to provide coverage under the State plan for commu-
nity-based attendant services and supports (or simi-
lar coverage) under section 1905(a), section 1915, 
section 1115, or otherwise. 
‘‘(2) ELIGIBILITY FOR ENHANCED MATCH.—In 
the case of a State that provides coverage for such 
services and supports under a waiver, the State shall 
not be eligible under subsection (a)(2) for the en-
hanced FMAP for the early provision of such cov-
erage unless the State submits a plan amendment to 
the Secretary that meets the requirements of this 
section and demonstrates that the State is able to 
fully comply with and implement the requirements of 
this section. 
‘‘(g) DEFINITIONS.—In this title: 
‘‘(1) COMMUNITY-BASED ATTENDANT SERVICES 
AND SUPPORTS.— 
‘‘(A) IN GENERAL.—The term ‘community- 
based attendant services and supports’ means 
attendant services and supports furnished to an 
individual, as needed, to assist in accomplishing 
activities of daily living, instrumental activities 
of daily living, and health-related tasks through 
hands-on assistance, supervision, or cueing— 
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‘‘(i) under a plan of services and sup-
ports that is based on an assessment of 
functional need and that is agreed to in 
writing by the individual or, as appro-
priate, the individual’s representative; 
‘‘(ii) in a home or community setting, 
which shall include but not be limited to a 
school, workplace, or recreation or religious 
facility, but does not include a nursing fa-
cility, institution for mental diseases, or an 
intermediate care facility for the mentally 
retarded; 
‘‘(iii) under an agency-provider model 
or other model (as defined in paragraph 
(2)(C)); 
‘‘(iv) the furnishing of which— 
‘‘(I) is selected, managed, and 
dismissed by the individual, or, as ap-
propriate, with assistance from the in-
dividual’s representative; and 
‘‘(II) provided by an individual 
who is qualified to provide such serv-
ices, including family members (as de-
fined by the Secretary). 
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‘‘(B) INCLUDED
SERVICES
AND
SUP-
PORTS.—Such term includes— 
‘‘(i) tasks necessary to assist an indi-
vidual in accomplishing activities of daily 
living, instrumental activities of daily liv-
ing, and health-related tasks; 
‘‘(ii) the acquisition, maintenance, and 
enhancement of skills necessary for the in-
dividual to accomplish activities of daily 
living, instrumental activities of daily liv-
ing, and health-related tasks; 
‘‘(iii) backup systems or mechanisms 
(such as the use of beepers) to ensure con-
tinuity of services and supports; and 
‘‘(iv) voluntary training on how to se-
lect, manage, and dismiss attendants. 
‘‘(C) EXCLUDED
SERVICES
AND
SUP-
PORTS.—Subject to subparagraph (D), such 
term does not include— 
‘‘(i) the provision of room and board 
for the individual; 
‘‘(ii) special education and related 
services provided under the Individuals 
with Disabilities Education Act and voca-
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tional 
rehabilitation 
services 
provided 
under the Rehabilitation Act of 1973; 
‘‘(iii) assistive technology devices and 
assistive technology services; 
‘‘(iv) durable medical equipment; or 
‘‘(v) home modifications. 
‘‘(D) FLEXIBILITY
IN
TRANSITION
TO 
COMMUNITY-BASED
HOME
SETTING.—Such 
term may include expenditures for transitional 
costs, such as rent and utility deposits, first 
month’s rent and utilities, bedding, basic kitch-
en supplies, and other necessities required for 
an individual to make the transition from a 
nursing facility, institution for mental diseases, 
or intermediate care facility for the mentally re-
tarded to a community-based home setting 
where the individual resides. 
‘‘(2) ADDITIONAL DEFINITIONS.— 
‘‘(A) ACTIVITIES OF DAILY LIVING.—The 
term ‘activities of daily living’ includes eating, 
toileting, grooming, dressing, bathing, and 
transferring. 
