[Federal Register Volume 60, Number 58 (Monday, March 27, 1995)]
[Notices]
[Pages 15770-15783]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-7506]
Appendix A--Executive Order 12372--State Single Points of Contact
ARIZONA
Mrs. Janice Dunn, Attn: Arizona State Clearinghouse, 3800 N.
Central Avenue, 14th Floor, Phoenix, Arizona 85012, Telephone (602)
280-1315
ARKANSAS
Tracie L. Copeland, Manager, State Clearinghouse, Office of
Intergovernmental Services, Department of Finance and Administration,
PO. Box 3278, Little Rock, Arkansas 72203, Telephone (501) 682-1074
CALIFORNIA
Glenn Stober, Grants Coordinator, Office of Planning and Research,
1400 Tenth Street, Sacramento, California 95814, Telephone (916) 323-
7480
DELAWARE
Ms. Francine Booth, State Single Point of Contact, Executive
Department, Thomas Collins Building, Dover, Delaware 19903, Telephone
(302) 736-3326
DISTRICT OF COLUMBIA
Rodney T. Hallman, State Single Point of Contact, Office of Grants
Management and Development, 717 14th Street, NW., Suite 500,
Washington, DC. 20005, Telephone (202) 727-6551
FLORIDA
Florida State Clearinghouse, Intergovernmental Affairs Policy Unit,
Executive Office of the [[Page 15771]] Governor, Office of Planning and
Budgeting, The Capitol, Tallahassee, Florida 32399-0001, Telephone
(904) 488-8441
GEORGIA
Mr. Charles H. Badger, Administrator, Georgia State Clearinghouse,
254 Washington Street, SW., Atlanta, Georgia 30334, Telephone (404)
656-3855
ILLINOIS
Steve Klokkenga, State Single Point of Contact, Office of the
Governor, 107 Stratton Building, Springfield, Illinois 62706, Telephone
(217) 782-1671
INDIANA
Jean S. Blackwell, Budget Director, State Budget Agency, 212 State
House, Indianapolis, Indiana 46204, Telephone (317) 232-5610
IOWA
Mr. Steven R. McCann, Division of Community Progress, Iowa
Department of Economic Development, 200 East Grand Avenue, Des Moines,
Iowa 50309, Telephone (515) 281-3725
KENTUCKY
Ronald W. Cook, Office of the Governor, Department of Local
Government, 1024 Capitol Center Drive, Frankfort, Kentucky 40601,
Telephone (502) 564-2382
MAINE
Ms. Joyce Benson, State Planning Office, State House Station #38,
Augusta, Maine 04333, Telephone (207) 289-3261
MARYLAND
Ms. Mary Abrams, Chief, Maryland State Clearinghouse, Department of
State Planning, 301 West Preston Street, Baltimore, Maryland 21201-
2365, Telephone (301) 225-4490
MASSACHUSETTS
Karen Arone, State Clearinghouse, Executive Office of Communities
and Development, 100 Cambridge Street, Room 1803, Boston, Massachusetts
02202, Telephone (617) 727-7001
MICHIGAN
Richard S. Pastula, Director, Michigan Department of Commerce,
Lansing, Michigan 48909, Telephone (517) 373-7356
MISSISSIPPI
Ms. Cathy Mallette, Clearinghouse Officer, Office of Federal Grant
Management and Reporting, 301 West Peral Street, Jackson, Mississippi
39203, Telephone (601) 960-2174
MISSOURI
Ms. Lois Pohl, Federal Assistance Clearinghouse, Office of
Administration, P.O. Box 809, Room 430, Truman Building, Jefferson
City, Missouri 65102, Telephone (314) 751-4834
NEVADA
Department of Administration, State Clearinghouse, Capitol Complex,
Carson City, Nevada 89710, Telephone (702) 687-4065, Attention: Ron
Sparks, Clearinghouse Coordinator
NEW HAMPSHIRE
Mr. Jeffrey H. Taylor, Director, New Hampshire Office of State
Planning, Attn: Intergovernmental Review, Process/James E. Bieber, 2\1/
2\ Beacon Street, Concord, New Hampshire 03301, Telephone (603) 271-
2155
NEW JERSEY
Gregory W. Adkins, Acting Director, Division of Community
Resources, N.J. Department of Community Affairs, Trenton, New Jersey
