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###### Department of Health and Human Services

###### Administration for Children and Families 

          - [Program Announcement No. FV02-2004] 

# AGENCY:

Family and Youth Services Bureau, Administration on Children, Youth and Families, (ACYF) and the Office of Community Services (OCS), Administration for Children and Families, Department of Health and Human Services. 

# ACTION:

Notice of the availability of funding to Native American Tribes, Alaskan Villages, and Tribal organizations for family violence prevention and services. 

# SUMMARY:

This announcement governs the proposed award of formula grants under the Family Violence Prevention and Services Act to Native American Tribes, Alaskan Villages, and Tribal organizations. The purpose of these grants is to assist Tribes in establishing, maintaining, and expanding programs and projects to prevent family violence and to provide immediate shelter and related assistance for victims of family violence and their dependents. 

                        This announcement sets forth the application requirements, the application process, and other administrative and fiscal requirements for grants in fiscal year (FY) 2004. *Grantees are to be mindful that although the expenditure period for grants is a two year period, an application is required every year to provide continuity in the provision of services. (                        *See*                         B. Expenditure Period).                     

# DATES:

Applications for FY 2004 Native American Tribes, Alaskan Villages, and Tribal Organizations grant awards meeting the criteria specified in this instruction should be received no later than February 21, 2003. 

# ADDRESSES:

Applications should be sent to Family and Youth Services Bureau, Administration on Children, Youth and Families, Administration for Children and Families, Attn: William Riley, 330 C Street, SW, Room 2117, Washington, DC 20447. 

# FOR FURTHER INFORMATION CONTACT:

                        William D. Riley at (202) 401-5529; or e-mail at                         *WRiley@acf.hhs.gov,*                         or Sunni Knight at (202) 401-5319 or e-mail at                         *GKnight@acf.hhs.gov.*

# SUPPLEMENTARY INFORMATION:

## Annual Native American and Alaskan Native Villages Grantee Conference 

The annual grantee conference is a training and technical assistance activity. Attendance at these activities is mandatory. Family Violence Prevention and Services Act (FVPSA) funds may be used to support attendance and participation. A subsequent Program Instruction will advise Tribal FVPSA administrators of the date, time, and location of their grantee conference. 

## Client Confidentiality 

FVPSA programs must establish or implement policies and protocols for maintaining the safety and confidentiality of the adult victims and their children of domestic violence, sexual assault, and stalking. It is essential that the confidentiality of individuals receiving FVPSA services be protected. Consequently, when providing statistical data on program activities, individual identifiers of client records will not be used (section 303(a)(2)(E)). 

## Stop Family Violence Postal Stamp 

The U.S. Postal Service was directed by the “Stamp Out Domestic Violence Act of 2001” (the Act), Pub. L. 107-67, to make available a “semipostal” stamp to provide funding for domestic violence programs. Funds raised in connection with sales of the stamp, less reasonable costs, will be transferred to the U.S. Department of Health and Human Services in accordance with the Act for support of services to children and youth affected by domestic violence. It is projected that initial revenues will be received during the third quarter of FY 2004. Subsequent to the receipt of the stamp proceeds, a program announcement will be issued providing guidance and information on the process and requirements for awards to programs providing services to children and youth. 

## The Importance of Coordination of Services 

The impact of family and intimate violence include physical injury and death of primary or secondary victims, psychological trauma, isolation from family and friends, harm to children witnessing or experiencing violence in homes in which the violence occurs, increased fear, reduced mobility and employability, homelessness, substance abuse, and a host of other health and related mental health consequences. 

                    The physical and cultural obstacles existing in much of Indian country compound the basic dynamics of domestic violence. Barriers such as the isolation of vast rural areas, the concern                           ( print page 5172)                        for safety in isolated settings, and the transportation requirements over long distances, heighten the need for the coordination of the services through an often limited delivery system.                 

It is estimated that between 12 percent and 35 percent of women visiting emergency rooms with injuries are there because of battery. In a project intended to broaden the reach of the Native American domestic violence community, the Indian Health Service (IHS) and FVPSA have collaborated to oversee the development of domestic violence community projects. These projects are designed to develop improved health care responses to domestic violence and to facilitate collaboration between the local health care system and local American Indian and Alaskan Native domestic violence advocacy programs. In this effort the IHS also is collaborating with representatives of Mending the Sacred Hoop, Cangleska, Inc., and the Family Violence Prevention Fund to provide training, technical assistance and oversight to the pilot projects. 

