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COMMUNITY SERVICES BLOCK GRANT (CSBG)
TRIBAL PLAN & APPLICATION
FILLABLE-PDF TOOL
FOR TRIBES & TRIBAL ORGANIZATIONS
A resource provided by the
CSBG Tribal Training and Technical Assistance
Program
June 2019
Under contract with the HHS/ACF Office of Community Services, the CSBG Training & Technical
Assistance Program for Tribes and Tribal organizations connects CSBG Tribal grantees and provides
information and assistance through webinars, conferences, and direct phone support to maximize the
impact of CSBG funding. The program offers free comprehensive training and technical assistance,
tools and resource materials, and 1:1 phone consultation.
Page 2 of 42
INSTRUCTIONS
The following fillable-PDF form is provided as a technical assistance tool to assist grantees
in producing the CSBG Tribal Plan and Application as required in Section 676 of the CSBG
Act. Please follow the step-by-step directions provided in the CSBG Tribal Plan &
Application Tool Guide to ensure successful completion.
As you work through this fillable-PDF, please remember that help is available anytime from
the CSBG Tribal T&TA Program team at tribalta@luxcg.com or 301-244-3557.
Note: Grantees with previously approved two-year CSBG Tribal Plans that covered FY
2019 and FY 2020 are only required to submit an updated electronic SF-424M and Annual
Report each year to receive funding. Grantees in the middle of their two-year plan are NOT
required to re-submit the CSBG Tribal Plan.
OLDC ACCESS
Current CSBG Grant Administrators: Login to the OLDC System and confirm that CSBG is
listed as one of your programs. If you are unable to log in or do not have CSBG listed as one
of your programs, please complete an OLDC Access form and submit to Niki Frazier, OCS
Senior Records Specialist/Project Lead, at nikita.frazier@acf.hhs.gov.
New CSBG Administrators (Current Grantees): To gain access to the OLDC, new
administrators of current CSBG grantees must complete an OLDC Access Form and email it
to Niki Frazier, OCS Senior Records Specialist/Project Lead, at nikita.frazier@acf.hhs.gov.
Prospective New Grantees: Any federally- or state-recognized Tribe or Tribal
organization that is interested in receiving CSBG funds directly must first contact the
Office Community Services at csbgtribes@acf.hhs.gov to receive specific instructions. First-
time applicants/prospective grantees will then submit the following before completing a
CSBG Tribal Plan and Application:
• Employer Identification Number (EIN) Number; and
• A signed statement of agreement between the Tribe or Tribal Organization and the
state confirming the Tribal population and the percentage of Tribal poverty in the state.
Page 3 of 42
CSBG TRIBAL PLAN & APPLICATION MATERIALS
SF-424M
SF-424M Form: All grantees must complete an updated SF-424M with their application
materials. (Including those grantees in the middle of a two-year plan.) Please verify that the
Tribe or Tribal Organization will complete the SF-424M form as a returning grantee or as
first-time/prospective grantee.
The Tribe or Tribal Organization is a returning grantee and will complete the
electronic SF-424M form in the OLDC system.
The Tribe or Tribal Organization is a first-time/prospective grantee and will follow
the instructions provided by their OCS Program Specialist regarding the SF-424M.
SECTION 1
TRIBAL CSBG ADMINISTRATIVE INFORMATION
1.1 CSBG Tribal Plan for: Name of Tribe or Tribal Organization
1.1a Fiscal Years covered by the CSBG Tribal Plan:
One-Year Plan: 2020
Two-Year Plan: Year One 2020 | Year Two 2021
1.2 Transmittal Letter: Please provide the following information in relation to the
Tribe or Tribal Organization designated to administer CSBG as required in Sections
676 and 677 of the CSBG Act, the Human Services Reauthorization Act of 1998 (P.L.
105-285), and relevant federal policy guidance.
✔
✔
Page 4 of 42
The following information should mirror the information provided on the
Application for Federal Assistance, SF-424M.
