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OMB Control Number: 0985-0007

Expiration Date: 06/30/2022

Application for Older Americans Act,

Title VI 2023-2026 Grant Funds

Public Burden Statement:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such

collection displays a valid OMB control number (OMB 0985-0007). Public reporting burden for this collection of information is

estimated to average 4.5 hours per response, including time for gathering and maintaining the data needed and completing and

reviewing the collection of information. The obligation to respond to this collection is required to retain or maintain benefits

under the statutory authority 42 U.S. Code § 3057e.
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APPLICANT ORGANIZATION

INFORMATION

Field Response

Name of Organization

Grant(s) for Which 

Organization is Applying

Part A only (Nutrition & Supportive Services Grants to 

American Indian and Alaskan Native Tribes)

Parts A & C (Nutrition & Supportive Services and 

Caregiver Grants to American Indian and Alaskan 

Native Tribes)

Part B only (Nutrition & Supportive Services Grants to 

Native Hawaiian Organizations)

Parts B & C (Nutrition & Supportive Services and 

Caregiver Grants to Native Hawaiian Organizations)

StreetAddress

City

State

Zip Code

Organization's 9-Digit EIN

Suffix to Organization's EIN 

Unique Entity Identifier

Current Title VI Part A/B 

Grant Number

(Do not complete this 

question if you were not a 

Title VI grantee for the 

2020-2023 grant cycle.)
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Field Response

Number of elders age 60+ 

living in service area (for 

more information on service 

area, see Application 

Instructions)

Source of elders data (choose 

only one)

U.S. Census (must attach a copy of Census data. For 

more information, see Application Instructions )

Tribal Enrollment (Tribal Enrollment official must sign 

below or sign a separate page and attach it to 

application. For more information, see Application 

Instructions)

Signature of Tribal

Enrollment Official. 

(Signature is verification 

that number of elders age 

60+ is accurate (signature 

and enrollment data may

also be attached as a 

separate page))

Date of signature of Tribal

Enrollment Official

Are elders under age 60

allowed to participate in

your program’s Title VI 

services?

Yes

No

If you answered yes to 

previous question, what is 

your program's age for an 

eligible elder?

If your program allows 

participation by elders 

under age 60, h o w m a ny 

elders below age 60 live in 

the service area?

Is your organization Yes
4

Field Response

applying as a consortium of 

tribes? If “yes”, you must 

complete Consortium 

Information Chart (Chart 

begins on p.7).

No

For your application to be 

complete, you must attach 

to this application a 

description of your planned 

service area. Have you 

attached this to the

application?

Yes

No

For your application to be 

complete, you must attach 

to this application a signed

Tribal resolution for the 

current grant cycle. Have 

you attached this to the 

application?

Yes

No
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APPLICANT CONTACT

INFORMATION

Field Response

Name of Title VI Director

Email Address

Phone Number

Name of Tribal Fiscal 

Contact for Title VI Grant

Title of Tribal Fiscal Contact

Email Address

Phone Number

Name of Principal Official

(The Principal Official is the 

person authorized to apply 

for grant funds.)

Title of Principal Official

Email Address

Phone Number

Signature of Principal 

Official

This signature verifies that all 

information in this application, 

including service area and 

population data, is truthful and 

accurate.

Date of Signature of 

Principal Official
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Field Response

OTHER CONTACT INFORMATION (OPTIONAL)

Use the space below to include contact information for any other Title VI staff you would 

like ACL to have a record of.

Name of Caregiver Program

Contact

Title

Email Address

Phone Number

Name

Title

Email Address

Phone Number

Name

Title

Email Address

Phone Number
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CONSORTIUM INFORMATION

Complete the following section only if your organization is applying as a consortium of

tribes. If your program's consortium is made up of more than 4 tribes, please add as many

additional pages as necessary to the application to list the additional tribes.

EACH MEMBER OF THE CONSORTIUM IS REQUIRED TO INCLUDE A TRIBAL 

RESOLUTION AUTHORIZING THE TRIBE/VILLAGE TO APPLY FOR TITLE VI 

GRANTS AND A SIGNATURE FROM THE TRIBAL ENROLLMENT CLERK OR CENSUS 

DATA SUPPORTING THE POPULATION STATISTICS BELOW.