To help bring about a more effective response to the problem of domestic violence, the Department of Health and Human Services (HHS) urges Native American Tribes, Alaskan Native Villages, and Tribal organizations receiving funds under this grant announcement to coordinate activities under this grant with other new and existing resources for the prevention of family and intimate violence. 

## Programmatic and Funding Information 

### A. Background 

                    Title III of the Child Abuse Amendments of 1984 (Pub. L. 98-457, 42 U.S.C. 10401*et seq.*) is entitled the “Family Violence Prevention and Services Act” (the Act). The Act was first implemented in FY 1986, reauthorized and amended in 1992 by Pub. L. 102-295, in 1994 by Pub. L. 103-322, the Violent Crime Control and Law Enforcement Act, in 1996 by Pub. L. 104-235, the Child Abuse Prevention and Treatment Act (CAPTA) of 1996, and in 2000 by the “Victims of Trafficking and Violence Protection Act” (Pub. L. 106-386, 10/28/2000). The Act was most recently amended by the Keeping Children and Families Safe Act of 2003, Pub. L. 108-36.                 

The purpose of this legislation is to assist States and Native American Tribes, Alaskan Villages and Tribal organizations in supporting the establishment, maintenance, and expansion of programs and projects to prevent incidents of family violence and to provide immediate shelter and related assistance for victims of family violence and their dependents. 

During FY 2003, 227 grants were made to States and Native American Tribes. The Department also made 53 family violence prevention grant awards to nonprofit State domestic violence coalitions. 

In addition, the Department supports the Domestic Violence Resource Center Network (DVRN). The DVRN consist of the National Resource Center for Domestic Violence (NRC) and four Special Issue Resource Centers (SIRCs). The SIRCs are the Battered Women's Justice Project; the Resource Center on Child Custody and Protection, the Resource Center for the Elimination of Domestic Violence Against Native Women (Sacred Circle), and the Health Resource Center on Domestic Violence. The purpose of the NRC and the SIRCs is to provide resource information, training, and technical assistance to Federal, State, and Native American agencies, local domestic violence prevention programs, and other professionals who provide services to victims of domestic violence. 

In February, 1996, the Department funded the National Domestic Violence Hotline to ensure that every woman has access to information and emergency assistance wherever and whenever she needs it. The NDVH is a 24-hour, toll-free service which provides crisis assistance, counseling, and local shelter referrals to women across the country. Hotline counselors also are available for non-English speaking persons and for people who are hearing-impaired. The hotline number is 1-800-799-SAFE; the TDY number for the hearing impaired is 1-800-787-3224. As of August 31, 2003 the National Domestic Violence Hotline had answered over 1 million calls. 

### B. Funds Available 

Of the total appropriation for the Family Violence Prevention and Services Program for FY 2004, the Department of Health and Human Services will allocate 70 percent to the designated State agencies administering Family Violence Prevention and Services programs. In this separate announcement the Department will allocate 10 percent to the Tribes, Alaskan Villages and Tribal organizations for the establishment and operation of shelters, safe houses, and the provision of related services. Additionally, in a subsequent announcement, 10 percent will be allocated to the State Domestic Violence Coalitions to continue their work within the domestic violence community by providing technical assistance and training, and advocacy services among other activities with local domestic violence programs, and to encourage appropriate responses to domestic violence within the States. 

Five percent of the FVPSA FY 2004 appropriation will be available to continue the support for the National Resource Center and the four Special Issue Resource Centers. The remaining 5 percent of the FY 2004 family violence prevention and services funding will be used to support training and technical assistance, collaborative projects with advocacy organizations and service providers, data collection efforts, public education activities, research and other demonstration activities at the national level through the competitive or discretionary grant process. 

### C. Native American Tribal Allocations 

The Secretary is required to make 10 percent of amounts appropriated under section 310(a) for grants to Native American Tribes. Native American Tribes and Tribal organizations are eligible for funding under this program if they meet the definition of such entities as found in the Indian Self-Determination and Education Assistance Act, 25 U.S.C. 450, and are able to demonstrate their capacity to carry out a family violence prevention and services program. 

