[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.

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BILLING CODE 4184-01-C

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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.)

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BILLING CODE 4184-01-C

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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

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BILLING CODE 4184-01-C

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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.

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[[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