### SOCIAL	INNOV **AT ION	FUND	(SIF)**  **PA**

**Y	FOR	SUCCESS	PILOT PROGRAM**  **APPLICA TION	INSTR** **UCTIONS OMB Contr**  **ol #: 3045**  **- 0160**  **Expiration Date: 12/31/2014** 2



## IMPORTANT	NOTICE These	application	instructions	conform	to	the	Corporation	for	National	and	Community	Service’s	online	grant application	system, eGrants .	All	funding	announcements	by	the	Corporation	for	National and	Community Service	(CNCS)	are	posted	on www .nationalservice.gov and www .grants.gov . **Public	Burden	Statement:** Public	reporting	burden	for	this	collection	of	information	is	estimated	to	average 30 hours	per	submission,	including	reviewing	instructions,	gathering	and	maintaining	the	data	needed,	and completing	the	form.	Comments	on	the	burden	or	content	of	this	ins trument	may	be	sent	to	the	Corporation for	National	and	Community	Service,	Attn:	Am y	Borgstrom,	1201	New	Y ork	A ve nue,	NW

,	W ashington,	D.C. 20525.	CNCS	informs	people	who	may	respond	to	this	collection	of	information	that	they	are	not	required	to respond	to the	collection	of	information	unless	the	OMB	control	number	and	expiration	date	displayed	on page	one	are	current	and	valid.	(See	5	C.F .R.	§	1320.5(b)(2)(i).) **Privacy	Act	Notice:** The	Privacy	Act	of	1974	(5	U.S.C	§	552a)	requires	that	the	following	notic e	be	provided	to you:	The	information	requested	on	the	Social	Innovation	Fund	P ayfor	Success	Application	Instructions	is collected	pursuant	to	42	U.S.C.	§§	12581 b
- 12585	of	the	National	and	Community	Service	Act	of	1990	as amended, and	42	U.S.C.	12639 .	P urposes	and	Uses
- The	information	requested	is	collected	for	the	purposes	of reviewing	grant	applications	and	granting	funding	requests.	Routine	Uses
- Routine	uses	may	include disclosure	of	the	information	to	federal,	state,	or	local	agencies	pursuant	to lawfully	authorized	requests.	In some	programs,	the	information	may	also	be	provided	to	federal,	state,	and	local	law	enforcement	agencies	to determine	the	existence	of	an y	prior	criminal	con victions.	The	information	may	also	be	provided	to appropriate	fe deral	agencies	and	Department	contractors	that	have	a	need	to	know	the	information	for	the purpose	of	assisting	the	Department’s	efforts	to	respond	to	a	suspected	or	confirmed	breach	of	the	security	or confidentiality	or	information	maintained	in	this	syst em	of	records,	and	the	information	disclosed	is	relevant and	unnecessary	for	the	assistance.	Executi ve	Summaries	of	all	compliant	applications	recei ved	and applications	of	successful	applicants	will	be	published	on	the	CNCS	website	as	part	of	ongoing	effor ts	to increase	transparency	in	grantmaking.	This	is	described	in	more	detail	in	the Notice	of	Federal	Funding Av ailabilit

y/Opportunity

. The	information	will	not	otherwise	be	disclosed	to	entities	outside	of	the	Social Innovation	Fund	and	CNCS	without	prior written	permission.	Effects	of	Nondisclosure
- The	information requested	is	mandatory	in	order	to	recei ve	benefits. **Fe deral	Funding	Accountability	and	T**  **ransparency	Act:** Grant	recipients	will	be	required	to	report	at www .FSRS.gov on	all	subawards	over	$25,000	and	may	be	required	to	report	on	ex ecuti ve compensation	for recipients	and	subrecipients.	Recipients	must	have	the	necessary	systems	in	place	to	collect	and	report	this information. See 2	C.F

.R.	P art	170	for	more	information	and	to	determine	how	these	requirements	apply
. **Universal	Identifier:** Applications	must	include	a	Dun	and	Bradstreet	Data	Universal	Numbering	S ystem (DUNS)	number	and	register	with	the	Central	Contractor’s	Registry (CCR). All	grant	recipients	are	required	to maintain	a	valid	registration,	which	must	be	renewed	annually
.3 

## APPLICA **TION	RESOUR CES**  Use	these	instructions	in	conjunction	with	the Social	Innov ation	Fund Pay	for	Success Gr ants	Competition	(PFS	Competition) Notice	of	Federal Funding	A vailability ( Notice )
. **The Notice**  **includes	deadlines,	eligibility	requirements,	submission	requirements, funding	priorities	and	other	rele**  **va nt	information	that	might	change	annuall**  **y.** Other	resources	for	completing	y our application	includ ing technical	assistance	conference calls	and how	to submit	inquiries can	be	accessed	from	the Social	Innov ation	Fund	( SIF ) webpage	on	the	CNCS	website ( http:/ /www .nationalservice.gov/progr ams/social
innov ation - fund )
. 

## CREA **TING	AN	EGRANTS	USER OR	OR**  **GANIZA TION**  **ACCOUNT** First - time	eGrants users need	to create an	eGrants	account	by	accessing	this	link: https://egrants.cns.gov/espan/main/login.jsp and	selecting **Don’t	have	an	eGrants account?	Create	an	account.**  If	y ou	need	help	establishing	a	new	organization	account	or	a	new	user	account	for	an existing	organization	account, or	with	other	aspects	of	eGr ants, contact	the	National	Service Hotline	at	800
- 942
- 2677 or	via:	https://questions.nationalservice.gov/app/ask
. **If	y ou	are	appl**  **ying	for	continuation	funding	( for	y** **ears	2	and	be yo**  **nd )	of	an	e**  **xisting SIF	gr**  **ant,	please	skip	to	the	‘REQUESTING	C ONTINU**  **AT ION**  **FUNDING’	Section of	this**  **document .**  

## NEW	APPLICA **TIONS** To	initiate	an	application :  Start	a	n ew g rant a pplication:	Select **New** under	the **Creating	an	Application** heading on	your	Home	Page  Select	a	Program	Area : **Other**  Select	a NOFA : Social	Innovation	Fund	Pay	for	Success Grants	Competition [ Applicable year	of	funding] Once	y ou	have	initiated	an	application,	it	will	be	listed	in	the **View	My	Grants/Applications** section	of yo ur homepage.		If	y ou	exit	and	then	return	to	eGr ants and	wish	to	continue entering	or	editing	y our	application,	please	open	y our	saved	version	by	selecting **View	My Grants/Applications** 
. Yo u	should	not use	the **New** button	again	as	this	will	start	a	br and new	application. 

## APPLICA **TION	C ONTENT**  Your	application	consists	of	the	following section s . Please complete	each	section. I. Applicant	Info4



### II. Application	Info III. Narratives IV. Performance	Measures

– if	required	in	the Notice V. Documents VI. Budget VII. Review,	Authorize,	and	Submit Information	entered	in	the Applicant	Info ,	Application	Info,	and	Budget	sections	will populate	the	SF	424	Face sheet of	your	application
. 