Any Native American Tribe that believes it meets the eligibility criteria should provide supportive documentation in its application and a request for inclusion on the list of eligible tribes. (See Native American Tribal Application Requirements.) 

In computing Native American Tribal allocations, we will use the latest available population figures from the Census Bureau. Where Census Bureau data are unavailable, we will use figures from the BIA Indian Population and Labor Force Report. 

Because section 304 of the Act specifies a minimum base amount for State allocations, we have set a base amount for Native American Tribal allocations. Since FY 1986, we have found, in practice, that the establishment of a base amount has facilitated our efforts to make a fair and equitable distribution of limited grant funds. 

                    Due to the expanded interest in the prevention of family violence and in the provision of services to victims of family violence and their dependents, we have received an increasing number of tribal applications over the past several years. In order to ensure the continuance of an equitable distribution of family violence prevention and services funding in response to the                           ( print page 5173)                        increased number of tribes that apply, we have adjusted the funding formula for the allocation of family violence funds.                 

Native American Tribes which meet the application requirements and whose reservation and surrounding Tribal Trust Lands population is: 
    - Less than or equal to 1,500 will receive a minimum base amount of $1,500;
    - Greater than 1,500 but less than 3,001 will receive a minimum base amount of $3,000;
    - Between 3,001 and 4,000 will receive a minimum base amount of $4,000; and
    - Between 4,001 and 5,000 will receive a minimum base amount of $5,000.

The minimum base amounts are in relation to the Tribe's population and the progression of an additional $1,000 per 1,000 persons in the population range continues until the Tribe's population is 50,000. 

Tribes with a population of 50,000 to 100, 000 will receive a minimum of $50,000, and Tribes with a population of 100,001 to 150,000 will receive a minimum of $100,000. 

Once the base amounts have been distributed to the Tribes that have applied for family violence funding, the ratio of the Tribe's population to the total population of all the applicant Tribes is then considered in allocating the remainder of the funds. With the distribution of a proportional amount plus a base amount to the Tribes we have accounted for the variance in actual population and scope of the family violence programs. Under the previous allocation plan we did not have a method by which to consider the variance in tribal census counts. As in previous years, Tribes are encouraged to apply as consortia for the family violence funding. 

## General Grant Requirements for Native American Tribes 

### A. Definitions 

Native American Tribes should use the following definitions in carrying out their programs. The definitions are found in section 320 of the Act. 

(1) Family Violence: Any act or threatened act of violence, including any forceful detention of an individual, which (a) results or threatens to result in physical injury and (b) is committed by a person against another individual (including an elderly person) to whom such person is or was related by blood or marriage or otherwise legally related or with whom such person is or was lawfully residing. 

(2) Indian Tribe and Tribal organization: Have the same meanings given such terms in subsections (b) and (c), respectively, of section 4 of the Indian Self-Determination and Education Assistance Act. 

(3) Shelter: The provision of temporary refuge and related assistance in compliance with applicable State law and regulation governing the provision, on a regular basis, which includes shelter, safe homes, meals, and related assistance to victims of family violence and their dependents. 

(4) Related assistance: The provision of direct assistance to victims of family violence and their dependents for the purpose of preventing further violence, helping such victims to gain access to civil and criminal courts and other community services, facilitating the efforts of such victims to make decisions concerning their lives in the interest of safety, and assisting such victims in healing from the effects of the violence. Related assistance includes: 

(a) Prevention services such as outreach and prevention services for victims and their children, assistance to children who witness domestic violence, employment training, parenting and other educational services for victims and their children, preventive health services within domestic violence programs (including services promoting nutrition, disease prevention, exercise, and prevention of substance abuse), domestic violence prevention programs for school age children, family violence public awareness campaigns, and violence prevention counseling services to abusers; 

(b) Counseling with respect to family violence, counseling or other supportive services by peers individually or in groups, and referral to community social services; 

(c) Transportation, technical assistance with respect to obtaining financial assistance under Federal and State programs, and referrals for appropriate health-care services (including alcohol and drug abuse treatment), but shall not include reimbursement for any health-care services; 

(d) Legal advocacy to provide victims with information and assistance through the civil and criminal courts, and legal assistance; or 

(e) Children's counseling and support services, and child care services for children who are victims of family violence or the dependents of such victims, and children who witness domestic violence. 