1.2a Name of Tribe or Tribal Organization:
1.2b Fiscal Years to be covered by the CSBG Tribal Plan:
1.2c Authorized Tribal Official to receive the CSBG Grant Award: Contact
information for the Authorized Tribal Official (Chairperson/Chief/CEO) who
is to receive the CSBG Grant Award, including:
1.2d Authorized Tribal Official Name:
1.2e Authorized Tribal Official Title:
1.2 Street Address:
1.2g City, State, Zip Code:
1.2h Telephone:
1.2i Fax:
1.2j Email:
1.2k Website:
Delaware Nation
2020
Deborah Dotson
President
31064 US Highway 281/P.O. Box 825
Anadarko, OK 73005
(405)247-2448
(405)247-9393
ddotson@delawarenation-nsn.gov
www.delawarenation-nsn.gov
Page 5 of 42
1.3 Tribal CSBG Program Contact Person: Individual designated within the Tribe or
Tribal Organization to take the lead in administering the Community Services Block
Grant and serve as the primary contact on all programmatic activities. The Tribal
Program Contact Person information is as follows:
1.3a CSBG Program Contact Person Name:
1.3b CSBG Program Contact Person Title:
1.3c Street Address:
1.3d City, State, Zip Code:
1.3e Telephone:
1.3f Fax:
1.3g
Email:
1.4 Delegation of Authority: Is this Tribe or Tribal Organization’s Authorized Tribal
Official (Chairperson/Chief/CEO) delegating signature authority to any other
individual to sign assurances, certifications, and other required CSBG documents on
their behalf?
No, Chairperson/Chief/CEO does not delegate authority to another individual.
Yes, Chairperson/Chief/CEO does delegate authority to another individual, as
follows:
✔
Sylvia Pitner
Social Services Director
31064 US Highway 281 / P.O. Box 825
Anadarko, OK 73005
(405)247-2448
(405)247-5942
spitner@delawarenation-nsn.gov
Page 6 of 42
Signature Authority is delegated to the following additional Authorized Tribal
Official:
1.4a Name:
1.4b Title:
1.4c Telephone Number:
1.4d Email:
1.5 Chairperson/Chief/CEO Signature: I hereby attest that I delegate signature
authority to the individual listed above to sign assurances, certifications, and other
required CSBG documents on my behalf.
1.5a Name of Tribe:
1.5b Chairperson/Chief/CEO Name:
1.5c Chairperson/Chief/CEO Title:
1.5d Chairperson/Chief/CEO Signature: (NOTE: Please wait until the CSBG Plan
is fully completed before adding all signatures.)
Please Note: The designation should be updated whenever there is a change to the
designee.
Sylvia Pitner
Social Services Director
(405)247-2448
spitner@delawarenation-nsn.gov
Delaware Nation
Deborah Dotson
President
Sylvia Pitner
Digitally signed by Sylvia Pitner
Date: 2019.08.19 15:45:08 -04'00'
click to sign
signature
click to edit
Page 7 of 42
SECTION 2
CSBG LEGISLATION AND RESOLUTION
2.1 Tribal Resolution:
Is the applicant representing more than one Tribe? ☐ Yes ☐ No
If marked “YES”, attached are copies of the Tribal Resolutions granting authority
to receive CSBG funds.
2.2 Federal or State Recognition
2.2a Does the Tribe or Tribal Organization have Federal Recognition? ☐ Yes ☐ No
If marked “Yes,” please provide the full name of the Tribe or Tribal Organization as it
appears in the U.S. Federal Register list of Indian Entities Recognized by and Eligible To
Receive Services From the United States Bureau of Indian Affairs, published on
02/01/2019:
2.2b If not Federally-recognized, does the Tribe or Tribal Organization have State
Recognition? ☐ Yes ☐ No
If marked “Yes,” please provide a link to proof of State Recognition or citation
information for the State statute or code acknowledging State Recognition:
✔
✔
Delaware Nation, Oklahoma
Page 8 of 42
SECTION 3
TRIBAL CSBG PLAN DEVELOPMENT AND MISSION, GOALS/OBJECTIVES
3.1 Mission & Responsibilities: The mission and responsibilities of the agency or
department within the Tribe or Tribal Organization that will administer the CSBG
program are as follows: (Briefly describe the mission and responsibilities.)
