State Information

Chief Executive Officer’s Funding Agreement – Certifications and Assurances / Letter Designating Authority [MH]

Fiscal Year 2024

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Funding Agreements

as required by

Community Mental Health Services 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 1911 Formula Grant 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 U.S.C. 300x-9

Section 1920 Crisis Services 42 U.S.C. 300x-9

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
ASSURANCES - NON-CONSTRUCTION PROGRAMS

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 all interests in real

property acquired for project purposes regardless of Federal participation in purchases.

8. Will comply, as applicable, with 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 Amendments of 

1996 and OMB Circular No. A-133, "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.
LIST of CERTIFICATIONS

1. Certification Regarding Debarment and Suspension

The undersigned (authorized official signing for the applicant organization) certifies to the best of his or her knowledge and belief, that 

the applicant, defined as the primary participant in accordance with 2 CFR part 180, and its principals:

a. Agrees to comply with 2 CFR Part 180, Subpart C by administering each lower tier subaward or contract that exceeds $25,000 as a

"covered transaction" and verify each lower tier participant of a "covered transaction" under the award is not presently debarred

or otherwise disqualified from participation in this federally assisted project by:

a. Checking the Exclusion Extract located on the System for Award Management (SAM) at http://sam.gov [sam.gov]

b. Collecting a certification statement similar to paragraph (a)

c. Inserting a clause or condition in the covered transaction with the lower tier contract

2. Certification Regarding Drug-Free Workplace Requirements

The undersigned (authorized official signing for the applicant organization) certifies that the applicant will, or will continue to, provide a 

drug-free work-place in accordance with 2 CFR Part 182by:

a. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a

controlled substance is prohibited in the grantee's work-place and specifying the actions that will be taken against employees for

violation of such prohibition;

b. Establishing an ongoing drug-free awareness program to inform employees about--

1. The dangers of drug abuse in the workplace;

2. The grantee's policy of maintaining a drug-free workplace;

3. Any available drug counseling, rehabilitation, and employee assistance programs; and

4. The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;

c. Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement

required by paragraph (a) above;

d. Notifying the employee in the statement required by paragraph (a), above, that, as a condition of employment under the grant, the

employee will--

1. Abide by the terms of the statement; and

2. Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no

later than five calendar days after such conviction;

e. Notifying the agency in writing within ten calendar days after receiving notice under paragraph (d)(2) from an employee or

otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title,

to every grant officer or other designee on whose grant activity the convicted employee was working, unless the Federal agency

has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected

grant;

f. Taking one of the following actions, within 30 calendar days of receiving notice under paragraph (d) (2), with respect to any

employee who is so convicted?

1. Taking appropriate personnel action against such an employee, up to and including termination, consistent with the

requirements of the Rehabilitation Act of 1973, as amended; or

2. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such

purposes by a Federal, State, or local health, law enforcement, or other appropriate agency;

g. Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d),

(e), and (f).

3. Certifications Regarding Lobbying

Per 45 CFR §75.215, Recipients are subject to the restrictions on lobbying as set forth in 45 CFR part 93. 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.

The undersigned (authorized official signing for the applicant organization) certifies, to the best of his or her knowledge and belief, that

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned to any person for influencing 

or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or

an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, 

the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, 

amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. If any funds other than Federally appropriated funds have been paid or will be paid to any person for influencing or attempting to

influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a

Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall 

complete and submit Standard Form-LLL, "Disclosure of Lobbying Activities," in accordance with its instructions. (If needed, 

Standard Form-LLL, "Disclosure of Lobbying Activities," its instructions, and continuation sheet are included at the end of this 

application form.)

3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all 

tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients 

shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. 

Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, U.S. Code. Any 

person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 

for each such failure.

4. Certification Regarding Program Fraud Civil Remedies Act (PFCRA) (31 U.S.C § 3801- 3812)

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 Public Health Service terms and conditions of award if a grant is awarded as a result of this application.

5. 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, daycare, 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.

By signing the certification, the undersigned 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 subawards which contain 

provisions for children's services and that all subrecipients shall certify accordingly.
The Public Health 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 PHS mission to protect and advance the physical and mental health of the American 

people.