### B. Expenditure Periods 

                    The FVPSA funds may be used for expenditures on and after October 1 of each fiscal year for which they are granted, and will be available for expenditure through September 30 of the following fiscal year,                     *i.e.*, FY 2004 funds may be used for expenditures from October 1, 2003 through September 30, 2005. Funds will be available for obligation through October 1, 2004.                 

Reallotted funds, if any, are available for expenditure until the end of the fiscal year following the fiscal year that the funds became available for reallotment. FY 2004 grant funds which are made available to Tribes and Tribal Organizations through reallotment, under section 304(d)(2), must be expended by the grantee no later than September 30, 2005. 

### C. Reporting Requirements 

Section 303(a)(4) requires that a performance report be filed with the Department describing the activities carried out, and including an assessment of the effectiveness of those activities in achieving the purposes of the grant. A section of this performance report must be completed by each grantee or sub grantee that performed the direct services contemplated in the application certifying performance of such services. Consortia grantees should compile performance reports into a comprehensive report for submission. 

Please note that section 303(a)(4) of the FVPS Act also requires that the director of the FVPS program suspend funding for an approved application if an applicant fails to submit an annual Performance Report. The Performance Report should include the following data elements: 

Funding—The total amount of the FVPSA grant funds awarded; the percentage of funding used for shelters, and the percentage of funding used for related services and assistance. 

Shelters—The number of shelters and shelter programs (safe homes/motels, etc.) assisted by FVPSA program funding. Data elements should include: 
    - The number of shelters.
    - The number of women sheltered.
    - The number of young children sheltered (birth-12 years of age).
    - The number of teenagers and young adults (13-17 years of age).
    - The number of men sheltered.
    - The number of the elderly serviced.
    - The average length of stay.
    - The number of women, children, teens, and other who were turned away because shelter was unavailable.       ( print page 5174)      
    - The number of women, children, teens, and others were referred to other shelters due to lack of space.

Types of individuals served including special populations. Record information by numbers and percentages against the total population served. Individuals and special populations served should include: 
    - The elderly.
    - Individuals with physical challenges.
    - And other special needs populations.

Related services and assistance. List the types of related services and assistance provided to victims and their family members by indicating the number of women, children, and men that have received services. Services and assistance may include but are not limited to the following: 
    - Individual counseling.
    - Services to Children.
    - Crisis intervention/hotline.
    - Information and referral.
    - Batterers support services.
    - Legal advocacy services.
    - Transportation.
    - Services to teenagers.
    - Child Care.
    - Training and technical assistance.
    - Housing advocacy.
    - Other innovative program activities.

Volunteers—List the total number of volunteers and hours worked. 

Identified Abuse—Indicate (if available) the number of women, children, and men who were identified as victims of physical, sexual, and/or emotional abuse. 

Service referrals—List the number of women, children, and men referred for the following services: (Note: If the individual was identified as a batterer please indicate.) 
    - Physical abuse.
    - Alcohol abuse.
    - Drug abuse.
    - Batterer intervention services.
    - Child abuse.
    - Witnessed abuse.
    - Emergency medical intervention.
    - Law enforcement intervention.

The performance report should include narratives of success stories about services provided and the positive impact on the lives of children and families. Examples may include the following: 
    - An explanation of the activities carried out including an assessment of the major activities supported by the family violence funds, what particular priorities within the Tribe or Tribal organization were addressed, and what special emphases were placed on these activities;
    - A description of the specific services and facilities that your program funded, contracted with, or otherwise used in the implementation of your program, e.g. , shelters, safe houses, related assistance, programs for batterers;                 
    - An assessment of the effectiveness of the direct service activities contemplated in the application;
    - A description of how the needs of under-served populations, including those persons geographically isolated were addressed; and
    - A description and assessment of the prevention activities supported during the program year, e.g. , community education events, and public awareness efforts.                 

Performance reports for the Tribes, Alaskan Native Villages and Tribal organizations are due on an annual basis on December 30 of each year. 

### D. Departmental Grants Management Reports 

                    All grantees are reminded that the annual Program Reports and annual Financial Status Reports (Standard Form 269) are due 90 days after the end of the expenditure period,                     *i.e.*, December 30 of each year.                 