### I. **Applicant	Info**

 Under **Project	Information** select **Enter	New** , create a	title	for	the	proposed	project, and	enter the	contact	information
.  **Select	a	Project	Initiative** :		Choose	the	oper ational	model	which	best	describes	y our PFS	Competition application .		Please	see	the Notice for	details.  S elect	an	individual	as	the **Project	Director** , by choos ing a	name	from	the	pull
- down menu	or	add ing a	new	c ontact. Please	note	that	the **Au thorized	R**  **epresentative** will	be	filled	in	at	the	end	of	the application	when	completing the	Assur ances and	Certifications section .	(Attachment	A) 

### II. **Application	Info Complete	this	section	as	follows:**   **Areas	affected	by	the project**  :		List	onl y	the	largest	political	or	municipal	entities affected	(e.g.,	counties	and	cities). Please	include	the	two
- letter	abbreviation	with	both letters	capitalized	for	each	state	where	y ou	plan	to	oper ate.	Separ ate	each	two
- letter state	abbr eviation	with	a	comma.	F or	city	or	county	information,	please	follow	each	one with	the	two
- letter	capita lized	state	abbreviation.  **Proposed	project	start	and	end	dates**
. Please	see	the Notice for	details about	the project	period	to	select
.  **Intergovernmental	Review	of	F ederal	Programs:**  Enter ‘No.’ This program	is	NOT subject	to	Ex ecutiv e	Or der	12372.  **Delinque nt	on	any	federal	debt:**  Check	the	appropriate	box.		This	question	applies	to the	applicant	organization,	not	the	person	who	signs	as	the	authorized	representativ e. Categories	of	debt	include	delinquent	audit	allow ances,	loans,	and	tax es.		If ‘Ye s ’ ,	type yo ur	explanation	in	the	text	box	provided.  **Sta te	Application	Identifier**  :		Enter	N/A. **Note:** Fa lsification	or	concealment	of	a	material	fact	or	submission	of	false,	fictitious , or fr audulent	statements	or	representations	to	any	department	or	agency	of	the	United	States Government	may	result	in	a	fine	or	imprisonment	for	not	more	than	fiv e	(5)	y ears,	or	both. (18	USC	§	1001).5 

### III. **Narrativ es**  **Pa ge	Limit**  **and	F ormatting**   It	is	important	that	y ou	preview	the	eGr ants PDF of	y our	application	to	ensure	that	y ou don ’t	ex ceed	the	page	limit of	40	pages as	prescribed	in	the Notice .		R eviewers	will stop reading	y our	application	when	they	reach	the	page	limit.  Also,	p lease	note	that	bold	face,	bullets,	underlines, charts,	diagr ams,	and	tables or	other types	of formatting will	not	copy	into	eGr ants. **The	Notice	provides	guidance	on	how	to submit**  **each	section	of	the	application narrative.**  **A. Ex**  **ecuti ve**  **Summary** Please	note that	ex ecuti ve summaries	for	all	applications	will	be	made	public	and posted	to	CNCS’	website. **B. Program	Design**  **C. Organizational	Capa**  **bilit y**  **D. Leadership	and	Team**  **E. Cost	Effecti** **ve ness	and	Budget	Adequacy**  **The	following	three	sections are	not	relevant	to**  **this	application.	Please	enter	N/A	for not	applicable	under	these	narrative	sections.**  **F. Amendment	Justification**  Enter	N/A.	This	field is	used	when	requesting	an	amendment	to	an	awarded	grant
. **G. Clarification	Information**  Enter	N/A.	This	field is used	to enter	information	that	requires	clarification	in	the	post
review	period. **H. Continuation	Changes**  Enter	N/A.	This	field is used	to	enter information	for yo ur	continuation	requests. 

### IV. **Pe rformance	Measur**  **es If**  **Performance Measures**  **are required**  **in the**  **Notice ,**  **follow the**  **instructions in**  **Attachment	B .**  

### V. **Documents** In	addition	to	the	application	submitted	in	eGr ants,	y ou	are	required	to	provide6



### documentation	of	match	as	described	in	section **Submitting	Match	V erification**  section	of the Notice
. After yo u	have	submitted all	required	documentation ,	change	the	status	in eGr ants	from	the	default	“Not	Sent”	to	the	applicable	status	“Sent
. ” 

### VI. **Budget A.**  **Budget	R equirements**  Applicants	must	submit	a	proposed	budget for	each	of	the	three	y ears	of	the	project period that	includes	both	feder al	and	match	funding.		If	an	application	is	selected	for award,	CNCS	will	determine	the	final	amount	of	the	aw ard	of	feder al	funds,	and	will negotiate	a	final	budget.		Upon	aw ard,	co mpliance	with	the	approv ed	budget	will	be	a material	term	and	condition	of	the	cooper ative	agreement	with	the grantee . Yo ur	proposed	budget	should	be	sufficient	to	allow	y ou	to	perform	the	tasks	described in	y our	narr ative fo r	each	y ear	of	the	project and provide	a	full	explanation	of	costs including	their	purpose,	justification,	and	the	basis	of	y our	calculations. Reviewers	will consider	the	information	y ou	provide	in yo ur	budget as	part	of their	assessment	of	the Cost Effectiv eness	and	Budget	Adequacy c riteria
. In	eGr ants,	the	prepar ation	of	a	detailed	budget	provides	the	data	that	creates	the summary	budget	and	the	budget	narr ative.		The d etailed	budget	should	provide	a	full explanation	of	associated	costs	including	their	purpose,	justification,	and the	basis	of the	calculations. eGr ants	will	perform	a	limited	compliance	check	to	v alidate	the	budget. If	it	finds	any	compliance	issues	y ou	will	receiv e	a	w arning	and/or	error	messages.	Y ou must	resolv e	all	errors	before	y ou	can	submit	y our	budget. As	yo u	prepare	your	budget:  Divide	project	costs	by	year	and	submit	one	for	each	year	of	the proposed project period.  All	the	amounts	you	request	must	be	for	a	particular	purpose.	Do	not	include miscellaneous,	contingency,	or	other	undefined	budget	amounts.  A m inimum	of	80%	of	federal	dollars	granted	must	be	spent	on	services	or	sub
grants	provided	to	sub
- recipients.  Itemize	each	cost	and	present	the	basis	for	all	calculations	in	the	form	of	an equation ,	identifying	the	number	of	persons	inv ol ve d	with	the	ev en t,	the	cost	per person	or	unit,	and/or	the	annual	salary	cost.  Do	not	include	fractional	amounts	(cents).  PFS	Competition	gr antees	are	requir ed to match	feder al	dollars	gr anted	on	a	one
- to one	basis .	U p	to	50%	of	the	match can	be provided	by in - kind cont ributions
. Otherwise, the	match	must	be provided	by	nonf eder al	dollars.  Because	of	the	required	one
- to - one	match	for	Social	Innovation	Fund Pay	for	Success grantees,	the	budget	must	reflect **total** costs	being	distributed	equall y	between	the feder al	and	gr an tee	shares,	but	individual	categories **do	not** have	to	be	equally distributed.7



### Programs	must	comply	with	all	applicable	feder al	laws,	regulations,	and	OMB	circulars for	gr ant	management,	allow able	costs,	and	audits,	including	providing	audits	to	the	A
133 clearinghouse	if	expending	ov er	$500,000	in	feder al	funds,	as	required	in	OMB Circular	A
- 133. Allowable	Costs Please	refer	to	the	relevant	OMB	Circulars	for	further	guidance on	allowable	costs .	The OMB	circulars	are	online	at www.whitehouse.gov/OMB/circulars ,	and	have	been codified	in	Title	2	of	the	Code	of	Federal	Regulations	(CFR)	as	indicated	below  A
- 21
- Cost	Principles	for	Educational	Institutions,	2	CFR Part 220  A
- 87
- Cost	Principles	for	State ,	Local,	and	Indian	Tribal	Governments,	2	CFR Part 225  A
- 122
- Cost	Principles	for	Non	Profit	Organizations,	2	CFR Part 230 It	is	important	to understand	that	“allow able	costs”	under	feder al	aw ards	do	not necessaril y	include	all	costs	that	the	organizat ion	will	incur	in	order	to	perform	their awards. **Fo r	example,	the	cost	of	raising	funds	in	order	to	meet	the	nonfederal**  **share	of	the	budget	(“matching	funds”) is**  **not	allowable	under the**  **OMB	cost principles.**  The	cost	principles reflect	gov ernment - wide req uirements that	one	must be	aw are	of	when	dev eloping	a	budget
. **B. Matching	Funds**  The	non
- feder al	share	of	the	budget	represents	the	dollar
- for
- dollar cash and in - kind contributions matching	requirement.		A ny	organization	that	receiv es	a	SIF award	is responsible	for securing	the	necessary	match
. The	non
- feder al	dollar	component	of	the	m atch must	equal	at	least	50%	of	the	match and may	come	from	state,	local,	or	priv ate	sources,	which	may	include	state	or	local government agencies,	business es,	private	philanthropic	organizations,	or	individuals. Fe der al	funds	may	not	be	used	tow ards	the	match	requirement. The in - kind contributions component	of	this	match	may	not	ex ceed	50%	of	the	match and must be fully

described, valued and publicized in the sub
- recipient selection process
. Third party