Describe the mission and responsibilities of the agency or department within the Tribe
or Tribal Organization that will administer the CSBG program.
Page 9 of 42
3.1a CSBG Goals & Objectives: The CSBG-specific goals and objectives for the
proposed CSBG funding within the Tribe or Tribal Organization are as
follows: (Briefly describe the specific goals and objectives.)
Describe the CSBG-specific goals and objectives for the proposed CSBG funding
within the Tribe or Tribal organization
The Community Service Block Grant will provide assistance to tribal elders,
low-income families and tribal youth through cultural and recreational activities while
increasing participation in the affairs of the tribal community. It is the objective of the
proposed CSBG funding to sponsor a youth activity/event during the fiscal year in
collaboration with the tribal administrative structure and the consolidated tribal
government program, to promote cultural awareness among our tribal youth by
participating in a local community cultural event. Secondly, CSBG funding will be
used to sponsor an elder activity in order to increase elder participation and provide
supplemental nutrition assistance during the holiday season. This service is to assist
elders with limited income/resources.
Page 10 of 42
SECTION 4
CSBG HEARING REQUIREMENTS
4.1 CSBG Public Hearing(s): Detail how the Tribe provided the CSBG Tribal Plan to
the public for review and comments. Provide the date(s) and location(s) of the
CSBG public hearings as required under Section 676(e)(2) of the CSBG Act:
Date
Enter a date for each hearing in the boxes
below
Location
Enter the location and address for each
public hearing in the boxes below.
4.1a All grantees must provide evidence that the public hearing took place and
was open to the community.
The Tribe or Tribal Organization will attach a copy of their Public Hearing
announcement in the OLDC system.
June 15, 2019
General Council, Tamanend Building
Delaware Nation
31064 US Highway 281
Anadarko, OK 73005
July 9, 2019
CSBG Public Hearing, AOA Building
31064 US Highway 281
Anadarko, OK 73005
■
Page 11 of 42
SECTION 5
USE OF FUNDS AND FISCAL CONTROLS
5.1 Planned CSBG Allocation Funds: According to the CSBG Act, not more than five (5)
percent can be allocated to administrative items, and not less than 95 percent can be
allocated to program funds. Provide the planned allocation in percent for
Administrative and Program CSBG funding. If this is a two-year plan, please provide
the planned allocations for both years.
Fiscal Year
[Enter fiscal year]
% of CSBG Funding
Fiscal Year
% of CSBG Funding
Administrative
(Not more than 5%)
Program
(Not less than 95%)
5.2 Limitation on the Use of Funds: The Tribe or Tribal Organization acknowledges
and assures that they will abide by the CSBG limitations outlined in Section 678F of
the CSBG Act as follows:
Note: Funds will not be used for the purchase or improvement of land, or the
purchase, construction, or permanent improvement (other than low-cost residential
weatherization or other energy-related home repairs) of any building or other
facility without an approved federal waiver. (View instructions in Section 678F of the
CSBG Act for information on waivers for construction.)
0
2020
100%
Page 12 of 42
5.3 Single Audit Review: Provide the date and the period (timeframe) that the most
recent audit covers.
DATE
PERIOD
April 26, 2019
October 1, 2017 - September 30, 2018
Page 13 of 42
SECTION 6
INDIVIDUAL ELIGIBILITY REQUIREMENTS AND TARGET COMMUNITIES
6.1 Individual and Community Income Eligibility Requirements: Please provide the
income eligibility information for services provided with CSBG funds in the sections
below.
6.1a Required Income Eligibility: Please describe any policy and/or procedures
for income eligibility, such as treatment of income and family/household
composition. (Please note the maximum eligibility is up to 125% of poverty
line.)
Enter or attach any policies and procedures made to ensure income eligibility
requirements are made.
Delaware Nation has general income eligibility guidelines to determine the poverty
level for its tribal citizens for most assistance programs. A benefit matrix is used in
assessing the need according to the family/household income. CSBG funds are
targeted towards low income families/households which are significant among the
service area.