‘‘(B) CONSUMER CONTROLLED.—The term 
‘consumer controlled’ means a method of select-
ing and providing services and supports that 
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allow the individual, or where appropriate, the 
individual’s representative, maximum control of 
the community-based attendant services and 
supports, regardless of who acts as the em-
ployer of record. 
‘‘(C) DELIVERY MODELS.— 
‘‘(i) AGENCY-PROVIDER MODEL.—The 
term ‘agency-provider model’ means, with 
respect to the provision of community- 
based attendant services and supports for 
an individual, subject to clause (iii), a 
method of providing consumer controlled 
services and supports under which entities 
contract for the provision of such services 
and supports. 
‘‘(ii) OTHER
MODELS.—The term 
‘other models’ means, subject to clause 
(iii), methods, other than an agency-pro-
vider model, for the provision of consumer 
controlled services and supports. Such 
models may include the provision of vouch-
ers, direct cash payments, or use of a fiscal 
agent to assist in obtaining services. 
‘‘(iii) COMPLIANCE
WITH
CERTAIN 
LAWS.—A State shall ensure that, regard-
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less of whether the State uses an agency- 
provider model or other models to provide 
services and supports under a State plan 
amendment under this section, such serv-
ices and supports are provided in accord-
ance with the requirements of the Fair 
Labor Standards Act of 1938 and applica-
ble Federal and State laws regarding— 
‘‘(I) withholding and payment of 
Federal and State income and payroll 
taxes; 
‘‘(II) the provision of unemploy-
ment and workers compensation in-
surance; 
‘‘(III) maintenance of general li-
ability insurance; and 
‘‘(IV) occupational health and 
safety. 
‘‘(D) 
HEALTH-RELATED
TASKS.—The 
term ‘health-related tasks’ means specific tasks 
that can be delegated or assigned by licensed 
health-care professionals under State law to be 
performed by an attendant. 
‘‘(E) INSTRUMENTAL ACTIVITIES OF DAILY 
LIVING.—The term ‘instrumental activities of 
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daily living’ includes, but is not limited to, meal 
planning and preparation, managing finances, 
shopping for food, clothing, and other essential 
items, performing essential household chores, 
communicating by phone and other media, and 
traveling around and participating in the com-
munity. 
‘‘(F) INDIVIDUALS
REPRESENTATIVE.— 
The term ‘individual’s representative’ means a 
parent, a family member, a guardian, an advo-
cate, or other authorized representative of an 
individual.’’. 
(c) CONFORMING AMENDMENTS.— 
(1) 
MANDATORY
BENEFIT.—Section 
1902(a)(10)(A) of the Social Security Act (42 
U.S.C. 1396a(a)(10)(A)) is amended, in the matter 
preceding clause (i), by striking ‘‘(17) and (21)’’ and 
inserting ‘‘(17), (21), and (28)’’. 
(2) DEFINITION
OF
MEDICAL
ASSISTANCE.— 
Section 1905(a) of the Social Security Act (42 
U.S.C. 1396d) is amended— 
(A) by striking ‘‘and’’ at the end of para-
graph (27); 
(B) by redesignating paragraph (28) as 
paragraph (29); and 
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(C) by inserting after paragraph (27) the 
following: 
‘‘(28) community-based attendant services and 
supports (to the extent allowed and as defined in 
section 1943); and’’. 
(3) 
IMD/ICFMR 
REQUIREMENTS.—Section 
1902(a)(10)(C)(iv) of the Social Security Act (42 
U.S.C. 1396a(a)(10)(C)(iv)) is amended by inserting 
‘‘and (28)’’ after ‘‘(24)’’. 
(d) EFFECTIVE DATES.— 
(1) IN GENERAL.—Except as provided in para-
graph (2), the amendments made by this section 
(other than the amendment made by subsection 
(c)(1)) take effect on October 1, 2009, and apply to 
medical assistance provided for community-based at-
tendant services and supports described in section 
1943 of the Social Security Act furnished on or 
after that date. 