08625-0803, Telephone (609) 292-6613
Please direct correspondence and questions to:
Andrew J. Jaskolka, State Review Process, Division of Community
Resources, CN 814, Room 609, Trenton, New Jersey 08625-0803, Telephone
(609) 292-9025
NEW MEXICO
George Elliott, Deputy Director, State Budget Division, Room 190,
Bataan Memorial Building, Santa Fe, New Mexico 87503, Telephone (505)
827-3640, FAX (505) 827-3006
NEW YORK
New York State Clearinghouse Division of the Budget, State Capitol,
Albany, New York 12224, Telephone (518) 474-1605
NORTH CAROLINA
Mrs. Chrys Baggett, Director, Office of the Secretary of Admin.,
N.C. State Clearinghouse, 116 W. Jones Street, Raleigh, North Carolina
27603-8003, Telephone (919) 733-7232
NORTH DAKOTA
N.D. Single Point of Contact, Office of Intergovernmental
Assistance, Office of Management and Budget, 600 East Boulevard Avenue,
Bismarck, North Dakota 58505-0170, Telephone (701) 224-2094
OHIO
Larry Weaver, State Single Point of Contract, State/Federal Funds
Coordinator, State Clearinghouse, Office of Budget and Management, 30
East Broad Street, 34th Floor, Columbus, Ohio 43266-0411, Telephone
(614) 466-0698
RHODE ISLAND
Mr. Daniel W. Varin, Associate Director, Statewide Planning
Program, Department of Administration, Division of Planning, 265
Melrose Street, Providence, Rhode Island 02907, Telephone (401) 277-
2656
Please direct correspondence and questions to:
Review Coordinator, Office of Strategic Planning
SOUTH CAROLINA
Omeagia Burgess, State Single Point of Contact, Grant Services,
Office of the Governor, 1205 Pendleton Street, Room 477, Columbia,
South Carolina 29201, Telephone (803) 734-0494
TENNESSEE
Mr. Charles Brown, State Single Point of Contact, State Planning
Office, 500 Charlotte Avenue, 309 John Sevier Building, Nashville,
Tennessee 37219, Telephone (615) 741-1676
TEXAS
Mr. Thomas Adams, Governor's Office of Budget and Planning, PO Box
12428, Austin, Texas 78711, Telephone (512) 463-1778
UTAH
Utah State Clearinghouse, Office of Planning and Budget, ATTN:
Carolyn Wright, Room 116 State Capitol, Salt Lake City, Utah 84114,
Telephone (801) 538-1535
VERMONT
Mr. Bernard D. Johnson, Assistant Director, Office of Policy
Research and Coordination, Pavilion Office Building, 109 State Street,
Montpelier, Vermont 05602, Telephone (802) 828-3326
WEST VIRGINIA
Mr. Fred Cutlip, Director, Community Development Division, West
Virginia Development Office, Building #6, Room 553, Charleston, West
Virginia 25305, Telephone (304) 348-4010
WISCONSIN
Mr. William C. Carey, Federal/State Relations, Wisconsin Department
of Administration, 101 South Webster Street, PO Box 7864, Madison,
Wisconsin 53707, Telephone (608) 266-0267
WYOMING
Sheryl Jeffries, State Single Point of Contact, Herschler Building,
4th Floor, East Wing, Cheyenne, Wyoming 82002, Telephone (307) 777-7574
GUAM
Mr. Michael J. Reidy, Director, Bureau of Budget and Management
Research, Office of the Governor, PO Box 2950, Agana, Guam 96910,
Telephone (671) 472-2285
NORTHERN MARIANA ISLANDS
State Single Point of Contact, Planning and Budget Office, Office
of the Governor, Saipan, CM, Northern Mariana Islands 96950
[[Page 15772]]
PUERTO RICO
Norma Burgos/Jose H. Caro, Chairman/Director, Puerto Rico Planning
Board, Minillas Government Center, PO Box 41119, San Juan, Puerto Rico
00940-9985, Telephone (809) 727-4444
VIRGIN ISLANDS
Jose L. George, Director, Office of Management and Budget, #41
Norregade Emancipation Garden Station, Second Floor, Saint Thomas,
Virgin Islands 00802
Please direct correspondence to: Linda Clarke, Telephone (809) 774-
0750.