, in
- kind contributions means the value of non
- cash contributions provided b y non - Federal third parties. Third part y in
- kind contributions may be in the form of equipment, supplies and other expendable prope rty , and the value of goods and services directly benefiting and specifically identifiable to the project or program, or the monetary value of time contributed by

professional and technical personnel and other skilled labor. The contributions or services p rovided must be a strategic, integral and necessary part of a funded project for which the grantee or sub
- recipient would otherwise have to pay
. The value of the services must be determined by what the TA provider or Tr ansaction Coordinator normally charge s for the services or, if fees are not charged, at the amount the service costs the organization, such as costs for staf f time, required travel, of fice space, allocation of indirect expenses, etc.8



### The total non - feder al	share	of	the	budget	must	equal	or	ex ceed	the	feder al	share	of	the budget	(this	implements	the	dollar
- for
- dollar	match	requirement). However ,	t here	is	no requirement	that	the	non
- feder al	share	of	the	budget	“mirror”	or	be	allocated	on	the same basis	as	the	feder al	share	of	the	budget. **C. Budget**  **Line	Items Section	I.	Progr**  **am	Costs**  

### Project **Pe rsonnel	Expenses**  List	each	staff	position	separ ately	with	a	brief	statement	of	responsibilities, salary, and the	percentage	of	staff	time	that	will	appl y	to the	gr ant .	Each	staff person ’s	role	listed	in	the	budget	must	be	described	in	the	application	narr ative and	each	staff	person	mentioned	in	the	narr ative	must	be	listed	in	the	budget	as either	CNCS	or	Gr antee	share.

 

### Pe **rsonnel	F ringe	Benefits**  Include costs	of	benefit(s)	for the	project	staff. Identify	the	types	of	fringe benefits	to	be	cov ered	and	the	costs	of	benefit(s)	for	each	staff	position. Allow able	fringe	benefits	typicall y	include	FICA,	W ork er’s	Compensation, Re tirement,	SUT

A,	Health	and	Life Insur ance,	IRA,	and	401K.	Y ou	may	provide	a calculation	for	total	benefits	as	a	percentage	of	the	salaries	to	which	they	appl y or	list	each	benefit	as	a	separ ate	item.	If	a	fringe	benefit	amount	is	ov er	30%, please	list	cov ered	items	separ ately	and	justify the	high	cost.	Holidays,	leav e,	and other	similar	v acation	benefits	are	not	included	in	the	fringe	benefit	r at es,	but are	absorbed	into	the	personnel	expenses	(salary)	budget	line	item.

 

### Staff	T **rave l**  Describe	the	purpose	for	which project staff	will	tr ave l. A llow able costs are tr ansportation,	lodging,	subsistence,	and	other	related	expenses. Provide	a calculation	that	includes	itemized	costs	for	airfare,	tr ansportation,	lodging,	per	diem, and	other	tr ave l
- related	expenses	multiplied	by	the	number	of	trips /staff.	Where applicable,	identify	the	current	standard	reimbursement	r ate(s)	of	the	organization for	mileage,	dail y	per	diem,	and	similar	supporting	information.	R eimbursement should	not	ex ceed	the	feder al	mileage	r ate	unless it	is a	result	of	applicant	p olicy	and it	is justified	in	the	budget	narr ative.	Only	domestic	tr ave l	is	allow able. Include	costs for key project staff including	representativ es	of the	project’s	partners to	attend a c onvening of	Pay	for	Success	Pilot	gr antees . E xample of	budget	detail	required : The	project	lead will conduct	a	monitoring	visit : 1 person X	$750	airfare	+	$50	ground	transportation	+	$ 150 lodging +	$35	per	diem X		two	days =	$ 1 , 1 70 for Monitoring
.
 

### Equipment Equipment	is	defined	as	tangible,	non
- expendable	personal	property	having	a	useful life	of	more	than	one	y ear AND an	acquisition	cost	of	$5,000	or	more per	unit (including	accessories,	attachments,	and	modifications). If	applicable,	show	the	unit cost	and number	of	units	y ou	are	requesting.	Pr ovide	a	brief	justification	for	the9



### purchase	of	the	equipment	under	Item/Purpose. Yo u	might	be	ask ed	to	provide further	explanation	of	equipment	costs	that	ex ceed	10%	of	the	total	CNCS	funds requested. Any	items	tha t	do	not	meet	this	definition	should	be	entered	under Supplies.

 

### Supplies Include	the	funds	for	the	purchase	of	consumable supplies	and	materials	that	do not fit	the	definition	abov e. Applicants must	individually	list	any	single	item	costing $1,000	(o ne	thousand)	or	more. Applicants should	provide	the	calculation	for c o s t determinations.

 

### Contractual	and	Consultant	Services I nclude	costs	for	consultants	related	to	the	project’s	oper ations ,	except tr aining or	evaluation	consultants	who	should	be	listed in	those	sections .		Wher e applicable,	indicate	the	dail y	r ate	for	consultants.

 

### Tra **ining** I nclude	the	costs	associated with	tr aining	of	staff	working	directl y	on	the p roject, especiall y	tr aining	that	specificall y	enhances	staff	project implementation	and	pr ofessional	skills
. If	using	a	consultant(s)	for	tr aining, indicate	the	estimated	dail y	r ate.

 

### Eva **luation** Include	costs	for	project	evaluation	activities,	such	as the use	of evaluation consultants, the purchase	of	instrumentation	and	other	costs	specificall y	for this	activity

.		Indicate	dail y	r ates	of	consultants,	where	applicable.

 

### Other	Costs Subgrants
- Please	enter	all	subgr ant	costs	in	a	line	titled,	“Subgr ants. ” Criminal	History	Checks
- Please	include	a	line	titled “ Criminal	History	Checks”	and enter the costs	for	criminal	history	background	checks	for	all	employees	or	other individuals	who	receive	a	salary,	stipend , or	similar	payment	from	the	grant	(CNCS or	non - CNCS	share). Please	note	that	criminal	history	checks	are	required	at	both the	intermediary	and	subgrantee	levels. Other	allow able costs	in	this	section	may	include	office	space	rental,	utilities, and	telephone	and	Internet	expenses	that	directl y	invo lve progr am	staff	and	are not	part	of	the	organization ’s	indirect	cost/admin	cost.		If	shared	with	other projects	or	activities,	y ou	must	pror ate	the	costs	equitabl y. List	each	item	and provide	a	justification	in	the	budget.

 

### Administrati**ve C**  **osts** Administ ra tive	costs	are	gener al	or	centr alized	expenses	of	the	ov er all administr ation	of	an	organization	and	do	not	include	particular	project	costs. As prescribed	in	the Notice ,	this	category	may	not	ex ceed	20%	of	the	budget. These10



### costs	may	include	administr ative	staff	positions,	rent,	IT	costs,	etc.

 If	y ou	hav e	a	feder all y	approv e d	indirect	cost	(IDC)	r ate	y ou must use	it	unless authorized	by CNCS to	use	another	method.		Specify	the	Cost	T ype	for	which	y our organization	has	curre nt	documentation	on	file,	i.e.,	Pr ovisional,	Predetermined, Fix ed,	or	Final	indirect	cost	r ate.		Suppl y	y our	approv ed	IDC	r ate	(percentage).		It is	at	y our	discretion	whether	or	not	to	use	y our	entire	IDC	r ate to	calculate administr ative	costs.		If	y ou	cho ose	to	claim	a	lower	r ate,	please	include	this	r ate under	the	Rate	Claimed	field.