TRIBE 1

Name of federallyrecognized Tribe

Number of elders age 60+ 

living in service area

Name of Contact Person for 

Tribe 

Email Address of Contact for 

Tribe 

Phone Number of Contact for 

Tribe

Street address for meal site 

(if there is one) at this Tribe

TRIBE 2

Name of federallyrecognized Tribe

Number of elders age 60+ 

living in service area

Name of Contact Person for 

Tribe 

Email Address of Contact for 

Tribe 
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Phone Number of Contact for 

Tribe

Street address for meal site 

(if there is one) at this Tribe

TRIBE 3

Name of federallyrecognized Tribe

Number of elders age 60+ 

living in service area

Name of Contact Person for 

Tribe 

Email Address of Contact for 

Tribe 

Phone Number of Contact for 

Tribe

Street address for meal site 

(if there is one) at this Tribe

TRIBE 4

Name of federallyrecognized Tribe

Number of elders age 60+ 

living in service area

Name of Contact Person for 

Tribe 

Email Address of Contact for 

Tribe 

Phone Number of Contact for 

Tribe

Street address for meal site 

(if there is one) at this Tribe 
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PROGRAM PLANNING AND

ADMINISTRATION

Question Response

During what date(s) or 

timeframe did you 

conduct the elder needs 

assessment on which you 

are basing your 

application responses?

Describe the elder needs 

assessment process you 

used.

(Select one.)

National Resource Center on Native American Aging

needs assessment

Other (please specify): 

According to your recent 

elder needs assessment, 

what are the top three 

nutrition and supportive 

service needs of the elders

in your service area?

How will your program 

address the top 3

nutrition and supportive

service needs you 

identified in the previous 

question? 

Are any services 

unavailable in parts of 

your service area? If so, 

which services, and why

are they unavailable?

Describe the top 3

obstacles to providing 

nutrition and supportive 

services to your elders.
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Question Response

Describe how your

program will overcome

the obstacles you 

identified in the previous

question.

Describe your program’s 

intake process.

For your application to 

be complete, you must 

attach a copy of your 

program’s intake form. 

Have you attached a copy 

to this application?

Yes 

No

How often does your 

program update an 

elder’s intake form?

Does your program 

coordinate with any of 

the following types of 

organizations to provide 

nutrition or supportive 

services to your elders? If 

so, specify the names of 

the entities.

(Check all that apply 

and specify the names of 

the entities in each 

section.)

Intra-Tribal Departments/Programs (If yes, specify 

which departments/programs):

State/Local Organizations (If yes, specify which 

organizations):

Federal Agencies (If yes, specify which agencies):

Non-profit Organizations (If yes, specify which 

organizations):

Other (Specify name of organization):

Describe how your 

program will coordinate 

with OAA Title III 

service providers, such as 

area agencies on aging 

(AAAs) or the State Unit 

Referrals to each other’s organizations (for example,

when appropriate, Title VI refers clients to Title III and 

Title III refers clients to Title VI):

Regular communication (email, phone calls) to keep 

each other updated on service delivery:
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Question Response

on Aging (SUA). 

(Check all that apply and 

describe coordination.)

Funding/Grants (the Title III organization provides 

funding through grants or another mechanism to your 

organization):

Joint events (Title III and your organization work 

together to put on events for elders/caregivers):

Participate in advisory councils (your organization 

participates in a Title III advisory council, or Title III 

participates in your advisory council):

Other (specify):

Please list the name of the 

Area Agency(ies) on 

Aging and/or State Unit 

on Aging with which you 

coordinate. 

Does your program 

coordinate with these 

Administration for 

Community Livingsupported programs?

(Check all that apply and 

describe coordination.)

Adult Protective Services (APS):

Aging & Disability Resource Center/No Wrong Door:

Centers for Independent Living (CILs):

Protection and advocacy (P&A):

Senior Medicare Patrol (SMP):

State Health Insurance Assistance Program (SHIP):

State Long-Term Care Ombudsman Program 

(LTCOP):

Other (specify):

Who certifies that your

program's meals meet the

Older Americans Act

nutritional requirements

(1/3 DRIs and DGAs for 

Tribal Dietician

IHS Dietician

Contract Dietician
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Question Response

each meal served)? 

(Click here to access the 

current Dietary 

Guidelines for 

Americans.)

Other (please specify):

Does your tribe have a 

tribal veterans program?