BILLING CODE 4184-01-M
[[Page 15773]]
[GRAPHIC][TIFF OMITTED]TN27MR95.000
BILLING CODE 4184-01-C
[[Page 15774]]
Instructions for the SF 424
This is a standard form used by applicants as a required
facesheet for preapplications and applications submitted for Federal
assistance. It will be used by Federal agencies to obtain applicant
certification that States which have established a review and
comment procedure in response to Executive Order 12372 and have
selected the program to be included in their process, have been
given an opportunity to review the applicant's submission.
Item and Entry
1. Self-explanatory.
2. Date application submitted to Federal agency (or State if
applicable) & applicant's control number (if applicable).
3. State use only (if applicable).
4. If this application is to continue or revise an existing
award, enter present Federal identifer number. If for a new project,
leave blank.
5. Legal name of applicant, name of primary organizational unit
which will undertake the assistance activity, complete address of
the applicant, and name and telephone number of the person to
contact on matters related to this application.
6. Enter Employer Identification Number (EIN) as assigned by the
Internal Revenue Service.
7. Enter the appropriate letter in the space provided.
8. Check appropriate box and enter appropriate letter(s) in the
space(s) provided:
--``New'' means a new assistance award.
--``Continuation'' means an extension for an additional funding/
budget period for a project with a projected completion date.
--``Revision'' means any change in the Federal Government's
financial obligation or contingent liability from an existing
obligation.
9. Name of Federal agency from which assistance is being
requested with this application.
10. Use the Catalog of Federal Domestic Assistance number and
title of the program under which assistance is requested.
11. Enter a brief descriptive tite of the project. If more than
one program is involved, you should append an explanation on a
separate sheet. If appropriate (e.g., construction or real property
projects), attach a map showing project location. For
preapplications, use a separate sheet to provide a summary
description of this project.
12. List only the largest political entities affected (e.g.,
State, counties, cities).
13. Self-explanatory.
14. List the applicant's Congressional District and any
District(s) affected by the program or project.
15. Amount requested or to be contributed during the first
funding/budget period by each contributor. Value of in-kind
contributions should be included on appropriate lines as applicable.
If the action will result in a dollar change to an existing award,
indicate only the amount of the change. For decreases, enclose the
amounts in parentheses. If both basic and supplemental amounts are
included, show breakdown on an attached sheet. For multiple program
funding, use totals and show breakdown using same categories as item
15.
16. Applicants should contact the State Single Point of Contact
(SPOC) for Federal Executive Order 12372 to determine whether the
application is subject to the State intergovernmental review
process.
17. This question applies to the applicant organization, not the
person who signs as the authorized representative. Categories of
debt include delinquent audit disallowances, loans and taxes.
18. To be signed by the authorized representative of the
applicant. A copy of the governing body's authorization for you to
sign this application as official representative must be on file in
the applicant's office. (Certain Federal agencies may require that
this authorization be submitted as part of the application.)