 If	y ou	do	not	hav e	an	IDC,	administr ative	costs	should	be	entered	as	direct expenses.

 

### Source	of **Matching	Funds** Describe	the	gr antee	match	contribution by	entering a	brief description,	the	amount, the	match	classification	(Cash ,	In - kind ,	or	Not	A va ilable)	and	Match	Source (State/Local,	Priv ate,	Other	or	Not	A va ilable) **for	y our	entire	match.**  Define	any acronyms	the	first	time	they	are	used. Each	source	should	be	entered	as a	separ ate line	item.	E.g.	if	y ou	receive	support	from	two	separ ate	foundations,	enter	each	one on	a	separ ate	line. Note:	Y ou	will	be	prev ented	from	validating	y our	budget	in	eGr ants	if	y ou	do not	meet	the dollar
- for
- dollar match.		Y ou	will	receiv e	an	err or	message	that	states,	“Gr antee	share	must be	greater	than	or	equal	to	CNCS	share.” 

### VII. **Review**

**,	Authorize,	and	Submit**
e Gr ants	requires	that	y ou	review	and	v erify	y our	entir e	application	before	submitting by completing	the	following steps :  Review  Authorize  Assur ances  Certifications  Ve rify  Submit Re ad	the	Authorization,	Assur ances,	and	Certifications carefully	(Attachment	A).	The person who	authorizes	the	application	must	be	the	applicant’s	Authorized	R epresentativ e or	his/her	designee	and	must	hav e	an	activ e	eGr ants	account	to	sign	these	documents electronicall y. An	Authorized	Representativ e	is	the	person	in	y our	organization	authorized to	accept	and	commit	funds	on	behalf	of	the	organization.	A	copy	of	the	gov erning	body’s authorization	for	this	official	re presentativ e	to	sign	must	be	on	file	in	the	applicant’s	office. Be	sure	to	check	y our	entire	application	to	mak e	sure	that	there	ar e	no	errors	before submitting	it.	eGr ants will	also	gener ate	a	list	of	errors	if	there	are	sections	that	need	to	be corrected	prior	to	submission	when	y ou	v erify	the	application.	If	someone	else	is	acting	in the	role	of	the	applicant’s	authorized	representativ e,	that	person	must	log	into	his/her11



### eGr ants	account	to	proceed	with	Authorize	and	Submit.	After	signing	off	on	the Authorization,	Assur ances,	and	Certifications,	his/her	name	will	ov erride	any	previous signatory	that	may	appear	and	show	on	the	application	as	the	Authorized	R epresentativ e. **N ote:	Anyone	within	your	organization	who	will	be	entering	information	in	the**  **application	at	any	point	during	application	preparation	and	submission	in	the	eGrants system	must	have	their	own	eGrants	account.**  Individuals	may	establish	an	eGr ants account	by	a ccessing	this	link: https://egr ants.cns.gov/espan/main/login.jsp and	selecting “Don ’t	have	an	eGr ants	account?		Create	an	account. ”i



## AT **TA CHMENT**  **A :	Assur**  **ances	&	Certifications**

**A SS**  **UR A**  **N C**  **ES** A s th e du ly autho riz e d r e p r e s e n t at i v e o f th e app l i can t , I assure , to t h e b e st o f m

y kn o w le d g e an d b e l i e f

, th at th e app l ic an t:

 H a s t h e le g a l autho ri ty to ap p ly f o r f e d e r a l a s s istan ce , an d th e i n st i tut i o n a l, man age rial, an d f i n an c ial cap ab i l i ty (i n c l u d i n g f und s s u ff i c ie n t to p ay t

h e n o n - f e d e r a l s h are o f p r o

je c t c o sts) to e n s ure p r op e r p lan

n i n g , ma n ag e me n t, an d c o m

p leti o n o f th e p r o

je c t d e s c ri be d in t

h is ap p l i cat i on .  W i l l g i v e th e aw ar d i n g ag e nc y , th e C o m p tr o l l e r G e n e r a l o f th e Un i t e d S tat e s, an d if app r o p riat e , t h e s t ate, thr o u gh any autho r iz e d r e p r e s e n tati ve , acce ss to an d t h e ri gh t t o exami n e a ll r e co r d s, b o o k s, p ap e rs, o r do c um e n ts r e lat e d to th e aw ar d ; an d w i l l e st ab l i sh a p r o p e r acc oun t i n g s y s t e m in acc o r d an c e w i t

h ge n e r a l l y a c ce p ted acc oun t i n g st and a r d s o r age nc y d ire c t iv e s.
 W i l l e st ab l i sh s a f

e gu a r d s to p r o h i b it e m

p l o ye e s f r o m u si n g th e ir po sit io n f o r a pur po se t h at co n sti tut e s o r p r e s e n ts t

h e a pp ear an c e o f p e rs on a l o r o r gan i z a t ion a l co n f l i c t o f i n ter e st, o r p e r s on a l ga i n .  W i l l i n i t iate an d c o m p lete t h e w o rk w i th i n th e ap p l i ca b le ti m e f r a m e a f ter r e ce i p t o f app r o va l o f th e aw a r d i n g a g e nc y .
 W i l l c o m

p l y w i th th e In ter g o ve rnme n tal P e rs o nn e l A c t o f 197 0 ( 4 2 U. S .C. 4 7 2 8
- 4 7 63 ) r e lati n g to p r e s c ri b e d st and ar d s f

o r m e rit s y st e m s f

o r p r o gr am s f

und e d un d e r o n e o f th e n i n e te e n s t a tutes o r r egu lati o n s s p ec i f

ied in A pp e nd ix A o f O P M ’s S tan d a r d s f o r a M e rit S y s t e m o f P e rs o nn e l A dmi n istrati o n ( 5 C F R 9 0 0 , S u b p art F )
.  W i l l c o m

p l y w i th a ll f

e d e r a l st a tutes r e lati n g to n o n d is c ri mi n a t ion
. T h e se i n c l ud e b ut a re n o t l i mi t e d t o : T i t le V I o f th e Ci v il Ri gh ts A c t o f 196 4 ( P
. L
. 8 8
- 3 5 2 ) w h ich p r oh i b i t s d is c ri mi n a t io n o n th e b a sis o f r ace , c o l o r, o r n a t i o n a l o ri g i n ; ( b ) T i t le IX o f th e E du cat i o n Ame ndme n ts o f 19 7 2 , a s ame nd e d ( 2 0 U
. S .C. 1 6 8 1
- 1 6 83 , an d 1 6 8 5
- 1 6 8 6 )
. w h ich p r o h i b i t s d is c ri mi n at io n o n t h e b a sis o f s e x ; ( c ) S ec t io n 5 0 4 o f th e R e h ab i l i t at io n A c t o f 197 3 , a s ame nd e d ( 2 9 U. S .C. 7 9 4 ), w h ich p r o h i b i t s d is c ri mi n a t io n o n th e b a sis o f d is ab i l i ty ( d ) T h e A g e Dis c r i mi n at io n A c t o f 19 7 5 , a s am e nd e d ( 4 2 U. S .C. 6 1 0 1
- 6 1 07 ), w h ich p r oh i b i t s d is c ri mi n at io n o n th e b a sis o f ag e ; ( e ) T h e Dr u g A bu se Of f i c e an d T r eatm e n t A c t o f 19 7 2 ( P
. L
. 9 2
- 2 5 5 ), a s ame nd e d , r e lati n g t o n o nd is c ri mi n a t io n o n th e b a sis o f dr u g ab u s e ; ( f