Yes

No

If you responded “yes” to 

the previous question,

describe how your elders 

and/or caregivers interact 

with the veterans

program. If you 

responded “no,” please 

move on to the next 

question.

(Check all that apply and 

describe coordination.)

Elder VA benefits coordination:

Caregiver VA benefits coordination:

Referring elders to the veterans program:

Other (please specify):

How do you assess and 

evaluate your program 

services?

(Check all that apply and 

describe coordination.)

Surveys of elders/caregivers:

Elder/caregiver advisory committee(s):

Talking circles/focus groups:

Suggestion box:

Other (specify):
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CONGREGATE MEAL PROGRAM

INFORMATION

Please answer the questions below as if your program was operating under normal 

(non-COVID) conditions when it is safe to gather in person. 

Question Response

Number of meal sites in 

your program’s service 

area:

If your program does not 

provide meals directly, 

enter the name of the 

organization that does 

provide meals in your 

service area.

Please list the street address 

for each of your meal sites.

If your program has more 

than 5 meal sites, attach a 

separate page to the 

application.

Address of meal site 1:

Address of meal site 2:

Address of meal site 3:

Address of meal site 4:

Address of meal site 5:

Estimated number of

unduplicated elders in 

service area who receive a

congregate meal annually:

Estimated number of

congregate meals your 

program provides

annually:

How frequently will each of 

your meal sites provide

congregate meals to eligible

participants?

Meal site 1:

5-7 Days/Week

2-4 Days/Week
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Question Response

If your program has more 

than 5 meal sites, attach a 

separate page to the 

application.

Less than 2 Days/Week

Meal site 2:

5-7 Days/Week

2-4 Days/Week

Less than 2 Days/Week

Meal site 3: 

5-7 Days/Week

2-4 Days/Week

Less than 2 Days/Week

Meal site 4:

5-7 Days/Week

2-4 Days/Week

Less than 2 Days/Week

Meal site 5:

5-7 Days/Week

2-4 Days/Week

Less than 2 Days/Week

What is the full cost of a 

congregate meal at your 

program? 

What is the dollar amount 

charged for a meal served 

to guests who are not 

eligible to participate in the 

program (guest meals)?

Does your program accept Yes
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Question Response

donations other than the 

voluntary monetary

donations received for

meals?

No

If you answered “yes” to 

the previous question, 

describe the type of 

donations your program 

accepts.

Donated meat, game or fish

Donated garden produce

Other (specify type of donation):
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HOME-DELIVERED MEAL

PROGRAM INFORMATION

Please answer the questions below as if your program was operating under normal 

(non-COVID) conditions. 

Question Response

How will your program

determine eligibility for

home-delivered meals?

In-home assessment

Note from health care provider

Other (please specify):

If you chose "In-home 

assessment" in the previous

question, who will conduct 

the in-home assessment for

your program?

If you did not choose Inhome assessment, skip to 

the next question.

Clinic staff

Dietician

Title VI staff

Tribal Social Services/Other Tribal Department

Other (please specify):

Estimated number of 

unduplicated elders in 

service area who receive a 

home-delivered meal 

annually:

Estimated number of 

home-delivered meals your 

program will provide 

annually:

How frequently will your 

program deliver meals to 

eligible participants?

5-7 Days/Week

2-4 Days/Week

Less than 2 Days/Week

Does your program provide

home-delivered meals on a 

temporary and intermittent 

Yes
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Question Response

basis for individuals who 

are temporarily unable to 

access a meal site? (For 

instance, due to health, 

harsh weather or 

emergencies.)

No
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SUPPORTIVE SERVICES PROGRAM 

INFORMATION

Question Response

How do you provide 

information and assistance 

services? 

Check all that apply.

Respond to phone calls from elders

Respond to elders who come to office with questions

Respond to questions from elders at events

Respond to emails or social media messages from 

elders

Other (please specify):

Which of the following 

supportive services will your

program provide?

Check all that apply.

Outreach

Case Management

Transportation

Homemaker 

Personal Care/Home Health Aide 

Chore 

Visiting

Telephoning

Social Events

Health Promotion and Wellness

Visits to persons in nursing facilities/homes or 

residential care communities

Elder Abuse Prevention

Other Supportive Service (please specify types of 

service):
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CAREGIVER PROGRAM

INFORMATION

Complete this section only if you are applying for Part C funds.

Question Response

What is your program’s 

caregiver intake process? 