## Application Requirements for Native American Tribes, Alaskan Native Villages and Tribal Organziations 

### A. Eligibility 

As described above, Native American Tribes, Tribal organizations, and Alaskan Native Villages are eligible for funding under this program if they meet the definition of such entities as found in subsections (b) and (c) of section 4 of the Indian Self-Determination and Education Assistance Act and are able to demonstrate their capacity to carry out a family violence prevention and services program. 

                    Any Native American Tribe or Tribal organization that believes it meets the eligibility criteria and should be included in the list of eligible tribes should provide supportive documentation and a request for inclusion in its application. (                    *See*                     Application Content Requirements below.)                 

As in previous years, Native American Tribes may apply singularly or as a consortium. In addition, a non-profit private organization, approved by a Native American Tribe for the operation of a family violence shelter or program on a reservation is eligible for funding. 

### B. Additional Information on Eligibility 

#### Approval/Disapproval of a Tribal, Alaskan Village, or Tribal Organization Application 

The Secretary will approve any application that meets the requirements of the Act and this Announcement, and will not disapprove an application unless the applicant organization has been given reasonable notice of the Department's intention to disapprove and an opportunity to correct any deficiencies (section 303(a)(3)). 

                    All applicants must have Dun and Bradstreet Number (DUNS). A DUNS number will be required for every application for a new award or renewal/continuation of an award under formula, entitlement and block grant programs. A DUNS number may be acquired at no cost by calling the dedicated toll-free DUNS number request line at 1-866-705-5711 or a number may be requested on-line at                     *http://www.dnb.com*.                 

                    Private, non-profit organizations are encouraged to submit with their applications the survey located under “Grant Related Documents and Forms” titled “Survey for Private, Non-Profit Grant Applicants.” The forms are located on the web at                     *http://www.acf.hhs.gov/​programs/​ofs/​forms.htm*.                 

### C. Application Content Requirements 

The application from the Native American Tribe, Tribal organization, or Alaskan Native Village must be signed by the Chief Executive Officer or Tribal Chairperson of the applicant organization. 

(1) The name of the organization or agency and the Chief Program Official designated as responsible for administering funds under the Act, and the name, telephone number, and fax number, if available, of a contact person in the designated organization or agency. 

(2) A copy of a current resolution stating that the designated organization or agency has the authority to submit an application on behalf of the Native American individuals in the Tribe(s) or Village(s) and to administer programs and activities funded under this program (section 303(b)(2)). 

                    (3) A description of the procedures designed to involve knowledgeable individuals and interested organizations in providing services under the Act (section 303(b)(2)). For example, knowledgeable individuals and interested organizations may include: Tribal officials or social services staff involved in child abuse or family violence prevention, Tribal law                           ( print page 5175)                        enforcement officials, representatives of State coalitions against domestic violence, and operators of family violence shelters and service programs.                 

(4) A description of the applicant's operation of and/or capacity to carry out a family violence prevention and services program. This might be demonstrated in ways such as the following: 

(a) The current operation of a shelter, safe house, or family violence prevention program; 

(b) The establishment of joint or collaborative service agreements with a local public agency or a private non-profit agency for the operation of family violence prevention activities or services; or 

(c) The operation of social services programs as evidenced by receipt of “638” contracts with the Bureau of Indian Affairs (BIA); Title II Indian Child Welfare grants from the BIA; Child Welfare Services grants under Title IV-B of the Social Security Act; or Family Preservation and Family Support grants under title IV-B of the Social Security Act. 

(5) A description of the services to be provided, how the applicant organization plans to use the grant funds to provide the direct services, to whom the services will be provided, and the expected results of the services. 

(6) Documentation of the procedures that assure the confidentiality of records pertaining to any individual provided family violence prevention or treatment services by any program assisted under the Act (section 303(a)(2)(E)). 

(7) The EIN number of the applicant organization submitting the application. 

D. Each application must contain the following assurances:

(a) That not less than 70 percent of the funds shall be used for immediate shelter and related assistance for victims of family violence and their dependents and not less than 25% of the funds distributed shall be used to provide related assistance (section 303(g)). 

(b) That grant funds made available under the Act will not be used as direct payment to any victim or dependent of a victim of family violence (section 303(d)). 

(c) That the address or location of any shelter or facility assisted under the Act will not be made public, except with the written authorization of the person or persons responsible for the operations of such shelter (section 303(a)(2)(E)). 