Page 14 of 42
6.1b Target Communities: Describe how the organization ensures that services
target and benefit low-income communities, for those services that provide a
community-wide benefit.
In order to target the low income elder community who benefit from the programs
offered by CSBG funds, announcements are made available to the elder community
by postings in bi-monthly newsletters, websites and onsite at the tribal complex. More
specifically, the Administration On Aging program, which offers nutritional support
Monday thru Friday for low income elders over the age of 55.
Page 15 of 42
SECTION 7
CSBG ASSURANCES & IMPLEMENTATION NARRATIVES
Community Services Block Grant Assurances
Community Services Block Grant Reauthorization Act of 1998: P.L. 105-285g
Please read all sections of the CSBG Assurances (summarized below and detailed in Section
676 of the Community Services Block Grant Reauthorization Act of 1998: P.L. 105-285) and
apply the Authorized Tribal Official’s signature to affirm. (NOTE: Please wait until the CSBG
Plan is fully completed before adding all signatures. Also, signatures will be authorized for up to
two-years (FY2020 and FY2021) provided that there is not a change in the Authorized Official. If
there is a change in Authorized Official, new signatures will be needed on the FY21 CSBG Tribal
Plan & Application.)
7.1 Statement of CSBG Assurances:
As a part of the annual or biannual application and plan required by subsection 676 of
Community Services Block Gant Act, as amended, (412 U.S. C.9901 et seq.) (The Act), the
designee of the Chief Executive of the State hereby agrees to the Assurances in Section 676
of the Act (summarized below and detailed in Section 676 of the CSBG Act) —
Programmatic Assurances
(1) An assurance that funds
made available through the grant or allotment will be used for
at least one of the following purposes [per 676(b)1] —
(A) to support activities that are designed to assist low-income families and
individuals, including families and individuals receiving assistance under part A of
title IV of the Social Security Act (42 U.S.C. 601 et seq.), homeless families and
individuals, migrant or seasonal farm workers, and elderly low-income individuals
and families:
(i) to remove obstacles and solve problems that block the achievement of
self-sufficiency;
(ii) to secure and retain meaningful employment;
(iii) to attain an adequate education with particular attention toward
improving literacy skills of the low-income families in the community,
which may include family literacy initiatives;
(iv) to make better use of available income;
(v) to obtain and maintain adequate housing and a suitable living
environment;
(vi) to obtain emergency assistance through loans, grants, or other means to
meet immediate and urgent individual and family needs;
Page 16 of 42
(vii) to achieve greater participation in the affairs of the communities
involved, including the development of public and private grassroots
partnerships with local law enforcement agencies, local housing
authorities, private foundations, and other public and private
partners.
(B) to address the needs of youth in low-income communities through youth
development programs that support the primary role of the family, give priority
to the prevention of youth problems and crime, and promote increased
community coordination and collaboration in meeting the needs of youth, and
support development and expansion of innovative community-based youth
development programs that have demonstrated success in preventing or
reducing youth crime, such as
(i) programs for the establishment of violent-free zones that would involve
youth development and intervention models (such as models involving
youth mediation, youth mentoring, life skills training, job creation, and
entrepreneurship programs);
(ii) after-school child care programs
(C) to make more effective use of, and to coordinate with, other programs related to
the purposes of this subtitle.
(2) An assurance that information provided by the Tribe will contain the following [per
676(b)3] —
(A) a description of the service delivery system, for services provided or coordinated
with funds made available through grants made under section 675C(a), targeted to
low-income Individuals and families in communities within the Tribe;
(B) a description of how linkages will be developed to fill identified gaps in the
services, through the provision of information, referrals, case management, and
follow-up consultations;
(C) a description of how funds made available through grants made under section
675C(a) will be coordinated with other Public and private sources;
(D) a description of how the Tribe will use the funds to support innovative initiatives,
which may include fatherhood initiatives and other initiatives with the goals of
strengthening families and encouraging effective parenting.