Attach a copy of your 

program’s caregiver intake 

form to this application.

Estimated number of 

unduplicated caregivers to 

elders who receive a caregiver 

service each year

Estimated number of 

unduplicated caregivers to 

individuals of any age with 

Alzheimer’s disease and 

related disorders who receive 

a caregiver service each year

Estimated number of 

unduplicated elders who are 

caregivers for children under 

age 18 who receive a caregiver 

service each year

Estimated number of 

unduplicated elders who are 

caregivers to adults age 18-59 

with disabilities who receive a 

caregiver service each year

How will your program 

deliver caregiver information

services?

Booth/Exhibit at a fair or community health event

Hosting a conference or other event

Radio/TV/Website
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Question Response

Check all that apply.

If your program does not 

provide this service directly, 

indicate the organization that 

provides it in the “Other” 

field.

Other (please specify):

How will your program 

deliver caregiver information 

and assistance services? 

Check all that apply.

If your program does not 

provide this service directly, 

indicate the organization that 

provides it in the “Other” 

field.

Respond to phone calls from caregivers

Respond to caregivers who come to office with 

questions

Respond to emails or social media messages from 

caregivers

Respond to questions from caregivers at events

Case management service

Other (please specify):

How will your program

deliver caregiver counseling or 

support group services?

Check all that apply.

If your program does not 

provide this service directly, 

indicate the organization that 

provides it in the “Other” 

field.

Peer counseling to individuals

Individual counseling through a licensed mental 

health professional

Peer support groups/talking circles

Support groups/talking circles facilitated by a 

licensed mental health professional

Other (please specify):

How will your program 

deliver caregiver training 

services? 

Check all that apply.

If your program does not 

provide this service directly, 

indicate the organization that 

provides it in the “Other” 

field.

Trainings on caregiving skills (such as bathing, 

transferring, toileting, etc)

Trainings on caregiver self-care

Trainings on diseases or health conditions of 

interest to caregivers (such as Alzheimer’s disease 

or dementia, stroke, diabetes, cancer, heart 

disease)

Other (please specify):
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Question Response

How will your program 

deliver caregiver supplemental 

services? 

Check all that apply.

If your program does not 

provide this service directly, 

indicate the organization that 

provides it in the “Other” 

field.

Lending closet of durable medical equipment and 

other items returnable to the program

Single-use items (such as incontinence supplies)

Home modification/repairs

Homemaker/Chore/Personal Care Service

Financial/Crisis support

Other (please specify):

How does your program

deliver respite care? 

Check all that apply.

If your program does not 

provide this service directly, 

indicate the organization that 

provides it in the “Other” 

field.

Title VI staff (directly or through contracted 

providers) provide respite

Caregivers choose their own care provider, and 

program reimburses caregiver

Adult Day Care/Institutional

Other (please describe):
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Certification Forms

Department of Health and Human Services, Administration for 

Community Living 

CERTIFICATIONS REGARDINGDEBARMENT, SUSPENSION AND 

OTHER RESPONSIBILITY MATTERS, DRUG-FREE WORKPLACE 

REQUIREMENTS AND LOBBYING

Applicants should refer to the regulations cited below to determine the certification to which 

they are required to attest. Applicants should also review the instructions for certification 

included in the regulations before completing this form. Signature on this form provides for 

compliance with certification requirements under 45CFR Part 76, "Government Debarment and 

Suspension (Non- procurement)" and "Government wide Requirements for Drug-Free 

Workplace" and 45CFR Part 93. "New Restrictions on Lobbying." The certifications shall be 

treated as a material representation of fact upon which reliance will be placed when the 

Administration on Aging determines to award the covered transaction, grant, or cooperative

agreement.

Debarment, Suspension, and Other Responsibility Matters

As required by Executive Order 12549, Debarment and Suspension, and implemented at 45

CFR Part 76, for prospective participants in primary covered transactions, as defined at 45

CFR Part, 76, Sections 76.105 and 76.110:

(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.
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Certification Regarding Drug-Free Workplace Requirements

Alternate I. (Grantees Other Than Individuals)

As required by the Drug-Free Workplace Act of 1988, and implemented at 45 CFR Part 

76, Subpart F, for grantees, as defined at 45 CFR Part 76, Sections 76.605 and 76.610 –

A. 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 actionsthat will be 

taken against employees for violation of such prohibition;