(2) MANDATORY
BENEFIT.—The amendment 
made by subsection (c)(1) takes effect on October 1, 
2014. 
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SEC. 102. ENHANCED FMAP FOR ONGOING ACTIVITIES OF 
EARLY COVERAGE STATES THAT ENHANCE 
AND PROMOTE THE USE OF COMMUNITY- 
BASED 
ATTENDANT 
SERVICES 
AND 
SUP-
PORTS. 
(a) IN GENERAL.—Section 1943 of the Social Secu-
rity Act, as added by section 101(b), is amended— 
(1) by redesignating subsections (d) through (g) 
as subsections (f) through (i), respectively; 
(2) in subsection (a)(1), by striking ‘‘subsection 
(g)(1)’’ and inserting ‘‘subsection (i)(1)’’; 
(3) in subsection (a)(2), by inserting ‘‘, and 
with respect to expenditures described in subsection 
(d), the Secretary shall pay the State the amount 
described in subsection (d)(1)’’ before the period; 
(4) in subsection (c)(1)(C), by striking ‘‘sub-
section 
(g)(2)(B)’’ 
and 
inserting 
‘‘subsection 
(i)(2)(B)’’; and 
(5) by inserting after subsection (c), the fol-
lowing: 
‘‘(d) INCREASED FEDERAL FINANCIAL PARTICIPA-
TION FOR EARLY COVERAGE STATES THAT MEET CER-
TAIN BENCHMARKS.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
for purposes of subsection (a)(2), the amount and 
expenditures described in this subsection are an 
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amount equal to the Federal medical assistance per-
centage, increased by 10 percentage points, of the 
expenditures incurred by the State for the provision 
or conduct of the services or activities described in 
paragraph (3). 
‘‘(2) EXPENDITURE CRITERIA.—A State shall— 
‘‘(A) develop criteria for determining the 
expenditures described in paragraph (1) in col-
laboration with the individuals and representa-
tives described in subsection (b)(1); and 
‘‘(B) submit such criteria for approval by 
the Secretary. 
‘‘(3) SERVICES, SUPPORTS AND ACTIVITIES DE-
SCRIBED.—For purposes of paragraph (1), the serv-
ices, supports and activities described in this sub-
paragraph are the following: 
‘‘(A) 1-stop intake, referral, and institu-
tional diversion services. 
‘‘(B) Identifying and remedying gaps and 
inequities in the State’s current provision of 
long-term services and supports, particularly 
those services and supports that are provided 
based on such factors as age, severity of dis-
ability, type of disability, ethnicity, income, in-
stitutional bias, or other similar factors. 
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‘‘(C) Establishment of consumer participa-
tion and consumer governance mechanisms, 
such as cooperatives and regional service au-
thorities, that are managed and controlled by 
individuals with significant disabilities who use 
community-based services and supports or their 
representatives. 
‘‘(D) Activities designed to enhance the 
skills, earnings, benefits, supply, career, and fu-
ture prospects of workers who provide commu-
nity-based attendant services and supports. 
‘‘(E) Continuous, comprehensive quality 
improvement activities that are designed to en-
sure and enhance the health and well-being of 
individuals who rely on community-based at-
tendant services and supports, particularly ac-
tivities involving or initiated by consumers of 
such services and supports or their representa-
tives. 
‘‘(F) Family support services to augment 
the efforts of families and friends to enable in-
dividuals with disabilities of all ages to live in 
their own homes and communities. 
‘‘(G) Health promotion and wellness serv-
ices and activities. 
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‘‘(H) Provider recruitment and enhance-
ment activities, particularly such activities that 
encourage the development and maintenance of 
consumer controlled cooperatives or other small 
businesses or micro-enterprises that provide 
community-based attendant services and sup-
ports or related services. 
‘‘(I) Activities designed to ensure service 
and systems coordination. 
