Attachment D
PART A: PLANNING
Eligible Grantee
Section 431 (a)(3)
A.1. Name of the tribal organization (the recognized governing body of the Indian Tribe) applying for family preservation and family support funds.
If the Indian Tribe administers the child welfare services program under title IV-B, subpart 1, the same component of the Indian Tribe shall administer or supervise the administration of subpart 2, family preservation and family support services.
Funds for Planning
Section 434 (a)(2)
-
Indicate the estimated amount of FY 1994 funds the tribal organization will use for planning, including the development of the five-year Plan.
$ _____________________
Section 432; and Section 434 (a)(2)
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(a) Describe the proposed planning activities for development of the five-year Plan, including active involvement of knowledgeable experts, agencies and organizations, parents, consumers, community representatives, and others.
Section 432 (a)(3)
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Describe how the tribal organization will coordinate the provision of services with representatives of Federal and federally-assisted programs to develop a more comprehensive and integrated service delivery system.
Section 434 (a)(2)
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List planned contacts and describe outreach activities to ensure that interested parties have an opportunity for active involvement in the planning process.
Section 432 (a)(2)(C)(ii)
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Describe how the tribal organization will inform appropriate parties about this new legislation and the planning, consultation, and coordination provisions.
Section 434 (a)(2)
-
Describe how the tribal organization will assess tribal needs or describe a recently conducted prior planning process which assessed such needs.
Section 434 (a)(2)
-
Describe the nature and scope of any existing family preservation and family support programs serving tribal families.
Section 434 (a)(2)
-
Describe other proposed activities for the development of a five-year Plan and implementation of service system reform, including training and technical assistance and assessment of services.
Section 432 (a)(6)
Section 432 (a)(7)(A)
Section 432 (a)(7)(B)
Section 432 (a)(8)
Section 432 (a)(8)
Section 434 (b)(2)
Assurances
-
Provide the following general assurances:
-
Assure that the tribal organization will perform administrative procedures the Secretary determines to be necessary for the proper and efficient operation of the plan.
-
Assure that the tribal organization will not use funds provided under this subpart to supplant Federal or non-Federal funds for existing family preservation and family support services and activities.
-
Assure that future reports on compliance with the supplantation prohibition will be provided at the request of the Secretary.
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Assure that the tribal organization will furnish reports as required by the Secretary, including the SF-269.
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Assure that the tribal organization will participate in evaluations as the Secretary may require.
-
Assure that the tribal organization will expend (obligate and liquidate) any FY 1994 Federal funds before the end of the immediately succeeding fiscal year.
-
45 CFR 93, Appendix A
45 CFR 76.600
45 CFR 76.500
Certifications
-
Submit the following certifications, found as an attachment to this preprint:
- Anti-Lobbying and Disclosure form;
- Drug-Free Workplace; and
- Debarment.
Application Approval for Planning
| _____________________ | _____________________ | _____________________ |
| Signature of Tribal Official | Title | Date |
The signature above certifies that the Indian Tribe or tribal organization will comply with the requirements of title IV-B, subpart 2, of the Social Security Act, including all the required assurances and certifications for planning.
_____________________
Name of tribal organization contact person, including title and telephone number to whom requests for clarification and/or additional information related to planning may be directed.
_____________________
Signature of Regional Office Approving Official/Title/Date
PART B: SERVICES
Funds for Services
- .1. Specify the estimated amount of funds the
tribal organization will use for services, training and technical
assistance and administrative costs in FY 1994, indicating both the
Federal and tribal share.
Indian Tribe Federal
Family preservation services $__________ $_________
Community-based family support services $__________ $_________
Total amount for services $__________ $_________
Total Tribal and Federal $_____________
Total amount for training * $______________
Total amount for technical assistance * $______________
Total amount for administrative costs $______________
-
Provide the findings of any needs assessment or prior planning process which led to the decision to spend FY 1994 funds for services. Include the method by which the assessment was conducted and a list of participants.
-
Describe how the public, including representatives of groups having expertise in family preservation and family support, parents and consumers and others participated in the development of the application to provide services in FY 1994.
* Estimate training and technical assistance expenditures under both planning and services.
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(a) Identify the goals for services in FY 1994 and indicate how the funds obtained under this program will assist in meeting these goals.
(b) Describe how funds obtained under this program will link to other services to improve the likelihood that children and families will receive care appropriate to meet their multiple needs.
-
Describe the community-based family support services and family preservation services that will be provided; include a description of the populations each of the programs will serve and the geographic areas in which each of the services will be provided.
-
Indicate the specific percentage of FY 1994 program funds that will be expended for family support and for family preservation services, respectively, and the rationale for that choice.
Provide an explanation of how the distribution was reached and why it meets the requirement that a "significant portion" of the service funds must be spent for each service.
Total of Planned Federal and Tribal Expenditures
Family Preservation ________%
Family Support ________%
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(a) Describe the types of activities that will be claimed as administrative costs.
(b) Describe the types of training and technical assistance activities that will be carried out.
Section 434 (a)(2)(B)
Section 434 (a)(2)(B)
Section 434 (b)(1)Additional Assurances
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Provide the following assurances that relate to services:
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Assure that no more than ten percent of expenditures will be used for administrative costs.
-
Assure that a significant portion of funds will be used for both family preservation and community-based family support services.
-
Except as provided by law, assure that Federal funds will not be used to meet the tribe's share of the costs of services not covered by the amount received under this law.
-
-
Application Approval for Services
| _____________________ | _____________________ | _____________________ |
| Signature of Tribal Official | Title | Date |
The signature above certifies that the Indian Tribe or tribal organization will comply with the requirements of title IV-B, subpart 2, of the Social Security Act, including the required assurances and certifications for services.
_____________________
Name of tribal organization contact person, including title and telephone number to whom requests for clarification and/or additional information related to planning may be directed.
_____________________
Signature of Regional Office Approving Official/Title/Date
Attachments:
Attachment A: Indian Tribal Allotments
FY 1994 and Estimated Allotments for FY 1995
Attachment B: Statute and Conference Report
Language
Attachment C: List of Resources/Models
Attachment E: FY 1995
State and Indian Tribal Plan Issues for Regulation
Attachment F: List of ACF Regional
Administrators
