal funds is Medicare or Medicaid, or facilities where WIC coupons are 

redeemed.

Failure to comply with the provisions of the law may result in the imposition of a civil 

monetary penalty of up to $1,000 for each violation and/or the imposition of an 

administrative compliance order on the responsible entity. 
The authorized official signing for the applicant organization certifies that the applicant 

organization will comply with the requirements of the Act and will not allow smoking 

within any portion of any indoor facility used for the provision of services for children 

as defined by the Act. The applicant organization agrees that it will require that the 

language of this certification be included in any sub-awards which contain provisions 

for children’s services and that all sub-recipients shall certify accordingly.

The Department of Health and Human Services strongly encourages all grant recipients 

to provide a smoke-free workplace and promote the non-use of tobacco products. This 

is consistent with the DHHS mission to protect and advance the physical and mental 

health of the American people.