) T h e C o m p r e h e n si v e A lc oho l A

bu se an d A lc oh o l i sm P r eve n t ion , T r eatm e n t an d R e h a b i l i t at io n A c t o f 197 0 ( P
. L
. 9 1
- 6 16 ) , a s a m e nd e d , r e lati n g to n o nd is c ri mi n a t io n o n t h e b a sis o f a lc o h o l ab u se o r a lc o h o l i s m ; ( g ) s ec t ion s 5 2 3 an d 5 2 7 o f th e Pub l i c H ea l t h S e rv ice A c t o f 191 2 ( 4 2 U. S .C. 2 90 d d
- 3 an d 2 90 e e - 3 ), a s ame nd ed , r e lati n g to c on f i d e nt i a l i ty o f a l c oh o l an d dr u g abu se p at i e nt r ec o r d s; (h ) T i t le V I II o f th e Ci v il Ri gh ts A c t o f 19 6 8 ( 4 2 U
. S .C. 3 6 0 1 e t s e q .), a s ame nd e d , r e lat i n g to no n d is c ri mi n a t io n in th e s a le, r e n t a l o r f

i n an c i n g o f h ou s i n g ; (i) any o th e r n o n d is c ri mi n at io n p r o v isi o n s in t h e N a t i o n a l an d C o mm un i ty S e r v ice A c t o f 1 99 0 , a s ame nd e d ; an d ( j) t h e r e qu i r e m e n ts o f an y o th e r n o n d is c ri mi n at i o n st a tute( s ) w

h ich m ay app l y to th e ap p l i cat i o n .  W i l l c o m

p l y , o r h a s alr ea dy c o m

p l i e d , w i t h t h e r e qu ire me n ts o f T i t les II an d III o f th e Un i f o rm R e l o c a t io n A s s istan c e an d R ea l P r op e rty A c qu isi t i o n P o l i c ies A c t o f 19 7 0 ( P
. L
. 9 1
- 6 4 6 ) w h ich p r o v i d e f o r f a ir an d equ i t a

b le tr eatm e n t o f p e rs on s d is p la ce d o r w ho se p r o p e rty is ac qu ired a s a r e s u lt o f f e d e r a l o r f

e d e r a l l y a s s isted p r o gr a m s. T h e se r e qu ire me n ts ap p ly to a ll i n ter e sts in r ea l p r o p e rty ac qu ired f

o r p r o j ec t pur p o s e s re g a

r d le s s o f f

e d e r a l p art i c i p at i o n i n pur c h a s e s.ii

 W i l l c o m

p l y w i th th e p r o v isi on s o f th e H a tch A c t (5 U. S .C. 1 5 0 1
- 15 0 8 an d 7 3 2 4
- 7 3 28 ) w h ich l i mit th e p o l i tic a l ac t i v i t ies o f e m p l o yee s w

ho se p ri n c i p a l e m

p l o yme n t ac t i v i t ies a

re f und e d i n w ho le o r in p art w i th F e d e r a l f und s.
 W i l l c o m

p l y , a s app l i cab le, w i th t

h e p r o v is i on s o f th e D av i s - B ac o n A c t ( 4 0 U. S .C 2 7 6 a an d 2 7 6 a 7 7 ) , th e C op e lan d A c t ( 4 0 U. S .C 2 7 6 c an d 1 8 U. S
. C
. 8 7 4 ), an d th e C on tra c t W o r k H o urs an d S a f e t y S tand ar d s A c t ( 4 0 U. S .C. 3 2 7
- 3 33 ), r egar d i n g labo r st an d ar d s f o r F ede r a l l y a s s isted c on str u c t i o n s u b
- agr e e me n ts.

 W i l l c o m

p l y , if app l i cab le, w i th f

l oo d i n s ur an c e p u

r c h a se r e qu ire me n ts o f S ec t io n 1 0 2 ( a ) o f th e F l oo d Dis a st e r P r o te c t i o n A ct o f 19 7 3 ( P
. L
. 9 3
- 2 34 ) w h ich r equ ires t

h e r ec i p ie nts i n a s p ec ial f l oo d h azard ar e a to p a

rt i c i p ate in th e p r o gr am an d to pur c h a se f l oo d i n s ur an c e if th e t o tal c o st o f i n s ur a b le c on str u c t i o n an d ac qu isi t i o n is $1 0 , 0 0 0 o r mo r e .
 W i l l c o m

p l y w i th e nv ir onm e n t a l st and a r d s w h ich may b e p r e s c ri b e d p urs u an t to th e f o l l o wi n g : ( a ) i n sti tut i o n o f e nv ir onm e n tal qu a l i ty c on tr o l m e a s ur e s und e r t h e N at i o n a l E nv ir o nm e n tal P o l i c y A c t o f 196 9 ( P
. L
. 9 1
- 1 9 0 ) an d E xec ut i v e Or d e r (EO) 1 1 51 4 ; ( b ) no t i f ic at io n o f v i o lati n g f

ac i l i t ies purs u a n t t o EO 1 1 7 3 8 ; ( c ) p r o te c t i o n o f w e t l and s purs u a n t t o EO 1 1 9 9 0 ; ( d ) eva l u a t io n o f f l oo d h azar d s in f

l o o d p lai n s in acc o r d an c e wi th EO 1 1 9 8 8 ; ( e ) a s s ur an c e o f p r o je c t co n sist e n c y w i th th e ap p r o ve d st a te mana g e me n t p r o gr am d eve l op e d u n d e r t h e C o a s t a l Z on e M an ag e m e n t A c t o f 19 7 2 ( 1 6 U
. S .C 1 4 5 1 e t s eq .); (f ) c on f o r mi t y o f f

e d e r a l ac t ion s to S tate (Cle an A ir) I m p l e m e n tati o n P lan s un d e r S ec t io n 1 7 6 ( c ) o f th e Cle an A ir A c t o f 19 5 5 , a s ame nd e d ( 4 2 U. S
. C
. 7 4 0 1 e t s e q .); ( g ) p r o te c t io n o f und e r gr o un d s our c es o f dri nki n g w ater und e r t h e S a f e Dri nki n g W ater A c t o f 1 9 74 , a s ame nd e d ( P
. L
. 9 3
- 5 2 3 ); an d ( h ) p r o te c t io n o f e nd an ge r e d s p ec ies un d e r th e E ndan ge r e d Sp ec ies A c t o f 19 7 3 , a s ame nd e d ( P
. L
. 9 3
- 2 0 5 ).

 W i l l c o m

p l y w i th th e W i l d an d S ce n ic Ri ve rs A c t o f 196 8 ( 1 6 U. S
. C 1 2 7 1 e t s e q .) r e lat e d t o p r o te c t i n g c o m

pon e n ts o r po te nt i a l c o m

pon en ts o f th e n a t i o n a l w i l d an d s ce n ic r i ve rs s y st e m .  W i l l a s s ist th e aw a

r d i n g a g e nc y i n a s s uri n g c o m p l i an c e w i th S ec t io n 1 0 6 o f th e N a t i on a l His t o ric P r e s e rv a t io n A c t o f 19 6 6 , a s ame n d e d ( 1 6 U. S .C. 4 70 ), EO 1 1 5 9 3 (i d ent i f ic at io n an d p r o te c t io n o f h is t o ric p r op e rt i e s), an d th e Ar c ha e o l o g ic a l an d His t o ric P r e s e rvat io n A c t o f 197 4 ( 16 U
. S .C. 4 69 a - l e t s eq .).