(3) An assurance that the Tribe will provide, on an emergency basis, for the provision of
such supplies and services, nutritious foods, and Related services, as may be necessary to
counteract conditions of Starvation and malnutrition among low-income individuals. [per
676(b)4]
Page 17 of 42
(4) An assurance that the Tribe will ensure coordination between antipoverty programs in
each community within the Tribe, and ensure, where appropriate, the emergency energy
crisis intervention programs under title XXVI (relating to low-income home energy
assistance) are conducted in such community. [per 676(b)6]
(5) An assurance that the Tribe will permit and cooperate with Federal investigations
undertaken in accordance with section 678D. [per 676(b)7]
(6) An assurance that the Tribe will participate in the Results Oriented Management
Accountability (ROMA) System, another performance measure system for which the
Secretary facilitated development pursuant to section 678E(b), or an alternative system for
measuring performance and results that meets the requirements of that section, and a
description of outcome measures to be used to measure performance in promoting self-
sufficiency, family stability, and community revitalization. [per 676(b)13]
Administrative and Financial Assurances
The Tribe further agrees to the following administrative assurances, as required under the
Community Services Block Grant Act —
(1) An assurance to prohibit any activities to provide voters and perspective voters with
transportation to the polls or provide similar assistance in connection with an election or
any voter registration activity as required by Section 678F(b)(2)(B) and (C) of the Act.
(2) An assurance to expend for administrative expenses an amount not to exceed the
greater of five percent of its allotment or the percentage represented by the ratio of
$55.000 to the smallest State allotment for the fiscal year as required by Section
675(C)(b)(2) of the Act.
(3) An assurance that the Tribe agrees to provide that fiscal control and fund accounting
procedures will be established as may be necessary to assure the proper disbursal of the
accounting for Federal funds paid to the Tribe or Tribal Organization under this subtitle,
including monitoring the assistance under this subtitle. 678D(a)(1)(A)
(4) An assurance that each Tribe that expends $750,000 or more (during the fiscal year) in
all types of Federal financial assistance must conduct an audit in accordance with the Single
Audit Act, P.L. 98-502 (3) U.S.C 75 and OMB Circular A-133 Subpart B). 678D(2)(B)
(5) An assurance that the Tribe will make each CSBG Tribal Plan or revised plan available
for public inspection in such a manner as will facilitate public review of and comment on
the proposed use and distribution of CSBG funds. [per 676(a)(2)(B) and 676(e)(2)]
Page 18 of 42
Other Administrative Certifications
The Tribe also certifies the following —
(1) To provide assurances that cost and accounting standards of the Office of Management
and Budget shall apply to a recipient of Community Services Block Grant program funds.
[per 678D(a)(1)(B), as well as 2 CFR 200, Uniform Administrative Requirements and 45
CFR 75]
7.2 Authorized Tribal Official Affirmation Signature:
Please Note: These assurances will be valid for two years unless the organization and/or
the official changes
I hereby affirm that the Tribe or Tribal Organization will ensure compliance with the
assurances above.
7.2a Name of Tribe or Tribal Organization:
7.2b Authorized Tribal Official Name:
7.2c Authorized Tribal Official Signature:
(Note: Please wait until the CSBG Plan is fully completed before adding all signatures.)
Delaware Nation
Sylvia Pitner
Sylvia Pitner
Digitally signed by Sylvia Pitner
Date: 2019.08.19 15:45:41 -04'00'
Page 19 of 42
7.3 Implementation of CSBG Assurances:
7.3a CSBG Service Delivery System: A description of the service delivery system for
services provided by or coordinated with CSBG funds include the following:
Provide a description of CSBG Service Delivery System.
The Delaware Nation Social Services Department will be in charge of
administering the programs funded by CSBG in coordination with Child Care and
Development and tribal administration supported funds. Each winter funds from
CSBG provide turkeys or hams (dependent on survey) to enrolled Delaware
Nation tribal elders in the service area for nutritional support. The survey is a
key tool in determining the need or preference of the low income elder
community in providing the nutritional support and helps the program monitor the
success of the CSBG funds. The survey is made available during the Delaware
Nation's Annual General Council as well as during the annual public hearing.