BILLING CODE 4184-01-M
[[Page 15775]]
[GRAPHIC][TIFF OMITTED]TN27MR95.001
[[Page 15776]]
[GRAPHIC][TIFF OMITTED]TN27MR95.002
BILLING CODE 4184-01-C
[[Page 15777]]
Instructions for the SF-424A
General Instructions
This form is designed so that application can be made for funds
from one or more grant programs. In preparing the budget, adhere to
any existing Federal grantor agency guidelines which prescribe how
and whether budgeted amounts should be separately shown for
different functions or activities within the program. For some
programs, grantor agencies may require budgets to be separately
shown by function or activity. For other programs, grantor agencies
may require a breakdown by function or activity. Sections A, B, C,
and D should include budget estimates for the whole project except
when applying for assistance which requires Federal authorization in
annual or other funding period increments. In the latter case,
Sections A, B, C, and D should provide the budget for the first
budget period (usually a year) and Section E should present the need
for Federal assistance in the subsequent budget periods. All
applications should contain a breakdown by the object class
categories shown in Lines a-k of Section B.
Section A. Budget Summary
Lines 1-4, Columns (a) and (b)
For applications pertaining to a single Federal grant program
(Federal Domestic Assistance Catalog number) and not requiring a
functional or activity breakdown, enter on Line 1 under Column (a)
the catalog program title and the catalog number in Column (b).
For applications pertaining to a single program requiring budget
amounts by multiple functions or activities, enter the name of each
activity or function on each line in Column (a), and enter the
catalog number in Column (b). For applications pertaining to
multiple programs where none of the programs require a breakdown by
function or activity, enter the catalog program title on each line
in Column (a) and the respective catalog number on each line in
Column (b).
For applications pertaining to multiple programs where one or
more programs require a breakdown by function or activity, prepare a
separate sheet for each program requiring the breakdown. Additional
sheets should be used when one form does not provide adequate space
for all breakdown of data required. However, when more than one
sheet is used, the first page should provide the summary totals by
programs.
Lines 1-4, Columns (c) Through (g)
For new applications, leave Columns (c) and (d) blank. For each
line entry in Columns (a) and (b), enter in Columns (e), (f), and
(g) the appropriate amounts of funds needed to support the project
for the first funding period (usually a year).
For continuing grant program applications, submit these forms
before the end of each funding period as required by the grantor
agency. Enter in Columns (c) and (d) the estimated amounts of funds
which will remain unobligated at the end of the grant funding period
only if the Federal grantor agency instructions provide for this.
Otherwise, leave these columns blank. Enter in columns (e) and (f)
the amounts of funds needed for the upcoming period. The amount(s)
in Column (g) should be the sum of amounts in Columns (e) and (f).
For supplemental grants and changes to existing grants, do not
use Columns (c) and (d). Enter in Column (e) the amount of the
increase or decrease of Federal funds and enter in Column (f) the
amount of the increase or decrease of non-Federal funds. In Column
(g) enter the new total budgeted amount (Federal and non-Federal)
which includes the total previous authorized budgeted amounts plus
or minus, as appropriate, the amounts shown in Columns (e) and (f).
The amount(s) in Column (g) should not equal the sum of amounts in
Columns (e) and (f).
Line 5--Show the totals for all columns used.
Section B. Budget Categories
In the column headings (1) through (4), enter the titles of the
same programs, functions, and activities shown on Lines 1-4, Column
(a), Section A. When additional sheets are prepared for Section A,
provide similar column headings on each sheet. For each program,
function or activity, fill in the total requirements for funds (both
Federal and non-Federal) by object class categories.
Lines 6a-i--Show the total of Lines 6a to 6h in each column.
Line 6j--Show the amount of indirect cost.
Line 6k--Enter the total of amounts on Lines 6i and 6j. For all
applications for new grants and continuation grants the total amount
in column (5), Line 6k, should be the same as the total amount shown
in Section A, Column (g), Line 5. For supplemental grants and
changes to grants, the total amount of the increase or decrease as
shown in Columns (1)-(4), Line 6k should be the same as the sum of
the amounts in Section A, Columns (e) and (f) on Line 5.