HHS Assurances of Compliance (HHS 690)

ASSURANCE OF COMPLIANCE WITH TITLE VI OF THE CIVIL RIGHTS ACT OF 1964, SECTION 504 OF THE REHABILITATION ACT OF 1973, 

TITLE IX OF THE EDUCATION AMENDMENTS OF 1972, THE AGE DISCRIMINATION ACT OF 1975, AND SECTION 1557 OF THE 

AFFORDABLE CARE ACT

The Applicant provides this assurance in consideration of and for the purpose of obtaining Federal grants, loans, contracts, property, 

discounts or other Federal financial assistance from the U.S. Department of Health and Human Services.

THE APPLICANT HEREBY AGREES THAT IT WILL COMPLY WITH:

1. Title VI of the Civil Rights Act of 1964 (Pub. L. 88-352), as amended, and all requirements imposed by or pursuant to the Regulation

of the Department of Health and Human Services (45 C.F.R. Part 80), to the end that, in accordance with Title VI of that Act and the

Regulation, no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in,

be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Applicant

receives Federal financial assistance from the Department.

2. Section 504 of the Rehabilitation Act of 1973 (Pub. L. 93-112), as amended, and all requirements imposed by or pursuant to the

Regulation of the Department of Health and Human Services (45 C.F.R. Part 84), to the end that, in accordance with Section 504 of

that Act and the Regulation, no otherwise qualified individual with a disability in the United States shall, solely by reason of her or

his disability, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or

activity for which the Applicant receives Federal financial assistance from the Department.

3. Title IX of the Education Amendments of 1972 (Pub. L. 92-318), as amended, and all requirements imposed by or pursuant to the

Regulation of the Department of Health and Human Services (45 C.F.R. Part 86), to the end that, in accordance with Title IX and the

Regulation, no person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of,

or be otherwise subjected to discrimination under any education program or activity for which the Applicant receives Federal

financial assistance from the Department.

4. The Age Discrimination Act of 1975 (Pub. L. 94-135), as amended, and all requirements imposed by or pursuant to the Regulation

of the Department of Health and Human Services (45 C.F.R. Part 91), to the end that, in accordance with the Act and the Regulation,

no person in the United States shall, on the basis of age, be denied the benefits of, be excluded from participation in, or be

subjected to discrimination under any program or activity for which the Applicant receives Federal financial assistance from the

Department.

5. Section 1557 of the Affordable Care Act (Pub. L. 111-148), as amended, and all requirements imposed by or pursuant to the

Regulation of the Department of Health and Human Services (45 CFR Part 92), to the end that, in accordance with Section 1557 and

the Regulation, no person in the United States shall, on the ground of race, color, national origin, sex, age, or disability be

excluded from participation in, be denied the benefits of, or be subjected to discrimination under any health program or activity

for which the Applicant receives Federal financial assistance from the Department.

The Applicant agrees that compliance with this assurance constitutes a condition of continued receipt of Federal financial assistance,

and that it is binding upon the Applicant, its successors, transferees and assignees for the period during which such assistance is 

provided. If any real property or structure thereon is provided or improved with the aid of Federal financial assistance extended to the 

Applicant by the Department, this assurance shall obligate the Applicant, or in the case of any transfer of such property, any transferee, 

for the period during which the real property or structure is used for a purpose for which the Federal financial assistance is extended 

or for another purpose involving the provision of similar services or benefits. If any personal property is so provided, this assurance 

shall obligate the Applicant for the period during which it retains ownership or possession of the property. The Applicant further 

recognizes and agrees that the United States shall have the right to seek judicial enforcement of this assurance.

The grantee, as the awardee organization, is legally and financially responsible for all aspects of this award including funds provided to 

sub-recipients in accordance with 45 CFR §§ 75.351-75.352, Subrecipient monitoring and management.
Footnotes:

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.

I also certify that the state or territory will comply with the Assurances Non-Construction Programs and Certifications summarized above. 

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.

Please upload your state’s Bipartisan Safer Communities Act (BSCA) – 2nd allotment proposal to here in addition to other documents. You may also 

upload it in the attachments section of this application.

Based on the guidance issued on October 11th, 2022, please submit a proposal that includes a narrative describing how the funds will be used to help 

individuals with SMI/SED, along with a budget for the total amount of the second allotment. The proposal should also explain any new projects planned 

with the second allotment and describe ongoing projects that will continue with the second allotment. The performance period for the second allotment 

is from September 30th, 2023, to September 29th, 2025, and the proposal should be titled "BSCA Funding Plan 2024. The proposed plans are due to 

SAMHSA by September 1, 2023.

OMB No. 0930-0168 Approved: 04/19/2021 Expires: 04/30/2024