‘‘(J) Any other services or activities that 
the Secretary deems appropriate.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) take effect on October 1, 2009. 
SEC. 103. INCREASED FEDERAL FINANCIAL PARTICIPATION 
FOR CERTAIN EXPENDITURES. 
(a) IN GENERAL.—Section 1943 of the Social Secu-
rity Act, as added by section 101(b) and amended by sec-
tion 102, is amended by inserting after subsection (d) the 
following: 
‘‘(e) INCREASED FEDERAL FINANCIAL PARTICIPA-
TION FOR CERTAIN EXPENDITURES.— 
‘‘(1) ELIGIBILITY FOR PAYMENT.— 
‘‘(A) IN GENERAL.—In the case of a State 
that the Secretary determines satisfies the re-
quirements of subparagraph (B), the Secretary 
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shall pay the State the amounts described in 
paragraph (2) in addition to any other pay-
ments provided for under section 1903 or this 
section for the provision of community-based at-
tendant services and supports. 
‘‘(B) REQUIREMENTS.—The requirements 
of this subparagraph are the following: 
‘‘(i) The State has an approved plan 
amendment under this section. 
‘‘(ii) The State has incurred expendi-
tures described in paragraph (2). 
‘‘(iii) The State develops and submits 
to the Secretary criteria to identify and se-
lect such expenditures in accordance with 
the requirements of paragraph (3). 
‘‘(iv) The Secretary determines that 
payment of the applicable percentage of 
such expenditures (as determined under 
paragraph (2)(B)) would enable the State 
to provide a meaningful choice of receiving 
community-based services and supports to 
individuals with disabilities and elderly in-
dividuals who would otherwise only have 
the option of receiving institutional care. 
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‘‘(2) 
AMOUNTS
AND
EXPENDITURES
DE-
SCRIBED.— 
‘‘(A) EXPENDITURES
IN
EXCESS
OF
150 
PERCENT
OF
BASELINE
AMOUNT.—The 
amounts and expenditures described in this 
paragraph are an amount equal to the applica-
ble percentage, as determined by the Secretary 
in accordance with subparagraph (B), of the ex-
penditures incurred by the State for the provi-
sion of community-based attendant services and 
supports to an individual that exceed 150 per-
cent of the average cost of providing nursing fa-
cility services to an individual who resides in 
the State and is eligible for such services under 
this title, as determined in accordance with cri-
teria established by the Secretary. 
‘‘(B) 
APPLICABLE
PERCENTAGE.—The 
Secretary shall establish a payment scale for 
the expenditures described in subparagraph (A) 
so that the Federal financial participation for 
such expenditures gradually increases from 70 
percent to 90 percent as such expenditures in-
crease. 
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‘‘(3) SPECIFICATION OF ORDER OF SELECTION 
FOR
EXPENDITURES.—In order to receive the 
amounts described in paragraph (2), a State shall— 
‘‘(A) develop, in collaboration with the in-
dividuals and representatives described in sub-
section (b)(1) and pursuant to guidelines estab-
lished by the Secretary, criteria to identify and 
select the expenditures submitted under that 
paragraph; and 
‘‘(B) submit such criteria to the Sec-
retary.’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) takes effect on October 1, 2009. 
TITLE II—PROMOTION OF SYS-
TEMS CHANGE AND CAPACITY 
BUILDING 
SEC. 201. GRANTS TO PROMOTE SYSTEMS CHANGE AND CA-
PACITY BUILDING. 
(a) AUTHORITY TO AWARD GRANTS.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services (in this section referred to as the 
‘‘Secretary’’) shall award grants to eligible States to 
carry out the activities described in subsection (b). 
(2) APPLICATION.—In order to be eligible for a 
grant under this section, a State shall submit to the 
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Secretary an application in such form and manner, 
and that contains such information, as the Secretary 
may require. 