Line 7--Enter the estimated amount of income, if any, expected
to be generated from this project. Do not add or subtract this
amount from the total project amount. Show under the program
narrative statement the nature and source of income. The estimated
amount of program income may be considered by the federal grantor
agency in determining the total amount of the grant.
Section C. Non-Federal-Resources
Lines 8-11--Enter amounts of non-Federal resources that will be
used on the grant. If in-kind contributions are included, provide a
brief explanation on a separate sheet.
Column (a)--Enter the program titles identical to Column (a),
Section A. A breakdown by function or activity is not necessary.
Column (b)--Enter the contribution to be made by the applicant.
Column (c)--Enter the amount of the State's cash and in-kind
contribution if the applicant is not a State or State agency.
Applicants which are a State or State agencies should leave this
column blank.
Column (d)--Enter the amount of cash and in-kind contributions
to be made from all other sources.
Column (e)--Enter totals of Columns (b), (c), and (d).
Line 12--Enter the total for each of Columns (b)-(e). The amount
in Column (e) should be equal to the amount of Line 5, Column (f),
Section A.
Section D. Forecasted Cash Needs
Line 13--Enter the amount of cash needed by quarter from the
grantor agency during the first year.
Line 14--Enter the amount of cash from all other sources needed
by quarter during the first year.
Line 15--Enter the totals of amounts on Lines 13 and 14.
Section E. Budget Estimates of Federal Funds Needed for Balance of
the Project
Lines 16-19--Enter in Column (a) the same grant program titles
shown in Column (a), Section A. A breakdown by function or activity
is not necessary. For new applications and continuation grant
applications, enter in the proper columns amounts of Federal funds
which will be needed to complete the program or project over the
succeeding funding periods (usually in years). This section need not
be completed for revisions (amendments, changes, or supplements) to
funds for the current year of existing grants.
If more than four lines are needed to list the program titles,
submit additional schedules as necessary.
Line 20--Enter the total for each of the Columns (b)-(e). When
additional schedules are prepared for this Section, annotate
accordingly and show the overall totals on this line.
Section F. Other Budget Information
Line 21--Use this space to explain amounts for individual direct
object-class cost categories that may appear to be out of the
ordinary or to explain the details as required by the Federal
grantor agency.
Line 22--Enter the type of indirect rate (provisional,
predetermined, final or fixed) that will be in effect during the
funding period, the estimated amount of the base to which the rate
is applied, and the total indirect expense.
Line 23--Provide any other explanations or comments deemed
necessary.
Assurances--Non-Construction Programs
Note: Certain of these assurances may not be applicable to your
project or program. If you have questions, please contact the
awarding agency. Further, certain Federal awarding agencies may
require applicants to certify to additional assurances. If such is
the case, you will be notified.
As the duly authorized representative of the applicant I certify
that the applicant:
1. Has the legal authority to apply for Federal assistance, and
the institutional, managerial and financial capability (including
funds sufficient to pay the non-Federal share of the project costs)
to ensure proper planning, management and completion of the project
described in this application.
2. Will give the awarding agency, the Comptroller General of the
United States, and if appropriate, the State, through any authorized
representative, access to and the right to examine all records,
books, papers, or documents related to the award; and will
[[Page 15778]] establish a proper accounting system in accordance
with generally accepted accounting standards or agency directives.
3. Will establish safeguards to prohibit employees from using
their positions for a purpose that constitutes or presents the
appearance of personal or organizational conflict of interest, or
personal gain.
4. Will initiate and complete the work within the applicable
time frame after receipt of approval of the awarding agency.
5. Will comply with the Intergovernmental Personnel Act of 1970
(42 U.S.C. Secs. 4728-4763) relating to prescribed standards for
merit systems for programs funded under one of the nineteen statutes
or regulations specified in Appendix A of OPM's Standards for a
Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).
6. Will comply with all Federal statutes relating to
nondiscrimination. These include but are not limited to: (a) Title
VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits
discrimination on the basis of race, color or national origin; (b)
Title IX of the Education Amendments of 1972, as amended (20 U.S.C.
