SAMPLE

Notice of Award 

SAMPLE-PROGRAM Issue Date: 09/10/2016 

Department of Health and Human Services 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

Grant Number: 1H80T5012345-01 

FAIN: T5012345 

Program Director: Jane Doe 

Project Title: THIS IS A SAMPLE PROJECT TITLE (TISPT) 

Grantee Address 

RECOVERY HEALTH CENTER 

President & Chief Executive Officer 

100 Healthy Living Way 

Bran, MT 12345 

Business Address 

RECOVERY HEALTH CENTER 

President & CEO 

100 Healthy Living Way 

Bran, MT 12345 

Budget Period: 09/30/2016 – 09/29/2017 

Project Period: 09/30/2016 – 09/29/2019 

Dear Grantee: 

The Substance Abuse and Mental Health Services Administration hereby awards a grant in the amount of 

$250,000 (see “Award Calculation” in Section I and “Terms and Conditions” in Section III) to 

Recovery Health Center in support of the above referenced project. This award is pursuant to the 

authority of Section --- of the Public Health Service Act, as amended and is subject to the requirements of 

this statute and regulation and of other referenced, incorporated or attached terms and conditions. 

Award recipients may access the SAMHSA website at www.samhsa.gov (click on “Grants” then SAMHSA 

Grants Management), which provides information relating to the Division of Payment Management 

System, HHS Division of Cost Allocation and Postaward Administration Requirements. Please use your 

grant number for reference. 

Acceptance of this award including the “Terms and Conditions” is acknowledged by the grantee when 

funds are drawn down or otherwise obtained from the grant payment system. 

If you have any questions about this award, please contact your Grants Management Specialist and your 

Government Project Officer listed in your terms and conditions. 

Sincerely yours, 

/insert name/ 

Grants Management Officer 

Division of Grants Management 

See additional information below 

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SECTION I – AWARD DATA – 1H80T5012345-01 

Award Calculation (U.S. Dollars)

Salaries and Wages 

Fringe Benefits 

Personnel Costs (Subtotal) 

Supplies 

Travel Costs 

$100,550 

$27,099 

$127,649 

$3,350 

$9,402 

Other $86,872 

Direct Cost $227,273 

Indirect Cost $22,727 

Approved Budget 

Federal Share 

$250,000 

$250,000 

Cumulative Prior Awards for this Budget Period $0 

AMOUNT OF THIS ACTION (FEDERAL SHARE) $250,000 

SUMMARY TOTALS FOR ALL YEARS 

YR AMOUNT 

1 $250,000 

2 $250,000 

3 $250,000 

*Recommended future year total cost support, subject to the availability of funds and satisfactory

progress of the project. 

Fiscal Information: 

CFDA Number: 

EIN: 

Document Number: 

Fiscal Year: 

93.243 

0123456789Z1 

12T534567A 

2016 

IC 

T5 

CAN 

C00N000 

Amount 

$250,000 

IC CAN 2016 2017 2018 

T5 C00N000 $250,000 $250,000 $250,000 

TI Administrative Data: 

PCC: TCE-PTP / OC: 4145 

SECTION II – PAYMENT/HOTLINE INFORMATION – 1H80T5012345-01 

Payments under this award will be made available through the HHS Payment Management 

System (PMS). PMS is a centralized grants payment and cash management system, operated by 

the HHS Program Support Center (PSC), Division of Payment Management (DPM). Inquiries 

regarding payment should be directed to: The Division of Payment Management System, PO 

Box 6021, Rockville, MD 20852, Help Desk Support – Telephone Number: 1-800-000-0000. 

The HHS Inspector General maintains a toll-free hotline for receiving information concerning 

fraud, waste, or abuse under grants and cooperative agreements. The telephone number is: 1-

800-HHS-TIPS (1-800-447-8477). The mailing address is: Office of Inspector General, 

Department of Health and Human Services, Attn: HOTLINE, 330 Independence Ave., SW, 

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Washington, DC 20201.
	

SECTION III – TERMS AND CONDITIONS – 1H80T5012345-01 

This award is based on the application submitted to, and as approved by, SAMHSA on the 

above-title project and is subject to the terms and conditions incorporated either directly or by 

reference in the following: 

a. The grant program legislation and program regulation cited in this Notice of Award.

b. The restrictions on the expenditure of federal funds in appropriations acts to the extent

those restrictions are pertinent to the award.

c. 45 CFR Part 75 as applicable.

d. The HHS Grants Policy Statement.

e. This award notice, INCLUDING THE TERMS AND CONDITIONS CITED BELOW.