(b) PERMISSIBLE ACTIVITIES.—A State that receives 
a grant under this section may use funds provided under 
the grant for any of the following activities, focusing on 
areas of need identified by the State and the Consumer 
Task Force established under subsection (c): 
(1) The development and implementation of the 
provision of community-based attendant services and 
supports under section 1943 of the Social Security 
Act (as added by section 101(b) and amended by 
sections 102 and 103) through active collaboration 
with— 
(A) individuals with disabilities; 
(B) elderly individuals; 
(C) representatives of such individuals; and 
(D) providers of, and advocates for, serv-
ices and supports for such individuals. 
(2) Substantially involving individuals with sig-
nificant disabilities and representatives of such indi-
viduals in jointly developing, implementing, and con-
tinually improving a mutually acceptable comprehen-
sive, effectively working statewide plan for pre-
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venting and alleviating unnecessary institutionaliza-
tion of such individuals. 
(3) Engaging in system change and other ac-
tivities deemed necessary to achieve any or all of the 
goals of such statewide plan. 
(4) Identifying and remedying disparities and 
gaps in services to classes of individuals with disabil-
ities and elderly individuals who are currently expe-
riencing or who face substantial risk of unnecessary 
institutionalization. 
(5) Building and expanding system capacity to 
offer quality consumer controlled community-based 
services and supports to individuals with disabilities 
and elderly individuals, including by— 
(A) seeding the development and effective 
use of community-based attendant services and 
supports cooperatives, Independent Living Cen-
ters, small businesses, micro-enterprises, micro- 
boards, and similar joint ventures owned and 
controlled by individuals with disabilities or rep-
resentatives of such individuals and community- 
based attendant services and supports workers; 
(B) enhancing the choice and control indi-
viduals with disabilities and elderly individuals 
exercise, including through their representa-
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tives, with respect to the personal assistance 
and supports they rely upon to lead inde-
pendent, self-directed lives; 
(C) enhancing the skills, earnings, benefits, 
supply, career, and future prospects of workers 
who provide community-based attendant serv-
ices and supports; 
(D) engaging in a variety of needs assess-
ment and data gathering; 
(E) developing strategies for modifying 
policies, practices, and procedures that result in 
unnecessary institutional bias or the over- 
medicalization of long-term services and sup-
ports; 
(F) engaging in interagency coordination 
and single point of entry activities; 
(G) providing training and technical assist-
ance with respect to the provision of commu-
nity-based attendant services and supports; 
(H) engaging in— 
(i) public awareness campaigns; 
(ii) facility-to-community transitional 
activities; and 
(iii) 
demonstrations 
of 
new 
ap-
proaches; and 
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(I) engaging in other systems change ac-
tivities necessary for developing, implementing, 
or evaluating a comprehensive statewide system 
of community-based attendant services and sup-
ports. 
(6) Ensuring that the activities funded by the 
grant are coordinated with other efforts to increase 
personal attendant services and supports, includ-
ing— 
(A) programs funded under or amended by 
the Ticket to Work and Work Incentives Im-
provement Act of 1999 (Public Law 106–170; 
113 Stat. 1860); 
(B) grants funded under the Families of 
Children With Disabilities Support Act of 2000 
(42 U.S.C. 15091 et seq.); and 
(C) other initiatives designed to enhance 
the delivery of community-based services and 
supports to individuals with disabilities and el-
derly individuals. 
(7) Engaging in transition partnership activities 
with nursing facilities and intermediate care facili-
ties for the mentally retarded that utilize and build 
upon items and services provided to individuals with 
disabilities or elderly individuals under the Medicaid 
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program under title XIX of the Social Security Act, 
or by Federal, State, or local housing agencies, Inde-
pendent Living Centers, and other organizations 
controlled by consumers or their representatives. 
(c) CONSUMER TASK FORCE.— 
(1) ESTABLISHMENT AND DUTIES.—To be eli-
gible to receive a grant under this section, each 
State shall establish a Consumer Task Force (re-
ferred to in this subsection as the ‘‘Task Force’’) to 
assist the State in the development, implementation, 
and evaluation of real choice systems change initia-
tives. 