Secs. 1681-1683, and 1685-1686), which prohibits discrimination on
the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973,
as amended (29 U.S.C. Sec. 794), which prohibits discrimination on
the basis of handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 U.S.C. Secs. 6101-6107), which prohibits discrimination
on the basis of age; (e) the Drug Abuse Office and Treatment Act of
1972 (P.L. 92-255), as amended, relating to nondiscrimination on the
basis of drug abuse; (f) the Comprehensive Alcohol Abuse and
Alcoholism Prevention, Treatment and Rehabilitation Act of 1970
(P.L. 91-616), as amended, relating to nondiscrimination on the
basis of alcohol abuse or alcoholism; (g) Secs. 523 and 527 of the
Public Health Service Act of 1912 (42 U.S.C. 290 dd-3 and 290 ee-3),
as amended, relating to confidentiality of alcohol and drug abuse
patient records; (h) Title VIII of the Civil Rights Act of 1968 (42
U.S.C. Sec. 3601 et seq.), as amended, relating to nondiscrimination
in the sale, rental or financing of housing; (i) any other
nondiscrimination provisions in the specific statute(s) under which
application for Federal assistance is being made; and (j) the
requirements of any other nondiscrimination statute(s) which may
apply to the application.
7. Will comply, or has already complied, with the requirements
of Titles II and III of the Uniform Relocation Assistance and Real
Property Acquisition Policies Act of 1970 (P.L. 91-646) which
provide for fair and equitable treatment of persons displaced or
whose property is acquired as a result of Federal or federally
assisted programs. These requirements apply to all interests in real
property acquired for project purposes regardless of Federal
participation in purchases.
8. Will comply with the provisions of the Hatch Act (5 U.S.C.
Secs. 1501-1508 and 7324-7328) which limit the political activities
of employees whose principal employment activities are funded in
whole or in part with Federal funds.
9. Will comply, as applicable, with the provisions of the Davis-
Bacon Act (40 U.S.C. Secs. 276a to 276a-7), the Copeland Act (40
U.S.C. Sec. 276c and 18 U.S.C. Secs. 874), and the Contract Work
Hours and Safety Standards Act (40 U.S.C. Secs. 327-333), regarding
labor standards for federally assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase
requirements of Section 102(a) of the Flood Disaster Protection Act
of 1973 (P.L. 93-234) which requires recipients in a special flood
hazard area to participate in the program and to purchase flood
insurance if the total cost of insurable construction and
acquisition is $10,000 or more.
11. Will comply with environmental standards which may be
prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National
Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order
(EO) 11514; (b) notification of violating facilities pursuant to EO
11738; (c) protection of wetlands pursuant to EO 11990; (d)
evaluation of flood hazards in floodplains in accordance with EO
11988; (e) assurance of project consistency with the approved State
management program developed under the Coastal Zone Management Act
of 1972 (16 U.S.C. Secs. 1451 et seq.); (f) conformity of Federal
actions to State (Clear Air) Implementation Plans under Section
176(c) of the Clear Air Act of 1955, as amended (42 U.S.C. Sec. 7401
et seq.); (g) protection of underground sources of drinking water
under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-
523); and (h) protection of endangered species under the Endangered
Species Act of 1973, as amended, (P.L. 93-205).
12. Will comply with the Wild and Scenic Rivers Act of 1968 (16
U.S.C. Secs. 1271 et seq.) related to protecting components or
potential components of the national wild and scenic rivers system.
13. Will assist the awarding agency in assuring compliance with
Section 106 of the National Historic Preservation Act of 1966, as
amended (16 U.S.C. 470), EO 11593 (identification and protection of
historic properties), and the Archaeological and Historic
Preservation Act of 1974 (16 U.S.C. 469a-1 et seq.).
