I. State Information 

Chief Executive Officer’s Funding Agreements, Assurances NonConstruction Programs and Certifications (Form 3)

Fiscal Year 2020/21 

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administrations 

Funding Agreements as required by Substance Abuse Prevention and Treatment 

Block Grant Program as authorized by

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

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

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

Section Title Chapter

Section 1921 Formula Grants to States 42 USC § 300x-21

Section 1922 Certain Allocations 42 USC § 300x-22

Section 1923 Intravenous Substance Abuse 42 USC § 300x-23

Section 1925 Group Homes for Recovering Substance Abusers 42 USC § 300x-25

Section 1926 State Law Regarding the Sale of Tobacco Products to Individuals Under Age 18 42 USC § 300x-26

Section 1927 Treatment Services for Pregnant Women 42 USC § 300x-27

Section 1928 Additional Agreements 42 USC § 300x-28

Section 1930 Maintenance of Effort Regarding State Expenditures 42 USC § 300x-30

Section 1931 Restrictions on Expenditure of Grant 42 USC § 300x-31

Section 1932 Application for Grant; Approval of State Plan 42 USC § 300x-32

Section 1935 Core Data Set 42 USC § 300x-35

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

Section Title Chapter

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 II 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 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: 

1 Signature of CEO or Designee : 

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 nonFederal 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 

7. 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.

8. 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 eall interests in real property 

acquired for project purposes regardless of Federal participation in purchases. 

9. 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. 

10. 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 sub agreements. 

11. 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. 

12. 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).

13. 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. 

14. 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.).

15. 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.

16. 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. 

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

accordance with the Single Audit Act of 1984. 

19. 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.