I. State Information 

Chief Executive Officer’s Funding Agreements, Assurances NonConstruction Programs and Certifications (Form 03) 

Fiscal Year 2022/23 

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 

Title 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 

Section 1920 Early Serious Mental Illness 42 USC § 300x-9 

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 

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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. 

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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 

19 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 

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all interests in real property acquired for project purposes regardless of Federal 

participation in purchases. 

8. Will comply, as applicable, 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 arefunded 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 sub agreements. 

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 Amendments of 1996 and OMB Circular No. A133, "Audits of States, Local Governments, and Non-Profit Organizations." 

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

regulations and policies governing this program. 

19. Will comply with the requirements of Section 106(g) of the Trafficking Victims 

Protection Act (TVPA) of 2000, as amended (22 U.S.C. 7104) which prohibits grant 

award recipients or a sub-recipient from (1) Engaging in severe forms of trafficking in 

persons during the period of time that the award is in effect (2) Procuring a 

commercial sex act during the period of time that the award is in effect or (3) Using 

forced labor in the performance of the award or subawards under the award. 

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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 (non- appropriated) funds. These requirements apply to grants and 

cooperative agreements EXCEEDING $100,000 in total costs (45 CFR Part 93). By signingand 

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. 

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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 certificationbe 

included in any sub-awards which contain provisions for children’s services and that all subrecipients 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 ofthe American 

people. 

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