14. Will comply with P.L. 93-348 regarding the protection of
human subjects involved in research, development, and related
activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966
(P.L. 89-544, as amended, 7 U.S.C. 2131 et seq.) pertaining to the
care, handling, and treatment of warm blooded animals held for
research, teaching, or other activities supported by this award of
assistance.
16. Will comply with the Lead-Based Paint Poisoning Prevention
Act (42 U.S.C. Secs. 4801 et seq.) which prohibits the use of lead
based paint in construction or rehabilitation or residence
structures.
17. Will cause to be performed the required financial and
compliance audits in accordance with the Single Audit Act of 1984.
18. Will comply with all applicable requirements of all other
Federal laws, executive orders, regulations and policies governing
this program.
----------------------------------------------------------------------
Signature of authorized certifying official
----------------------------------------------------------------------
Title
----------------------------------------------------------------------
Applicant organization
----------------------------------------------------------------------
Date submitted
BILLING CODE 4184-01-M
[[Page 15779]]
[GRAPHIC][TIFF OMITTED]TN27MR95.003
[[Page 15780]]
[GRAPHIC][TIFF OMITTED]TN27MR95.004
BILLING CODE 4184-01-C
[[Page 15781]]
Certification Regarding Debarment, Suspension, and Other Responsibility
Matters--Primary Covered Transactions
By signing and submitting this proposal, the applicant, defined
as the primary participant in accordance with 45 CFR Part 76,
certifies to the best of its knowledge and believe that it and its
principals:
(1) are not presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from covered
transactions by any Federal Department or agency;
(b) have not within a 3-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 for commission of
embezzlement, theft, forgery, bribery, falsification or destruction
of records, making false statements, or receiving stolen property;
(c) are not presently indicted 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 3-year period preceding this application/
proposal had one or more public transactions (Federal, State, or
local) terminated for cause or default.
The inability of a person to provide the certification required
above will not necessarily result in denial of participation in this
covered transaction. If necessary, the prospective participant shall
submit an explanation of why it cannot provide the certification.
The certification or explanation will be considered in connection
with the Department of Health and Human Services (HHS) determination
whether to enter into this transaction. However, failure of the
prospective primary participant to furnish a certification or an
explanation shall disqualify such person from participation in this
transaction.
The prospective primary participant agrees that by submitting
this proposal, it will include the clause entitled ``Certification
Regarding Debarment, Suspension, Ineligibility, and Voluntary
Exclusion--Lower Tier Covered Transaction.'' provided below without
modification in all lower tier covered transactions and in all
solicitations for lower tier covered transactions.
Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion--Lower Tier Covered Transactions (To Be Supplied to
Lower Tier Participants)
By signing and submitting this lower tier proposal, the
prospective lower tier participant, as defined in 45 CFR Part 76,
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 from
participation in this transaction by any federal department or
agency.
(b) where the prospective lower tier participant is unable to
certify to any of the above, such prospective participant shall
attach an explanation to this proposal.
The prospective lower tier participant further agrees by
submitting this proposal that it will include this clause entitled
``certification Regarding Debarment, Suspension, Ineligibility, and
Voluntary Exclusion--Lower Tier Covered Transactions.'' without
modification in all lower tier covered transactions and in all
solicitations for lower tier covered transactions.
Appendix E--Certification Regarding Lobbying
Certification for Contracts, Grants, Loans, and Cooperative
Agreements
The undersigned certifies, 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 any
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 contract, grant, loan, or cooperative agreement.
(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 an 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 subawards
at all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all
subrecipients shall certify and disclose accordingly.
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.
State for Loan Guarantee 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.