Notification is made to the tribal community via the tribal newsletter, website and
community postings as to when activity will take place. Tribal elders are invited
to the tribal complex to receive services on a first come first serve basis. Every
summer the CSBG program collaborates with Child Care and Development, also
operated by the Delaware Nation Social Services Department, to offer one
cultural event pass to enrolled Delaware Nation tribal youth in the service area.
The purchase of the passes alleviate the cost and otherwise restraint on low
income families which might prevent participation in a community cultural event.
Passes are presented to tribal youth during the annual Back to School Bash
sponsored by the Child Care and Development Program. A sign in sheet in used
to record participation in both events.
Page 20 of 42
7.3b CSBG Geographical Areas and Individuals: Information about geographical
areas and categories of individuals to be served with CSBG funds include the
following:
Provide a description of geographical areas and categories of individuals being
served.
The Delaware Nation service area includes the following counties: Caddo,
Comanche, Grady, Canadian, Oklahoma, Cleveland, McClain, Pottawatomie
and Tulsa.
Specific age requirements are as follows: Enrolled Delaware Nation elders age
55 and up receive nutritional support once a year and enrolled Delaware Nation
youth school ages 3-13 receive a pass to the annual American Indian Expo, a
community cultural event.
Page 21 of 42
7.3c Method & Criteria for Distribution of Funds: A description of the criteria and
method used for the distribution of CSBG funds is as follows:
Provide a description of criteria and method used for distribution of funds.
The purchase of Thanksgiving turkeys (chosen my majority of tribal elders by
survey) are distributed to tribal elders at the Delaware Nation Tribal Complex on
a first come first serve basis. CSBG funds allow the Delaware Nation the
opportunity to provide nutritional support to more than 60 tribal elders. CSBG
funds allows for the purchase of fair bracelets for tribal youth ages 3-13 to attend
the annual American Indian Exposition, a local community cultural event.
Bracelets are distributed during and with the coordination of the Back to School
Bash in August sponsored by the Child Care and Development Fund along with
the Delaware Nation Social Services Department.
Page 22 of 42
7.3d Purpose of Funds: Tribes are required to implement at least one of the
programmatic assurances as stated in Section 676(b) of the CSBG Act of the CSBG
Act. Provide a description of the activities to be supported with CSBG funds that
will address at least one of the following areas (for any section that is not
applicable, please type N/A):
7.3.d.i. Assist low-income families and individuals in removing obstacles that
block the achievement of self-sufficiency; secure and retain meaningful
employment; attain adequate literacy and education; make better use of
available income; obtain and maintain adequate housing; obtain
emergency assistance and achieve greater participation in the affairs of
the communities.
Provide a description of activities that assist low-income
families/individuals in removing obstacles. (If you are not providing this
service, please indicate “N/A” for not applicable.)
CSBG funds in collaboration with the Child Care Development Fund provide
passes to enrolled Delaware Nation tribal youth ages 3-13 to the annual
American Indian Expo promoting greater participation in cultural and community
events when otherwise unable to attend due to income restraints.
Page 23 of 42
7.3.d.ii Address the needs of youth in low-income communities through youth
development programs, such as programs for the establishment of
violence-free zones and after- school child care programs.
Provide a description of activities that address needs of youth in low-income
communities. (If you are not providing this service, please indicate “N/A” for
not applicable.)
CSBG provides an opportunity for youth development through the participation
in a community cultural event highlighting youth development, art, education and
cultural preservation when otherwise unable to attend due to income restraints.
Page 24 of 42
7.3.d.iii Make more effective use of, and to coordinate with, other programs
related to the purposes of the CSBG Act (including welfare reform
efforts).
Provide a description of activities that coordinate with other programs
related to the purposes of the CSBG Act. (If you are not providing this
service, please indicate “N/A” for not applicable.)
CSBG collaborates with other internal programs with the same mission as to
provide assistance to low income families/households and address poverty at
the tribal community level. CSBG coordinates with the Child Care Development
Fund to provide passes to an annual community cultural event to enrolled
Delaware Nation youth ages 3-13. CSBG also collaborates with a tribally funded
assistance program to provide nutritional support to enrolled Delaware Nation
elders annually. Collaboration with other assistance programs is important due
to Delaware Nation's small CSBG funding amounts in order to achieve desired
successful outcomes of its programs.
click to sign
signature
click to edit
Page 25 of 42
7.3e Linkages: A description of how linkages will be developed to fill identified gaps
in services, through the provision of information, referrals, case management,
and follow up consultations.