(d) That law or procedure has been implemented for the eviction of an abusing spouse from a shared household (section 303(a)(2)(F)). 

(e) That applicant will comply with the applicable Departmental recordkeeping and reporting requirements and general requirements for the administration of grants under 45 CFR part 92. 

                    Additional Forms: Private, non-profit organizations may submit with their applications the additional suvey located under “Grant Related Documents and Forms” titled “Survey for Private, Non-Profit Grant Applicants”                     *at http://www.acf.hhs.gov/​program/​ofs/​form.htm.*

## Other Information 

### A. Notification Under Executive Order 12372

The review and comment provisions of the Executive Order and Part 100 do not apply. Federally-recognized Native American Tribes are exempt from all provisions and requirements of E.O. 12372. 

### B. Paperwork Reduction Act 

In accordance with the Paperwork Reduction Act of 1980 (Pub. L. 96-511), the application requirements contained in this instruction have been approved by the Office of Management and Budget under control number 0970-0062. 

### C. Required Certifications 

All applications must submit or comply with the required certifications found at the Appendices as follows: 
    -  Anti-Lobbying Certification and Disclosure Form must be signed and submitted with the application:                      If applicable, a standard Form LLL, which discloses lobbying payments, must be submitted.                 
    -  Certification Regarding Drug-Free Workplace Requirements and the Certification Regarding Debarment:                      The signature on the application by the chief program official attests to the applicants intent to comply with the Drug-Free Workplace requirements and compliance with the Debarment Certification. The Drug-Free Workplace and certification does not have to be returned with the application.                 
    -  Certification Regarding Environmental Tobacco Smoke:                      The signature on the application by the chief program official attests to the applicants intent to comply with the requirements of the Pro-Children Act of 1994 (Act). The applicant further agrees that it will require the language of this certification be included in any sub-awards which contain provisions for children's services and that all grantees shall certify accordingly.                

(Catalog of Federal Domestic Assistance Number 93.671, Family Violence Prevention and Services)

Dated: January 29, 2004. 

Clarence Carter, 

Director, Office of Community Services, Administration for Children and Families. 

Appendices: Required Certifications: 

Anti-Lobbying and Disclosure;

Drug-Free Workplace;

Regarding Debarment; and 

Regarding Environmental Tobacco Smoke 

# Appendix A—Certification Regarding Lobbying 

## Certification for Contracts, Grants, Loans, and Cooperative Agreements 

The undersigned 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 an 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 Federal 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 Form to Report Lobbying,” in accordance with its instructions. 

(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, title 31, 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. 

## Statement for Loan Guarantees and Loan Insurance 

The undersigned states, to the best of his or her knowledge and belief, that: 

                        If any 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                               ( print page 5176)                            commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions. Submission of this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.                    

Signature

Title

Organization 

# Appendix B—Certification Regarding Debarment, Suspension and Other Responsibility Matters 

## Certification Regarding Debarment, Suspension, and Other Responsibility Matters—Primary Covered Transactions 

### Instructions for Certification 

1. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below. 

2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction. 

3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. 

4. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 

5. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations. 

6. The prospective primary participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency entering into this transaction. 

7. The prospective primary participant further agrees by submitting this proposal that it will include the clause titled “Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,” provided by the department or agency entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. 

8. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs. 

9. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 

10. Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. 

## Certification Regarding Debarment, Suspension, and Other Responsibility Matters—Primary Covered Transactions 

(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals: 

(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency; 

(b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; 

(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and 

(d) Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default. 

(2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. 

## Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion—Lower Tier Covered Transactions 

### Instructions for Certification 

1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below. 

2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. 

3. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or had become erroneous by reason of changed circumstances. 

4. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations. 

5. The prospective lower tier participant agrees by submitting this proposal that, [[Page 33043]] should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated. 

                        6. The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled “Certification Regarding Debarment,                               ( print page 5177)                            Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,” without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.                     

7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transactions, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs. 

8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 

9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. 

## Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion—Lower Tier Covered Transactions 

(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. 

(2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. 

# Appendix C—Certification Regarding Environmental Tobacco Smoke 

Public Law 103227, Part C Environmental Tobacco Smoke, also known as the Pro Children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor routinely owned or leased or contracted for by an entity and used routinely or regularly for provision of health, day care, 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 does not apply to children's services provided in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1000 per day and/or the imposition of an administrative compliance order on the responsible entity. By signing and submitting this application the applicant/grantee certifies that it will comply with the requirements of the Act. 