----------------------------------------------------------------------
Signature
----------------------------------------------------------------------
Title
----------------------------------------------------------------------
Organization
----------------------------------------------------------------------
Date
BILLING CODE 4184-01-M
[[Page 15782]]
[GRAPHIC][TIFF OMITTED]TN27MR95.005
BILLING CODE 4184-01-C
[[Page 15783]] Appendix F--Certification Regarding Environmental
Tobacco Smoke
Public Law 103-227, Part C--Environmental Tobacco Smoke, also
known as the Pro-Children Act of 1994 (Act), requires that smoking
not be permitted in any portion of any indoor facility owned or
leased or contracted for by an entity and used routinely or
regularly for the provision of health, day care, education, or
library services to children under the age of 18, if the services
are funded by Federal programs either directly or through State or
local governments, by Federal grant, contract, loan, or loan
guarantee. The law does not apply to children's services provided in
private residences, facilities funded solely by Medicare or Medicaid
funds, and portions of facilities used for inpatient drug or alcohol
treatment. Failure to comply with the provisions of the law may
result in the imposition of a civil monetary penalty of up to $1,000
per day and/or the imposition of an administrative compliance order
on the responsible entity.
By signing and submitting this application the applicant/grantee
certifies that it will comply with the requirements of the Act. The
applicant/grantee further agrees that it will require the language
of this certification be included in any subawards which contain
provisions for children's services and that all subgrantees shall
certify accordingly.
Appendix G--ORR State Letter
Number 95-01
Date: January 12, 1995.
To: State Refugee Coordinators
From: Lavinia Limon, Director, Office of Refugee Resettlement
Subject: Impact of Medicaid Waivers on Refugee Medical Assistance
Several States have received Medicaid waivers to expand health
insurance for needy persons. These waivers have targeted needy
individuals who are not categorically eligible for Medicaid, such as
single persons, childless couples, and intact families without a
connection to the work force. Many refugees now receiving refugee
medical assistance (RMA) may become eligible under these new waiver
programs. This letter is to provide policy clarification to States
regarding how to handle eligibility in such situations and what
ORR's policy regarding cost reimbursement will be for such cases.
ORR's policy is that refugees who become eligible for Medicaid
through waiver provisions must be served under the Medicaid program,
rather than under RMA.
Currently, 45 CFR 400.94 provides that a determination of
eligibility for Medicaid must precede a determination of eligibility
for RMA. In addition, Sec. 400.100 restricts RMA coverage to
refugees who are ineligible for Medicaid but who meet the financial
eligibility requirements under Sec. 400.101. The Health Care
Financing Administration (HCFA) has informed us that the provisions
of an approved Medicaid waiver replaces the applicable sections of
the Medicaid State plan. Accordingly, under Sec. 400.94, States must
first determine refugee eligibility for the Medicaid waiver program.
Only those refugees not eligible under the Medicaid waiver program
could be eligible for RMA. If all refugees in a State are eligible
under the waiver, the RMA program would be supplanted in its
entirety by the Medicaid waiver program.
Costs incurred for refugees in a waiver program will be treated
in the following manner:
ORR will reimburse States for the State share of costs
for refugees who would otherwise be eligible for RMA but who become
eligible for Medicaid through the approved waiver provisions. The
reimbursable costs will include the State share of Medicaid costs
for these refugees for the first eight months of U.S. residency (or
for whatever period of eligibility is in effect for RMA), including
the State share of administrative costs of providing Medicaid to
these refugees.
ORR will not reimburse States for costs incurred by
refugees who would have been eligible for Medicaid without the
waiver provisions, such as refugees receiving SSI and AFDC.
We wish to emphasize the following two principles which guide
our policy considerations on health care reform:
(1) ORR is committed to allowing States to include refugees in
health care reform programs whenever possible, whether initiated at
the Federal or State level; and
(2) ORR is committed to holding States harmless by reimbursing
States for the State share of costs for RMA-eligible refugees in
State health care reform programs.
In the event that your State applies for a Medicaid waiver which
might affect the refugee program, please contact your State liaison
or the ORR Policy Division in order to assure common understanding
regarding the waiver and its implications for RMA and for refugees.
We want to work together to assure that there is no misunderstanding
regarding the regulations or how the costs will be covered.
[FR Doc. 95-7506 Filed 3-27-95; 8:45 am]
BILLING CODE 4184-01-P