1

OMB Control Number: 0985-New

Expiration Date: xx/xx/xxxx

Application for OlderAmericansAct,

Title VI 2020-2023 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-new). 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.

Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions

for reducing this burden, to the Administration for Community Living, U.S. Department of Health and Human Services,

330 C Street, SW, Washington, DC 20201-0008, Attention Leslie Green, or email leslie.green@acl.hhs.gov.
2

APPLICANT ORGANIZATION INFORMATION

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)

Street Address

City

State

Zip Code

Organization's 9-Digit EIN 

Suffix to EIN Organization's

Active DUNS

Current Title VI Part A/B Grant Number

(Do not complete this question if you are not a Title VI grantee for the

2017-2020 grant cycle.)

Number of Older Americans Act-eligible elders (Age 60+) 

living in service area

Source of Older Americans Act-eligible elders data U.S. Census

Tribal

Enrollment

Signature of Tribal Enrollment Official (signature and enrollment data may

also be attached as a separate page)

Date of signature of Tribal Enrollment Official

Does organization allow participation in Title VI services by elders under

age 60?

Yes

No

If "yes" to previous question, what is the organization's age for an eligible

elder?

If organization allows participation by elders under age 60, number of 

elders below age 60 living in service area

Total number of elders in service area

(Total of elders age 60+ and elders under 60)

Is your organization applying as a consortium of tribes? If “yes”, complete 

consortium chart on page 3.

Yes

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
3

For your application to be complete, you must attach to this application a 

signed Tribal resolution. Have you attached this to the application?

Yes

No
4

APPLICANT CONTACT INFORMATION

Name of Title VI Director

Email Address

Phone Number Fax Number

Name of Tribal Fiscal Contact for Title VI Grant

Title of Tribal Fiscal Contact

Email Address

Phone Number Fax 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 Fax Number

Signature of Principal Official

Date of Signature of Principal Official

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 Fax Number

Name 

Title

Email Address

Phone Number Fax Number

Name 

Title

Email Address

Phone Number Fax Number
5

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/villages, please add an additional page to the application to list the additional tribes/villages.

EACH MEMBER OFTHE CONSORTIUM IS REQUIRED TO INCLUDE ATRIBAL RESOLUTION TO PARTICIPATE IN THE

TITLE VI GRANTPROGRAM.

TRIBE/VILLAGE 1

Name of Tribe/ Village

Number of elders (age 60+) in Tribe/Village

Name of Contact Person for Tribe/Village

Email Address of Contact for Tribe/Village

Phone Number of Contact for Tribe/Village

TRIBE/VILLAGE 2

Name of Tribe/ Village

Number of elders (age 60+) in Tribe/Village

Name of Contact Person for Tribe/Village

Email Address of Contact for Tribe/Village

Phone Number of Contact for Tribe/Village

TRIBE/VILLAGE 3

Name of Tribe/ Village

Number of elders (age 60+) in Tribe/Village

Name of Contact Person for Tribe/Village

Email Address of Contact for Tribe/Village

Phone Number of Contact for Tribe/Village

TRIBE/VILLAGE 4

Name of Tribe/ Village

Number of elders (age 60+) in Tribe/Village

Name of Contact Person for Tribe/Village

Email Address of Contact for Tribe/Village

Phone Number of Contact for Tribe/Village
6

PROGRAM PLANNING AND ADMINISTRATION

1. What are the identified needs for supportive and nutrition services

among older individuals who are Indians, according to the results of your

program's Needs Assessment?

2. Describe the nutrition and supportive service programming your

program will provide and how your program will deliver the services.

Include how your program will ensure consistent service delivery across

the entire service area.

3. Describe any obstacles to nutrition and supportive service delivery that 

your program may encounter.
7

4. Describe how your program will overcome the obstacles described in

the previous question.

5. Describe any coordination between your program and other entities to

deliver nutrition or supportive services, including any work your program

does with:

-other Tribal programs or departments (Health Department or others);

-other Federal agencies or programs (IHS, USDA, VA, etc.);

-any state or local government organizations-

-any non-profit organizations.

Describe the structure of the Title VI program in your tribe/ organization. 

Include:

-where in your organization the Title VI Program is located (elder

services, social services, health department, etc);

-the number of full time staff, part time staff and volunteers your program

uses;

-how your program will communicate with the tribal fiscal contact/office.
8

6. Describe how your program will coordinate with OAA Title III service

providers. Include:

-whether your elders use any services provided by OAA Title III

organizations, such as area agencies on aging;

-whether your organization receives Title III funding;

-descriptions of any past or upcoming coordinated trainings or meetings;

-any other coordination with Title III-funded organizations.

Describe any additional sources of funding that support 

your nutrition and/or supportive services programming.

7. Who certifies that your program's meals meet the nutritional

requirements (DRIs, Dietary Goals for All Americans) specified in the

Older Americans Act?

Tribal Dietician

IHS Dietician 

Contract Dietician 

Other

8. Does your tribe have a tribal veterans program? Yes

No

I1. If you answered "yes" to the previous question, please describe your

tribe's veterans program.
9

CONGREGATE MEAL PROGRAM INFORMATION

1. Number of meal sites in service area

(If you do not provide meals directly, state the organization that does provide

meals in your service area.)

2. Number of unduplicated elders (using the age of eligibility set by your 

tribe) served at ALL meal sites in service area annually

3. Number of congregate meals your program will provide at ALL meal

sites in service area annually

4. How frequently will your program provide meals to eligible

participants?