The applicant/grantee further agrees that it will require the language of this certification be included in any subawards which contain provisions for the children's services and that all subgrantees shall certify accordingly. 

# Appendix D—Certification Regarding Drug-Free Workplace Requirements 

This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988: 45 CFR part 76, subpart, F, sections 76.630(c) and (d)(2) and 76.645(a)(1) and (b) provide that a Federal agency may designate a central receipt point for STATE-WIDE AND STATE AGENCY-WIDE certifications, and for notification of criminal drug convictions. For the Department of Health and Human Services, the central pint is: Division of Grants Management and Oversight, Office of Management and Acquisition, Department of Health and Human Services, Room 517-D, 200 Independence Avenue, SW., Washington, DC 20201. 

## Certification Regarding Drug-Free Workplace Requirements (Instructions for Certification) 

1. By signing and/or submitting this application or grant agreement, the grantee is providing the certification set out below. 

2. The certification set out below is a material representation of fact upon which reliance is placed when the agency awards the grant. If it is later determined that the grantee knowingly rendered a false certification, or otherwise violates the requirements of the Drug-Free Workplace Act, the agency, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act. 

3. For grantees other than individuals, Alternate I applies. 

4. For grantees who are individuals, Alternate II applies. 

5. Workplaces under grants, for grantees other than individuals, need not be identified on the certification. If known, they may be identified in the grant application. If the grantee does not identify the workplaces at the time of application, or upon award, if there is no application, the grantee must keep the identity of the workplace(s) on file in its office and make the information available for Federal inspection. Failure to identify all known workplaces constitutes a violation of the grantee's drug-free workplace requirements. 

                        6. Workplace identifications must include the actual address of buildings (or parts of buildings) or other sites where work under the grant takes place. Categorical descriptions may be used (                        *e.g.*, all vehicles of a mass transit authority or State highway department while in operation, State employees in each local unemployment office, performers in concert halls or radio studios).                     

                        7. If the workplace identified to the agency changes during the performance of the grant, the grantee shall inform the agency of the change(s), if it previously identified the workplaces in question (                        *see*                         paragraph five).                     

8. Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common rule apply to this certification. Grantees' attention is called, in particular, to the following definitions from these rules: 

*Controlled substance*                         means a controlled substance in Schedules I through V of the Controlled Substances Act (21 U.S.C. 812) and as further defined by regulation (21 CFR 1308.11 through 1308.15);                     

*Conviction*                         means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or both, by any judicial body charged with the responsibility to determine violations of the Federal or State criminal drug statutes;                     

*Criminal drug statute*                         means a Federal or non-Federal criminal statute involving the manufacture, distribution, dispensing, use, or possession of any controlled substance;                     

*Employee*                         means the employee of a grantee directly engaged in the performance of work under a grant, including: (i) All direct charge employees; (ii) All indirect charge employees unless their impact or involvement is insignificant to the performance of the grant; and, (iii) Temporary personnel and consultants who are directly engaged in the performance of work under the grant and who are on the grantee's payroll. This definition does not include workers not on the payroll of the grantee (                        *e.g.*, volunteers, even if used to meet a matching requirement; consultants or independent contractors not on the grantee's payroll; or employees of subrecipients or subcontractors in covered workplaces).                     

## Certification Regarding Drug-Free Workplace Requirements 

### Alternate I. (Grantees Other Than Individuals) 

The grantee certifies that it will or will continue to provide a drug-free workplace by: 

(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 workplace 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;                               ( print page 5178)    

(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); 

(d) Notifying the employee in the statement required by paragraph (a) 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). 

(B) The grantee may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant: 

Place of Performance (Street address, city, county, state, zip code) 

Check if there are workplaces on file that are not identified here. 

### Alternate II. (Grantees Who Are Individuals) 

(a) The grantee certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant; 

(b) If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant activity, he or she will report the conviction, in writing, within 10 calendar days of the conviction, to every grant officer or other designee, unless the Federal agency designates a central point for the receipt of such notices. When notice is made to such a central point, it shall include the identification number(s) of each affected grant. 

[FR Doc. 04-2174 Filed 2-2-04; 8:45 am] 

BILLING CODE 4184-01-P