 W i l l c o m

p l y w i th P
. L
. 9 3
- 3 4 8 r egar d i n g th e p r o te c t i o n o f human s u b je c ts i nv o l ve d i n r e s ear c h , d eve l op m e n t, an d r e lat e d ac t i v i t ies s up p o rted b y th is a w ard o f a s s istan ce .  W i l l c o m

p l y w i th th e L abo r a t o ry An i ma l W e l f a re A c t o f 196 6 ( P
. L
. 8 9
- 5 44 , a s ame nd e d , 7 U. S
. C
. 2 13 1 e t s e q .) p e rtai n i n g t o t h e car e , h an d l in g , a

n d tre atm e n t o f w ar m b l oo d e d an i ma ls h e ld f o r r e s ear c h , te ac h i n g , o r o t

h e r ac t i v i t ies s up p o rted b y th is aw ard o f a s s ist a n ce .  W i l l c o m

p l y w i th th e L ea d
- B a s e d P a i nt Po i s on i n g P r eve n t io n A c t ( 4 2 U
. S .C. § § 4 8 0 1 e t s e q .) w h ich p r o h i b i t s th e u se o f le a d b a s e d p a i n t in c on st r u c t i o n o r r e h ab i l i tati o n o f r e si d e n c e st r u c tur e s.
 W i l l cau se to b e p e r f

o rm e d th e r e qu ired f

i n an c ial an d c o m

p l i an c e aud i t s in acc o r d a

n c e wi th th e S i n g le A ud it A c t o f 19 8 4 , a s ame nd e d , an d OMB Cir c u lar A
- 133 , A ud i ts o f S tat e s, L o ca l G o ve rn m e n ts, an d N o n - P r o f it Or gan iz at i on s.
 W i l l c o m

p l y w i th a ll app l i cab le r e qu ire me n ts o f a ll o th e r F e d e r a l l aw s , ex e c ut i v e o r d e rs, r egu lati o n s , app l ic at io n gu i d e l in e s, an d po l i c ies g o ve rn i n g th is p r o gr am .
 Will comply with the pilot program on Contractor employee whistleblower protectionsiii

established at 41 U.S.C. 4712 by section 828 of the National Defense Authorization Act for Fiscal Year 2013 (Pub. L. 112
- 239).  This grant and employees working on this grant will be subject to the whistleblower rights and remedies in the pilot program.  Under this pilot program, an employee of a grantee may not be discharged, demoted, or otherwise discriminated against as a reprisal for disclosing information that the employee reasonably believes is evidence of gross mismanagement of a Federal contract or grant, a gross waste of Federal funds, an abuse of authority (an arbitrary and capricious exercise of authority that is inconsistent with the mission of CNCS or the successful performance of a contract or grant of CNCS) relating to a Federal contract or grant, a substantial and specific danger to public h ealth or safety, or a violation of law, rule, or regulation related to a Federal contract (including the competition for or negotiation of a contract) or grant.  The Grantee shall inform its employees in writing, in the predominant language of the workforce or organization, of employee whistleblower rights and protections under 41 U.S.C. 4712, as described above
.

## CERTIF **I CATIO** **N S**  **Ce rt**  **ific at**  **i o**  **n –**  **Deb a**  **r m**  **en t**  **, S**  **us p**  **e n**  **s i**  **o n,**  **a nd**  **Ot her**  **R e**  **s p**  **o n**  **s i**  **bi l**  **ity M**  **att e**  **rs** T h is c erti f

icati o n is r e qu ired b y th e g o v e r n me n t - w i d e r e gu l a ti o n s i m p l e m e n t i n g E x e c ut i v e O rd er 1 2 54 9 , De b arme n t a

n d S u s p e n s i o n , 2 C F R P ar t 1 80 , Secti o n 180
. 335 , W ha t i n f o rm a ti o n m u s t I p r o vi d

e b ef o r e e n ter i n g i n to a c o v e r ed tran s a cti o n w ith a Fe d era l age n c

y ? As th e du l y a ut h or ized r e pr es e ntat i v e o f t h e app licant, I c ertif y , to t h e b est o f m

y kn o w le d g e a

n d b elie f , th at n ei th er t

h e app lica

n t n o r its pr i n ci p al s :

 I s pr ese nt l y e x c l u d ed o r d i s qu ali f ie d ;  Has b e e n c onv icted w i t h in th e pr e c e d i n g th r ee ye ar s o f any o f th e of f e ns e s li s ted i n § 180
. 800( a) o r h ad a ci v il j u dg m e n t r e n d e r ed a g ai n s t it f o r o n e o f th o s e off

e ns e s wi t h in th at t i m e p e r i od ;  I s pr ese nt l y i n d icted f o r o r o th e r wi s e c r i m

i n al l y o r ci v il l y c h ar g ed b y a g o v e rn m e n tal e n ti t y ( Fe d e r al, State, o r l o c a l) wi th c o mm i s si o n o r any o f t h e of f e n s es l i s t e d in § 180
. 80 0 ( a ) ; o r  Has h ad o n e o r mor e p ub lic tra ns a c ti o n s ( Fe d e r al, State, o r l o c a l) te rm i n ated w i t h i n th e pr e c e d i n g t hr ee y e ar s f

o r c au s e o r d e f

a u l t . **D e**  **fi n**  **it io**  **n s**  T h e te r m s “ d e b a

r m e n t”, “ s u s p e n si on ” , “exc l ud e d ” , “ d is qu a l i f ie d ” , “ i n e l i g i b le ” , “ p art i c i p ant”, “ p e rs o n ” , “ p r i n c i p a l”, an d “v o l un tarily exc l ud e d ” a s u s e d in th is d o c um e n t h av e th e m e an i n g s s e t out in 2 C F R P art 1 8 0 , s u bp art I, “ D e f

i n i t i on s.” A tran s ac t io n s h a l l b e co n si d e r e d a “c o ve r e d tran s ac t ion ” if it m ee ts t h e d e f i n i t i o n i n 2 C F R p a

rt 1 8 0 s ubp art B, “ C o ve r e d T r an s ac t ion s.” **A s**  **sur a**  **n c**  **e r**  **e q**  **u i**  **r e**  **m e**  **n t**  **f o**  **r su bg**  **ra n**  **t a**  **g r**  **ee m**  **e n**  **ts** Y o u agr e e b y s ub mi t t in g th is p r o po s a l t h at if w e app r o v e your ap p l i cat io n yo u s h a ll n o t kn o wi n g l y en ter in t o any l o w e r t i e r c o ve r e d tran s ac t io n wi th a p e rs o n w h o is d e b a

rr e d , s u s p e nd e d , d ec l a

r e d i n e l i g i b le, o r v o l un tar i ly e xc l ud e d f

r o m p art i c i p at i o n i n th is c o ve r e d tran s ac t i o n , un le s s a uth o riz e d b y u s. **A s**  **sur a**  **n c**  **e i**  **n c**  **l u**  **si o**  **n in**  **s ub**  **gr a**  **n t**  **a g**  **re e**  **m e**  **n ts**  Y o u agr e e b y s ub mi t t in g th is p r o po s a l t h at yo u w i l l ob ta i n an a s sur an c e f r o m p r o s p ec t i v e p a

rt i c i p an ts in a ll l o w e r t i e r c o ve r e d tran s ac t ion s an d i n a ll s o l i c i t a t i on s f o r l o w e r t i e r c o ve r e d tra

n s ac t ion s th a t t

h e p art i c i p an ts are n o t d e b arr e d , s u s p e nd ed , i n e l i g i b le, o r v o l un tarily exc l ud e d f r o m t h e c o ve r e d tran s ac t ion
. **A s**  **sur a**  **n c**  **e o**  **f su**  **b g**  **r a**  **n t**  **p r**  **i n**  **c i**  **pa ls**  Y o u ma y r e l y upo n an a s s u r an c e o f a p r o s p ec t i v e p a

rt i c i p ant in a l o w e r - t i e r c o ve r e d tran s ac t io n th a t is n o t d e b arr e d , s u s p e nd e d , i n e l i g i b le, o r v o l un tarily exc l ud e d f r o m th e c o ve r e d tran s ac t ion , un l e ss yo u k no w th at th e a s s ur an c e i s err on eo u s. Y o u ma y d ec i d e th e m e tho d a n d f r e qu e n c y b y w