(2) APPOINTMENT.—Members of the Task 
Force shall be appointed by the Chief Executive Of-
ficer of the State in accordance with the require-
ments of paragraph (3), after the solicitation of rec-
ommendations from representatives of organizations 
representing a broad range of individuals with dis-
abilities, elderly individuals, representatives of such 
individuals, and organizations interested in individ-
uals with disabilities and elderly individuals. 
(3) COMPOSITION.— 
(A) IN GENERAL.—The Task Force shall 
represent a broad range of individuals with dis-
abilities from diverse backgrounds and shall in-
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clude representatives from Developmental Dis-
abilities Councils, Mental Health Councils, 
State Independent Living Centers and Councils, 
Commissions on Aging, organizations that pro-
vide services to individuals with disabilities and 
consumers of long-term services and supports. 
(B) INDIVIDUALS WITH DISABILITIES.—A 
majority of the members of the Task Force 
shall be individuals with disabilities or rep-
resentatives of such individuals. 
(C) LIMITATION.—The Task Force shall 
not include employees of any State agency pro-
viding services to individuals with disabilities 
other than employees of entities described in 
the Developmental Disabilities Assistance and 
Bill of Rights Act of 2000 (42 U.S.C. 15001 et 
seq.). 
(d) ANNUAL REPORT.— 
(1) STATES.—A State that receives a grant 
under this section shall submit an annual report to 
the Secretary on the use of funds provided under the 
grant in such form and manner as the Secretary 
may require. 
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(2) SECRETARY.—The Secretary shall submit 
to Congress an annual report on the grants made 
under this section. 
(e) AUTHORIZATION OF APPROPRIATIONS.— 
(1) IN GENERAL.—There is authorized to be 
appropriated to carry out this section, $50,000,000 
for each of fiscal years 2010 through 2012. 
(2) AVAILABILITY.—Amounts appropriated to 
carry out this section shall remain available without 
fiscal year limitation. 
SEC. 202. DEMONSTRATION PROJECT TO ENHANCE CO-
ORDINATION OF CARE UNDER THE MEDI-
CARE AND MEDICAID PROGRAMS FOR DUAL 
ELIGIBLE INDIVIDUALS. 
(a) DEFINITIONS.—In this section: 
(1) DUALLY ELIGIBLE INDIVIDUAL.—The term 
‘‘dually eligible individual’’ means an individual who 
is enrolled in the Medicare and Medicaid programs 
established under Titles XVIII and XIX, respec-
tively, of the Social Security Act (42 U.S.C. 1395 et 
seq., 1396 et seq.). 
(2) PROJECT.—The term ‘‘project’’ means the 
demonstration project authorized to be conducted 
under this section. 
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(3) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
(b) AUTHORITY TO CONDUCT PROJECT.—The Sec-
retary shall conduct a project under this section for the 
purpose of evaluating service coordination and cost-shar-
ing approaches with respect to the provision of commu-
nity-based services and supports to dually eligible individ-
uals. 
(c) REQUIREMENTS.— 
(1) NUMBER
OF
PARTICIPANTS.—Not more 
than 5 States may participate in the project. 
(2) APPLICATION.—A State that desires to par-
ticipate in the project shall submit an application to 
the Secretary, at such time and in such form and 
manner as the Secretary shall specify. 
(3) DURATION.—The project shall be conducted 
for at least 5, but not more than 10 years. 
(d) EVALUATION AND REPORT.— 
(1) EVALUATION.—Not later than 1 year prior 
to the termination date of the project, the Secretary, 
in consultation with States participating in the 
project, representatives of dually eligible individuals, 
and others, shall evaluate the impact and effective-
ness of the project. 
VerDate Nov 24 2008 
04:49 Mar 24, 2009
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