OMB Control Number: 0985-New Expiration Date: xx/xx/xxxx

# Application for Older Americans Act, 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.

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### 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

**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

### 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**

### 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 OF THE CONSORTIUM IS REQUIRED TO INCLUDE A TRIBAL RESOLUTION TO PARTICIPATE IN THE TITLE VI GRANT PROGRAM.**

**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**

### 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.**

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.**

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.**

### 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?)**

### 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 home- delivered 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**

### 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.**

### 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.**

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.**

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.**

# 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 (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.

#### 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.

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#### 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:

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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.

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(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

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# 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 Indianor 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.

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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	

# 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 HawaiianOrganizations) 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 the Commissioner;

(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 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