(b) Establishing an ongoing drug-free awareness program to inform employees 

about:

(1) The dangers of drug abuse in the workplace;

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

(3) Any available drug counseling, rehabilitation, and employee

assistance programs; and

(4) The penalties that may be imposed upon employees for drug abuse

violations occurring in the workplace;

(c) Making it a requirement that each employee to be engaged in the performance

of the grant be given a copy of the statement required by paragraph (a);

(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: Director, Office of Grants Management and Policy,

ASAM, Department of Health and Human Services,Room 336-E, HHH 

Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. 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).
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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)

Address 1:

Address 2:

City:

County:

State:

Zip Code:

Check this box if there are workplaces on file that are not identified here.
4

Lobbying

Certification for Contracts, Grants, Loans, and Cooperative Agreements

As required by Section 1352, Title 31 of the U.S. Code, and implemented at 45 CFR Part 93, 

for persons entering into a grant, cooperative agreement or contract over $100,000, or loan, or 

loan guarantee over $150,000, as defined at 45 CFR Part 93, Sections 93.105 and 93.110 the 

applicant certifies that to the best of his or her knowledge and belief, that:

(3) 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 certification is a material representation 

of fact upon which reliance was placed when this contract, grant, loan, or cooperative 

agreement.

(4) 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 FormLLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.

(5) The undersigned shall require that the language of this certification be included in the

award documents for all sub-awards at all tiers (including subcontracts,sub-grants, and

contracts under grants, loans, and cooperative agreements) and that allsub-recipients

shall certify and disclose accordingly. 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.

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.
5

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 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.

As the duly authorized representative of the applicant, I hereby certify that the applicant

will comply with the above applicable certification(s).

Signature of Principal Official

Date

Title

Organization 
1

Older Americans Act Title VI, Part A

Program Assurances

Complete this document only if your organization is applying for Title

VI Part A (Nutrition & Supportive Services Grants to American Indian

or Alaskan Native tribes) grants.

Older Americans Act Sec. 614(a) states No grant may be made under this part unless the

eligible tribal organization submits an application to the Assistant Secretary which meets such

criteria as the Assistant Secretary may by regulation prescribe. Each such application shall—

(1) provide that the eligible tribal organization will evaluate the need for supportiveand

nutrition services among older individuals who are Indians to be represented by the

tribal organizations;

(2) provide for the use of such methods of administration as are necessary for the proper

and efficient administration of the program to be assisted;

(3) provide that the tribal organization will make such reports in such form and

containing such information, as the Assistant Secretary may reasonably require,

and comply with such requirements as the Assistant Secretary may impose to

assure the correctness of such reports;

(4) provide for periodic evaluation of activities and projects carried out under the application;

(5) establish objectives consistent with the purposes of this part toward which activities

under the application will be directed, identify obstacles to the attainment of such

objectives, and indicate the manner in which the tribal organization proposesto

overcome such obstacles;

(6) provide for establishing and maintaining information and assistanceservices to assure

that older individuals who are Indians to be served by the assistance made available

under this part will have reasonably convenient accessto such services;

(7) provide a preference for older individuals who are Indians for full or part-time staff

positions wheneverfeasible;

(8) provide assistance that either directly or by way of grant or contract with appropriate

entities nutrition services will be delivered to older individuals who are Indians

represented by the tribal organization substantially in compliance with the provisions

of part C of title III, except that in any case in which the need for nutritional services

for older individuals who are Indians represented by the tribal organization is already

met from other sources, the tribal organization may use the funds otherwise required

to be expended under this paragraph for supportive services;

(9) provide that any legal or ombudsman services made available to older individuals

who are Indians represented by the tribal organization will be substantially in

compliance with the provisions of title III relating to the furnishing of similar

services;
2

(10) provide satisfactory assurance that fiscal control and fund accounting procedures

will be adopted as may be necessary to assure proper disbursement of, and

accounting for, Federal funds paid under this part to the tribal organization,

including any funds paid by the tribal organization to a recipient of a grant or

contract; and

(11) contain assurancesthat the tribal organization will coordinate services provided

under this part with services provided under title III in the same geographical area.