Daily 

Weekly

Monthly 

Other

5. Dollar amount charged for a meal served to guests who are not eligible

to participate in the program.

6, Does your program accept donations other than the voluntary

donations received for the meals at the time of service?

Yes

No

7. If you answered “yes” to the previous question, describe the type of

donations your program accepts.

8. Describe how your program ensures that meals appeal to program

participants. (For instance, does your program conduct client satisfaction

surveys?)
10

HOME-DELIVERED MEAL PROGRAM INFORMATION

1. How will your program determine eligibility for home-delivered meals? In-home assessment

Note from health care provider 

Other

2. If you chose "In-home assessment" in the previous question, who will

conduct the in-home assessment for your program?

Clinic staff

Dietician 

Title VI staff

Tribal Social Services/Other Tribal Department

Other

3. Number of unduplicated elders or other eligible participants your 

program will provide home-delivered meals to each year

4. Number of home-delivered meals your program will provide each year

5. How frequently will your program deliver meals to eligible

participants?

Daily 

Weekly

Monthly 

Other

6. What is the mileage (one-way) to your program's furthest homedelivered meal client?

7. What type of home-delivered meal will your program provide? Hot meal

Frozen meal

Food packages/boxes 

Emergency meals

Other

8. During harsh weather or when the meal site is closed for an emergency,

will your program deliver meals to all elders?

Yes

No

Meals will be sent in advance for emergencies

Other

9. Does your program provide home-delivered meals on a temporary and

intermittent basis for individuals who are temporarily unable to access a

meal site?

Yes

No
11

SUPPORTIVE SERVICES

1. Describe how your program will establish or maintain information and

assistance services and how your program will ensure that elders will have

reasonably convenient access to these services.

2. Which of the following supportive services will your program provide? Case Management

Chore

Elder Abuse Prevention

Health Promotion and Wellness

Homemaker

Legal Assistance 

Ombudsman 

Outreach

Personal Care/Home Health Aide 

Social Events

Telephoning

Transportation

Visiting

Other

3. If your program will provide legal assistance or ombudsman services,

describe how your program will ensure the services are substantially in

compliance with Title III of the Older Americans Act.
12

CAREGIVER PROGRAM INFORMATION

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

1. How many unduplicated caregivers to Elders or individuals of any age

with Alzheimer’s disease and related disorders does your program plan to

serve each year?

2. How many unduplicated Elder caregivers caring for children under the

age of 18 does your program plan to serve annually?

3. How many unduplicated Elder caregivers providing care to adults 18-59

years old with disabilities does your program plan to serve annually?

4. Describe how your program will deliver caregiver programming.

Include a description of how your program will provide or coordinate with

other organizations to provide the five required caregiver services

(Information, Assistance, Counseling/Support Groups/Training,

Supplemental Services, Respite).

5. Describe any obstacles to caregiver service delivery that your program

may encounter.
13

6. Describe how your program will overcome the obstacles described in

the previous question.

7. If your program coordinates with other programs or departments to

deliver caregiver services, describe who you partner with and for which

services.
14

9. Describe your respite program for caregivers to Elders or individuals of

any age with Alzheimer’s disease and related disorders.

10. Describe your respite program for Elder caregivers caring for children

under the age of 18.
Page 1 of 4

14

Certification Forms

Department of Health and Human Services

Administration on Aging

CERTIFICATIONS REGARDING DEBARMENT, 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 (Nonprocurement)" 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.

1. 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.
Page 2 of 4

15

2. 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 actions that will be taken against

employees for violation of such prohibition;

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

–

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

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

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

assistance programs; and

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

violations occurring in the workplace;

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

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

(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).

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:
Page 3 of 4

16

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

Address:

Address:

City:

County:

State:

Zip Code:

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

Alternate II. (Grantees Who Are 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, 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: 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. When notice is made to such a

central point, it shall include the identification number(s) of each affected grant.

3. 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:

(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 certification is a material representation of fact upon

which reliance was placed when this contract, grant, loan, or cooperative agreement.
Page 4 of 4

17

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

contracts under grants, loans, and cooperative agreements) and that all sub-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.

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
18

OlderAmericansAct Title VI, Part A

ProgramAssurances

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 supportive and 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 proposes to overcome such obstacles;

(6) provide for establishing and maintaining information and assistance services to assure that older

individuals who are Indians to be served by the assistance made available under this part will

have reasonably convenient access to such services;

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

whenever feasible;

(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;

(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 assurances that the tribal organization will coordinate services provided under

this part with services provided under title III in the same geographical area.
19

Additionally, 45 CFR 1326.19 requires that the application shall provide for:

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

established by the Commissioner.

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

services to older Indians, or documentation that the tribal organization has effectively

administered supportive and nutrition services within the last 3 years;

d) Assurances as prescribed by the Commissioner that:

(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 older Indians;

(4) Procedures to ensure that all services under this part are provided without

use of any means tests;

(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.

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

Signature of Principal

Official

Date

Title

Organization
20

OlderAmericansAct Title VI, Part B

ProgramAssurances

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) provides that 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 the organization;

(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 access to such services;

(8) provide a preference for Native Hawaiians 60 years of age and older for full or part-time staff

positions wherever feasible;

(9) provide that any legal or ombudsman services made 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 that the 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 nonprofit private organization, including any funds paid by the

organization to a recipient of a grant or contract.

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;
21

(d) Assurances as prescribed by the Commissioner that:

(1) The eligible organization represents at least 50 older Hawaiian Natives who have attained

60 years of age or older;

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

in 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 requirements for the provision of those services;

(4) The eligible organization shall ensure that all services 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