h ich yo u d e term

i n e th e e l i g i b i l i ty o f y our p r i n c i p a ls. Y o u ma y , but are no t r e qu ir e d t o , c h ec k th e L ist o f P art ie s E xc l ud e d f r o m F e d e r a l P r o c ur e m e n t an d N onp r o c ur e m e n t P r o gr am s. **N on**  **- a**  **s s**  **u r**  **a n**  **c e in**  **s u**  **b g**  **r a**  **n t**  **a g**  **r ee**  **m e**  **n ts**  If y o u kno w i n g l y e n ter in to a l o w e r t i e r c o ve r e d tran s ac t io n wi th a p e rs o n w h o is s u s p en d e d , d e b arr e d , i n e l i g i b le, o r v o l un t a ri l y exc l ud e d f r o m p art i c i pa t io n i n t

h i s tr an s ac t ion , in a dd i t i o n to o t h e r r e m e d ies av a i l ab le to t

h e f e d e r a l g o ve rn m e n t, w e m ay term i n a te th is tran s ac t io n f

o r cau s e o r d e f

au l t . **C er**  **tif i**  **ca ti**  **o n**  **– D**  **r u**  **g Fr**  **e e**  **W o**  **rk p**  **l a**  **c e**  T h is ce rt i f

i c at io n is r equ ired b y th e C o r po r at i o n ’s re g

u lati on s i m

p le me n t in g s ec t ion s 5 1 5 0
- 5 1 6 0 o f th eDr

u g - F r e e W o rk

p la c e A c t o f 19 8 8 ( P
. L
. 1 0 0
- 6 90 ), 2 CFR Parts 182 and 2245
. T h e r egu lati on s re q u ire c e rt i f ic at io n b y gr ante e s, p ri o r t o aw a r d , th at t h e y w i l l ma k e a g oo d f

a i th e f f o rt, o n a c on t i nu i n g b a sis, t o ma i n tain a dr

u g - f r e e w o r k p la ce . T h e ce rt i f

i c a t io n s e t o ut b e l o w is a materi a l r e p r e s e ntati o n o f f a c t up o n w h ich r e l i an c e w i l l b e p la ce d w h e n th e age n c y d e te r mi n e s to aw ard th e gr an t. F a lse ce rt i f i c at io n o r v i o lati o n o f th e ce rt i f

ic at io n ma y b e gr ound s f

o r s u s p e n si o n o f p aym e n ts, s u s p e n si o n o r term i n a t io n o f gr an ts, o r g o ve rnm e n t - w i d e s u s p e n si o n o r d e b arm e nt (s e e 2 C F R P art 1 8 0 , S u b p arts G an d H). A s th e du ly autho riz e d r e p r e s e n t at i v e o f th e gr an te e , I ce rt i f y , to t h e b e st o f m

y k no w le dg e an d b e l i e f , th a t th e gr antee w i l l p r o v i d e a dr u g - f r e e w o rk p la c e b y : A. Pub l is h i n g a dr

u g - f r e e w o r k p la c e st at e m e n t th a t: a. N o t i f ies e m p l o yee s th a t th e un law f

u l manu f ac tu r e , d istr ibut i o n , d i s p e n si n g , p o s se s s i on , o r u s e o f a c on tr o l l e d s ub st an c e is p r o h i b i t e d in th e gr a n te e ’s w o rk

p la ce ; b. Sp ec i f

ies th e ac t ion s th at th e gr an tee wi l l tak e aga i n st e m p l o yee s f o r v i o lati n g t

h a t p r oh i b i t i on ; an d c. I n f o rm s e m p l o ye e s th a t, a s a c o n d i t i o n o f e m p l o yme n t un d e r any aw ar d , eac h e m p l o ye e w i l l ab i d e b y th e term s o f t h e st a t e m e n t an d n o t i f

y th e gr an tee in w

ri t i n g if th e e m

p l o ye e is c onv ict e d f

o r a v i o lati o n o f a c ri mi n a l dr u g st atute o cc u

rr i n g in th e w o rk

p la c e w i th in f i v e day s o f th e co nv icti on ; B. R e qu ir i n g th a t a co p y o f th e st at e me n t d e s c ri b e d i n p a r agr ap h ( A) b e g i ve n to eac h e m p l o ye e w h o will b e e n gage d in th e p e r f o rman c e o f an y F e d e r a l aw a r d ; C. Estab l i s h i n g a dr

u g - f r e e aw ar e n e s s p r o gr am to i n f o rm e m p l o ye e s a bo ut: a. T h e d an ge rs o f dr

u g abu se in th e w o rk

p la ce ; b. T h e gr an te e ’s po l i c y o f ma i n tai n i n g a dr u g - f r e e w o rk p la ce ; c. An y ava i l ab le dr

u g c o un s e l in g , r e h ab i l i t at i o n , an d e m p l o ye e a s s ist a n c e p r o gr am s; an d d. T h e p e n a l t ies th a t t

h e gr antee may i m

po se upo n th e m f

o r dr u g ab u se v i o lati on s o cc urri n g i n t h e w o rk p la ce ; D. P r o v i d i n g u s, a s w e ll a s any o th e r F e d e r a l age nc y o n w ho se aw a rd t h e c onv ict e d e m

p l o ye e w a s w o rki n g , w i th w

ri t ten no t i f

ic at io n w i th i n 1 0 ca le n d a

r d a y s o f le a rn i n g th at an e m

p l o y e e h a s b ee n c onv ict e d o f a dr

u g v i o la t i o n in t

h e w o rk p la ce ; E. T aki n g on e o f th e f

o l lo w i n g ac t i o n s w i th in 3 0 ca l en d a r d ay s o f le ar n i n g t

h a t an e m p l o ye e h a s b ee n conv ict e d o f a dr

u g v i o lati o n in th e w o rk

p la ce : a. T aki n g app r o p riate p e rs o nn e l ac t i o n aga i n st th e e m p l o yee , u p to an d i n c l ud i n g ter

m i n a t ion ; o r b. R e qu ir i n g th a t t

h e e m p l o ye e p art i c i p a te s a t i s f

a c t o ri l y in a dr

u g ab u se a s s istan c e o r r e h ab i l i t at i o n p r ogr a m app r o ve d f o r t h e se pur po s e s b y a F e d e r a l, S tat e , o r l o ca l h ea l th , law e n f o r c e m e n t, o r o t

h e r a pp r op ri a te ag e nc y ; F. M aki n g a g oo d f

a i th e ff o rt to c on ti nu e t o ma i n tain a dr u g - f r e e w o rkp la c e thr o u gh i m p le me n tati o n o f p ar agr aph s ( A ) thr o u gh (E). **C er**  **tif i**  **ca ti**  **o n**  **- L**  **ob b**  **y i**  **n g**  **A c**  **ti v**  **i t**  **ies** A s re qu ired b y S ec t io n 1 3 5 2 , T i t l e 3 1 o f th e U. S
. C od e , a s t h e d u ly aut h o riz e d r e p r e s e n tati v e o f th e a pp l i can t , I ce rt i f

y , to t h e b e st o f m

y k n o w le d g e an d b e l i e f

, th at:

 No f und s re ce i ve d f

r o m CNCS hav e b ee n o r w i l l b e p a i d , b y o r o n b e h a lf o f th e app l i can t , to any p e rs o n o r age nt ac t in g f o r th e app l i can t , r e lat e d t o ac t i v i t y d e si gn e d to i n f l u e n c e th ee n ac tm e n t o f le g islati on , ap p r o p r iati on s, a dmi n istrati v e ac t ion , p r o po s e d o r p e n d i n g b e f o re th e C on gr e ss o r any S tate g ov e rnme n t, S tate le g islature o r l o ca l le g islature o r le g islati v e bod y .
 If an y f

und s o t h e r t h an f e d e r a l app r o p riat e d f

un d s h av e b ee n p a i d o r w i l l b e p a id to a ny p e rs o n f o r i n f l u e n c i n g o r at te m

p t in g to i n f

l u e n c e an o ff

i ce r o r e m

p l o ye e o f an y a ge nc y , a m e m b e r o f C on gr e s s , an o f

f ic e r o r e m

p l o ye e o f C on gr e s s , o r an e m p l o ye e o f a m e m

b e r o f C on gr e ss in c onn ec t i o n wi th th is f

e d e r a l c on tra c t, gr an t, l o an , o r c oop e r at i v e agr e e me n t, th e ap p l i c an t w i l l s ub mit S tand ar d F o rm - L L L , " Dis c l o s ure F o rm to R e po rt L obb yi n g ," in acc o r d an c e w i th i t s i n str u c t i on s;

 T h e app l i cant w i l l r equ ire th a t t h e lan gu ag e o f th is ce rt i f

i c at io n b e i n c l u d e d i n t

h e aw ard do c um e n ts f

o r a ll s ub co n tra c ts at a ll t i e rs ( i n c l u d i n g s ub co n tra c ts, s u b gr ants, an d c o n t

r ac ts und e r g r an ts, l o an s an d co o pe r a t i v e agr e e me n ts) an d th a t a l l s u b r ec i p i e n ts wi l l ce rt i fy an d d is c l o se acco r d i n g l y . **E rr**  **o n**  **e o**  **u s c**  **er tif** 

**ic a**  **ti o**  **n o**  **r a**  **s s**  **u r**  **a n**  **c e**  T h e a s s ur an ce s an d ce rt i f i c a t ion s are ma teri a l r e p r e s e ntati on s o f f a c t u p o n w h ich w e r e l y in d e term

i n i n g w h e t h e r to e n ter i nto t

h is tran s ac t ion
. If w e lat e r d e te rmi n e th a t yo u k no w i n g ly s ub mi t ted an e rr on eo u s c e rt i f ic at io n o r a s s ur a

nce , in ad d i t i o n t o o th e r r e m e d ies av a i l ab le to t h e f e d e r a l g o ve rn m e n t, w e m ay te r mi n ate th is tran s ac t io n f o r cau se o r d e f

au l t . **N o**  **tice o**  **f e**  **rr o**  **r in c**  **e r**  **tif**

**i ca**  **ti o**  **n o**  **r a**  **s s**  **u r**  **a n**  **c e**  Y o u m u st p r o v i d e imme d iate w

ri t ten n o t i c e to u s if a t any t i m e yo u le arn th a t a ce rt i f ic at io n o r a s s ur an c e w a s e rr on e ou s w

h e n s ub mi t ted o r h a s b ec o m e e rr on e ou s b ecau se o f c h an ge d c irc u m st an ce s. **Pru d**  **e n**  **t p**  **e r**  **s o**  **n st**  **an d**  **a r**  **d** Nothing contained in the aforementioned may be construed to require establishment of a system of records in order to render in good faith the assurances and certifications required. Your knowledge and information is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

## AT **TA CHMENT**  **B :**  **Instructions	for	Cr eating	P**  **erformance Measur**  **es	in	eGrants** In	the	Performance	Measures	module	of	eGrants	you	will	create	performance	measures;	set targets	and	describe	data	collection	plans	for	your	performance	measures;	identify interventions	associated	with	your	program;	and	identify	performance	measures	for s ubgrantees	(as	applicable) **A. Accessing	the	Performance	Measures	Home	Page**  You	can	either	access	the	Performance	Measures	Module	after	completing	the Documents	section	of	your	application	or	directly	by	clicking	on **Performance Measures**  on	the	left	side	of	your	screen.

 To	begin	entering	performance	measures,	click	the **Begin** button	on	the	Home	Page.

 As	you	proceed	through	the	module,	the	Home	Page	will	summarize	your	work and	provide	links	to	edit	the	parts	of	the	module	you	have completed.		You	may also	navigate	sections	of	the	module	using	the	tab	feature	at	the	top	of	each	page.

 Once	you	have	started	the	module,	clicking **Continue	Working** will	return	you	to the	tab	you	were	on	when	you	last	closed	the	module.  To	edit	a	performan ce	measure,	click	the **Edit** button.  To	delete	a	measure,	click **Delete**
.  To	create	a	new	performance	measure,	click	the **Add	New	Performance	Measure** button. **B. Creating	Performance	Measures**  On	the **Performance	Measures	Tab** ,	you	can create	performance	measures	for	all	the grant	activities	you	intend	to	measure.		Please	note	that	there	are	mandatory	measures for	which	you	must	set	targets	and	report.		There	are	additional	measures	that	you	will select	as	they	pertain	to	your	program. **1.** Select **Applicant	Type: Grantee** 
. **2.** Select **Applicant	Name:** Your	organization’s	name. **3.** Enter	a **Problem	Statement:** In	2
- 3	sentences,	briefly	describe	the	problem	that	you propose	to	address	through	your	SIF	grant	activities. **4.** Select **Targets	for	Mandatory	Performance	Measures**  Enter	a	baseline	and	target	number	for	mandatory	SIF	performance	measures.  For	each	measure,	select	and	describe	the	instrument(s)	you	will	use	to	measure the	appropriate	output	or	outcome.		Instruments	are	speci fic	tools	used	to	collect information	such	as	a	behavior	checklist,	attitude	questionnaire,	attendance sheet,	or	interview	protocol.		Include	the	title	of	the	instrument(s),	a	brief description	of	what	it	measures	and	how	it	will	be	administered,	and	detai ls about	its	reliability	and	validity	if	applicable.

### 5. **Add	Additional	Performance	Measures**

Select	additional	measures	if	they	are	applicable	to	your	program.		Consult	the	SIF Performance	Measures	Definitions	guidance	to	determine	which	performance measures are	appropriate	for	your	program.  Select	a	focus	area	and	relevant	outputs	and/or	outcomes.		Enter	a	baseline	and target	number	for	each	measure.  For	each	measure,	select	and	describe	the	instrument(s)	you	will	use	to	measure your	output	or	outcome.  To	create	additional	measures,	select **Add	Another	FA	End	Outcome** (FA=Focus Area)	and	select	desired	focus	areas,	outputs,	and	outcomes,	as	appropriate. **6. Identify	Interventions**  Select	the	interventions	that	you	will	carry	out	to	address	the	problem identified	in the	application.		Only	interventions	that	correspond	with	the	focus	area(s)	you selected	will	appear.  Select	all	interventions	that	are	a	part	of	your	program	design.  Click **Add	User	Intervention** to	add	and	describe	any	intervention	not	listed. **7. Saving	Performance	Measures**   After	entering	all	information,	select, **Complete	PM**.		This	will	return	you	to	the Home	Page.  If	you	are	an	existing	SIF	grantee	and	wish	to	create	performance	measures	for an other	subgrantee,	repeat	the	process.		If	you	would	like	to	continue	to	the **Summary	Tab** to	validate	your	performance	measures,	click **Next**
. **8. Validating	Performance	Measures**  You	will	not	be	able	to	submit	your	application	without	first	validating	your perfo rmance	measures.		The **Summary	Tab** allows	you	to	review	all	of	the	measures and	targets	that	you	selected.  You	can	select	to	print	the	performance	measures	by	clicking	either **Print	PDF	of Table**  or **Print	All	Performance	Measures**
.  If	you	need	to	edit	a	meas ure,	click **Edit	Performance	Measures** which	will	take you	back	to	the	Performance	Measures	Tab.  Once	your	performance	measures	are	complete,	click **Validate	Performance Measures**  to	include	them	in	your	application.