Additionally, 45 CFR 1326.19 requiresthat the application shall provide for:

a) Program objectives, as set forth in section 604(a)(5) of the Act, and any

objectives established by theCommissioner.

b) A description of the geographic boundaries of the service area proposed by

the tribal organization.

c) Documentation of the ability of the tribal organization to deliver supportive and

nutrition servicesto older Indians, or documentation thatthe tribal organization

has effectively administered supportive and nutrition services within the last 3

years;

d) Assurances as prescribedby theCommissionerthat:

(1) A tribal organization represents at least 50 individuals who have

attained 60 years of age or older;

(2) A tribal organization shall comply with all applicable State and

local license and safety requirements for the provision of those

services;

(3) If a substantial number of the older Indians residing in the service

area are of limited English-speaking ability, the tribal organization

shall utilize the services of workers who are fluent in the language

spoken by a predominant number of olderIndians;

(4) Procedures to ensure that allservices under this part are provided

without use of any meanstests;

(5) A tribal organization shall comply with all requirements set forth in Sec.

1326.7 through 1326.17; and

(6) The services provided under this part will be coordinated,

where applicable, with services provided under title III of the

Act.

e) A tribal resolution(s) authorizing the tribal organization to apply for a grant

under this part; and

f) Signature by the principal official of the tribe.
3

By signing below, you affirm that your organization has met the application requirements

detailed herein.

Signature of Principal Official

Date

Title

Organization
1

Older Americans Act Title VI, Part B

Program Assurances

Complete this document only if your organization is applying for Title

VI Part B (Nutrition & Supportive Services Grants to Native Hawaiian

Organizations) grants.

The Older Americans Act Sec. 624(a) providesthat no grant may be made under this part

unless the public or nonprofit private organization submits an application to the Assistant

Secretary which meets such criteria as the Assistant Secretary may by regulation prescribe.

Each such application shall—

(1) provide that the organization will evaluate the need for supportive and nutrition

services among older Native Hawaiians to be represented by theorganization;

(2) provide for the use of such methods of administration as are necessary for the proper

and efficient administration of the program to be assisted;

(3) provide assurances that the organization will coordinate its activities with the State

agency on aging and with the activities carried out under title III in the same

geographical area;

(4) provide that the organization will make such reports in such form and containing

such information as the Assistant Secretary may reasonably require, and comply

with such requirements as the Assistant Secretary may impose to ensure the

correctness of such reports;

(5) provide for periodic evaluation of activities and projects carried out under the application;

(6) establish objectives, consistent with the purpose of this title, toward which activities

described in the application will be directed, identify obstacles to the attainment of

such objectives, and indicate the manner in which the organization proposes to

overcome such obstacles;

(7) provide for establishing and maintaining information and assistance services to assure

that older Native Hawaiians to be served by the assistance made available under this

part will have reasonably convenient accessto such services;

(8) provide a preference for Native Hawaiians 60 years of age and older for full or parttime staff positions whereverfeasible;

(9) provide that any legal or ombudsman servicesmade available to older Native

Hawaiians represented by the nonprofit private organization will be substantially in

compliance with the provisions of title III relating to the furnishing and similar

services; and

(10) provide satisfactory assurance thatthe fiscal control and fundaccounting procedures

will be adopted as may be necessary to assure proper disbursement of, and accounting

for, Federal funds paid under this part to the nonprofit private organization, including

any funds paid by the organization to a recipient of a grant or contract.
2

45 CFR 1328.19 requires that the application shall provide for:

(a) Program objectives, as set forth in section 623(a)(6) of the Act, and any objectives

established by theCommissioner;

(b) A description of the geographic boundaries of the service area proposed by the

eligible organization;

(c) Documentation of the organization's ability to serve older Hawaiian Natives;

(d) Assurances as prescribedby theCommissionerthat:

(1) The eligible organization represents at least 50 olderHawaiian Natives who

have attained 60 years of age or older;

(2) The eligible organization shall conduct all activities on behalf of older

Hawaiian nativesin close coordination with the State agency and Area Agency

on Aging:

(3) The eligible organization shall comply with all applicable State and local

license and safety requirementsforthe provision of those services;

(4) The eligible organization shall ensure that allservices under this part are

provided without use of any means tests;

(5) The eligible organization shall comply with all requirements set forth in

Secs. 1328.7 through 1328.17; and

(6) The services provided under this part will be coordinated, where applicable,

with services provided under title III of the Act.

(e) Signature by the principal official of the eligible organization.

By signing below, you affirm that your organization has met the application requirements

detailed herein.

Signature of Principal Official

Date

Title

Organization