Treatment of Program Income: 

Additional Costs 

In accordance with the regulatory requirements provided at 45 CFR 75.113 and Appendix XII to 

45 CFR Part 75, recipients that have currently active Federal grants, cooperative agreements, 

and procurement contracts with cumulative total value greater than $10,000,000 must report and 

maintain information in the System for Award Management (SAM) about civil, criminal, and 

administrative proceedings in connection with the award or performance of a Federal award that 

reached final disposition within the most recent five-year period. The recipient must also make 

semiannual disclosures regarding such proceedings. Proceedings information will be made 

publicly available in the designated integrity and performance system (currently the Federal 

Awardee Performance and Integrity Information System (FAPIIS)). Full reporting requirements 

and procedures are found in Appendix XII to 45 CFR Part 75. 

SECTION IV – TI Special Terms and Conditions – 1H80T5012345-01 

REMARKS: 

1) As a reminder all SAMHSA official notifications will be electronically mailed to your

organization's Business Official addressasidentified in the HHS Checklist, Part C.
	

2) This award reflects approval of the revised budget submitted on May 31, 2016, by your

authorized representative in response to the application request.
	

SPECIAL TERMS OF AWARD: 

Disparity Impact Statement (DIS): 

By November 30, 2016 you must: 

Submit an electronic copy of a disparity impact statement to the Government Project Officer 

(GPO) and Grants Management Specialist (GMS) as identified under Contacts on this notice of 

award. The disparity impact statement should be consistent with information in your application 

regarding access, *service use and outcomes for the program and include three components as 

described below. Questions about the disparity impact statement should be directed to your 

GPO. Examples of disparity impact statements can be found on the SAMHSA website at 

http://www.samhsa.gov/grants/grants-management/disparity-impact-statement. 

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*Service use is inclusive of treatment services, prevention services as well as outreach,

engagement, training, and/or technical assistance activities.
	

The disparity impact statement, in response to the Special Term of Award, consists of three 

components:
	

1. Proposed number of individuals to be served by subpopulations in the grant

implementation area should be provided in a table that covers the entire grant period. The

disparate population(s) should be identified in a narrative that includes a description of the

population and rationale for how the determination was made.

2. A quality improvement plan for how you will use your program (GPRA) data on access,

use and outcomes to monitor and manage program outcomes by race, ethnicity and

LGBT status, when possible. The quality improvement plan should include strategies for

how processes and/or programmatic adjustments will support efforts to reduce disparities

for the identified sub-populations.

3. The quality improvement plan should include methods for the development and

implementation of policies and procedures to ensure adherence to the Enhanced

Culturally and Linguistically Appropriate Services (CLAS) Standards and the provision of

effective care and services that are responsive to:

1. Diverse cultural health beliefs and practices;

2. Preferred languages; and

3. Health literacy and other communication needs of all sub-populations within the

proposed geographic region.

DOMA: 

On June 26, 2013, in United States v. Windsor, the Supreme Court held that section 3 of the 

Defense of Marriage Act (DOMA), which prohibited federal recognition of same-sex 

spouses/marriages, was unconstitutional. As a result of that decision, SAMHSA is no longer 

prohibited from recognizing same sex marriages. Consistent with HHS policy and the purposes of 

SAMHSA programs, same-sex spouses/marriages are to be recognized in the SAMHSA Targeted 

Capacity Expansion-Peer-to-Peer (TCE-PTP). This means that, as a recipient of SAMHSA TCEPTP funds you are required to treat as valid the marriages of same-sex couples whose marriage 

was legal when entered into. This applies regardless of whether the couple now lives in a 

jurisdiction that recognizes same-sex marriage or a jurisdiction that does not recognize same-sex 

marriage. Any same-sex marriage legally entered into in one of the 50 states, the District of 

Columbia, a U.S. territory or a foreign country will be recognized. However, this does not apply to 

registered domestic partnerships, civil unions or similar formal relationships recognized under 

state law as something other than a marriage. 

STANDARD TERMS OF AWARD: 

Refer to the following SAMHSA website for Standard Terms of Award: 

http://www.samhsa.gov/grants/grants-management/notice-award-noa/standard-terms-conditions 

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REPORTING REQUIREMENTS: 

Submission of a Programmatic Quarterly Report is due no later than the dates as follows: 

1st Report - January 31, 2017 

2nd Report - April 30, 2017 

3rd Report - July 31, 2017 

4th Report - October 31, 2017 

Please submit your Programmatic Quarterly Report to 

DGMProgressReports@samhsa.hhs.gov and copy your Program Official. (HARD COPIES 

SUBMISSION IS NOT REQUIRED) 

Failure to comply with the above stated terms and conditions may result in suspension, 

classification as High Risk status, termination of this award or denial of funding in the 

future. 

All responses to special terms and conditions of award and post award requests may be 

electronically mailed to the Grants Management Specialist and to the Program Official as identified 

on your Notice of Award. 

It is essential that the Grant Number be included in the SUBJECT line of the email. 

CONTACTS:

James Doe, Program Official 

Phone: 240-276-0001 Email: jamesdoe@samhsa.hhs.gov 

John Doe, Grants Specialist 

Phone: (240) 276-0000 Email: johndo@samhsa.hhs.gov Fax: (240) 276-1430 

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