Provide a description of how linkages will be developed.
For those Delaware Nation citizens unable to participate in CSBG sponsored
activities, the Tribal Assistance Program offers nutritional support by way of food
assistance once a year for all enrolled Delaware Nation citizens. Applications
are available online, and by mail or pick up at the Delaware Nation Tribal
Complex Social Services Office. Delaware Nation Social Services assistants
are available to assist and process the applications. Outside resources are
available and the Delaware Nation Social Services assistants will offer
assistance and referrals to public and private agencies when requested. The
Delaware Nation Social Services Department also operates additional funded
programs to assist tribal citizens with energy, clothing, rental, educational and
health services. In addition, the Delaware Nation operates several departments
with funded services outside of the Social Services Department and often
collaborates to provide needed assistance to tribal members such as nutrition,
education, housing and health maintenance.
Page 26 of 42
7.3f Coordination with Other Public and Private Resources: A description of how
funds made available will be coordinated with other public and private
resources is as follows:
Provide a description of coordination with other resources.
CSBG funds are used in collaboration with tribal assistance funds, to
offset the limited funds available, for the purchase of turkeys or hams
for enrolled Delaware Nation elders during winter season. Secondly,
CSBG funds are used in collaboration with Child Care and
Development Funds, to offset the limited funds available, for the
purchase of American Indian Exposition passes for enrolled
Delaware Nation youth during the summer season.
Page 27 of 42
7.3g Innovative Community and Neighborhood-based Initiatives: A description of
how funds will be used to support innovative community and neighborhood-
based initiatives related to the purposes of the CSBG, which may include
fatherhood initiatives and other initiatives with the goal of strengthening
families and encouraging effective parenting is as follows:
Provide a description of how funds will be used to support innovative and
neighborhood-based initiatives.
Though CSBG funds are not directly utilized for innovative initiatives,
Delaware Nation offers community awareness through other funded
programs.
Page 28 of 42
7.3h Plan for the provision of emergency services: A description of how the
provision of emergency services will be provided with CSBG funds.
Provide a description of how emergency services will be provided. (OPTIONAL)
7.3i Performance Management and Accountability System: A description of the
outcome measures to be used to measure the performance of CSBG-specific
goals and objectives in promoting self- sufficiency, family stability, and
community revitalization is as follows:
Provide a description of how outcome measures will be used. (OPTIONAL.)
N/A
N/A
Page 29 of 42
SECTION 8
FEDERAL CERTIFICATIONS
Federal Certifications: Below are each of the four required Federal Certifications. At the
end of each certification, please provide the Authorized Tribal Official’s signature to affirm
compliance with the certifications.
Note: Please wait until the CSBG Plan is fully completed before adding all signatures. Also,
signatures will be authorized for up to two-years (FY 2020 and FY 2021) provided that there is
not a change in the Authorized Official. If there is a change in Authorized Official, new
signatures will be needed on the FY 2021 CSBG Tribal Plan & Application.
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 an agency, a Member of Congress, an officer or employee of Congress,
or an employee of a Member of Congress in connection with the awarding of any
Federal contract, the making of any Federal grant, the making of any Federal loan,
the entering into of any cooperative agreement, and the extension, continuation,
renewal, amendment, or modification of any Federal 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 any
agency, a Member of Congress, an officer or employee of Congress or an employee of
a Member of Congress in connection with this Federal contract, grant, loan, or
cooperative agreement, the undersigned shall complete and submit Standard Form-
LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in
the award documents for all 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
Page 30 of 42
transaction was made or entered into. Submission of this certification is a
prerequisite for making or entering into this transaction imposed by section 1352,
title 31, U.S. Code. Any person who fails to file the required certification shall be
subject to a civil penalty of not less than $10,000 and not more than $100,000 for
each such failure.
Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that:
If any funds have been paid or will be paid to any person for influencing or attempting to
influence an officer or employee of any agency, a Member of Congress, an officer or
employee of Congress, or an employee of a Member of Congress in connection with this
commitment providing for the United States to insure or guarantee a loan, the undersigned
shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in
accordance with its instructions. Submission of this statement is a prerequisite for making
or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person
who fails to file the required statement shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
8.1 Authorized Tribal Official Signature: I hereby affirm that the Tribe or Tribal
Organization will ensure compliance with the certification above.
Please Note: Effective FY 2020 these assurances will be for 2 years unless there
is a change in the authorizing officials or CSBG administrator.
8.1a Name of Tribe or Tribal Organization:
8.1b Authorized Tribal Official Name:
8.1c Authorized Tribal Official Signature:
(NOTE: Please wait until the CSBG Plan is fully completed before adding all
signatures.)
Delaware Nation
Sylvia Pitner
Sylvia Pitner
Digitally signed by Sylvia Pitner
Date: 2019.08.19 15:46:18 -04'00'
Page 31 of 42
Certification Regarding Drug-Free Workplace Requirements
This certification is required by the regulations implementing the Drug-Free Workplace Act
of 1988: 45 CFR Part 76, Subpart, F. Sections 76.630(c) and (d)(2) and 76.645 (a)(1) and
(b) provide that a Federal agency may designate a central receipt point for STATE-WIDE
AND STATE AGENCY-WIDE certifications, and for notification of criminal drug convictions.
For the Department of Health and Human Services, the central point is: Division of Grants
Management and Oversight, Office of Management and Acquisition, Department of Health
and Human Services, Room 517-D, 200 Independence Avenue, SW Washington, DC 20201.
Certification Regarding Drug-Free Workplace Requirements (Instructions for
Certification)
(1) By signing and/or submitting this application or grant agreement, the grantee is
providing the certification set out below.
(2) The certification set out below is a material representation of fact upon which reliance
is placed when the agency awards the grant. If it is later determined that the grantee
knowingly rendered a false certification, or otherwise violates the requirements of the
Drug-Free Workplace Act, the agency, in addition to any other remedies available to the
Federal Government, may take action authorized under the Drug-Free Workplace Act.
(3) For grantees other than individuals, Alternate I applies.
(4) For grantees who are individuals, Alternate II applies.
(5) Workplaces under grants, for grantees other than individuals, need to be identified on
the certification. If known, they may be identified in the grant application. If the grantee
does not identify the workplaces at the time of application, or upon award, if there is no
application, the grantee must keep the identity of the workplace(s) on file in its office
and make the information available for Federal inspection. Failure to identify all known
workplaces constitutes a violation of the grantee’s drug-free workplace requirements.
(6) Workplace identifications must include the actual address of buildings (or parts of
buildings) or other sites where work under the grant takes place. Categorical
descriptions may be used (e.g., all vehicles of a mass transit authority or State highway
department while in operation, State employees in each local unemployment office,
performers in concert halls or radio studios).
Page 32 of 42
(7) If the workplace identified to the agency changes during the performance of the grant,
the grantee shall inform the agency of the change(s), if it previously identified the
workplaces in question (see paragraph five).
(8) Definitions of terms in the Nonprocurement Suspension and Debarment common rule
and Drug-Free Workplace common rule apply to this certification. Grantees’ attention is
called, in particular, to the following definitions from these rules:
Controlled substance means a controlled substance in Schedules I through V of the
Controlled Substances Act (21 U.S.C. 812) and as further defined by regulation (21 CFR
1308.11 through 1308.15);
Conviction means a finding of guilt (including a plea of nolo contendere) or imposition
of sentence, or both, by any judicial body charged with the responsibility to determine
violations of the Federal or State criminal drug statutes;
Criminal drug statute means a Federal or non-Federal criminal statute involving the
manufacture, distribution, dispensing, use, or possession of any controlled substance;
Employee means the employee of a grantee directly engaged in the performance of work
under a grant, including: (i) All direct charge employees; (ii) All indirect charge
employees unless their impact or involvement is insignificant to the performance of the
grant; and, (iii) Temporary personnel and consultants who are directly engaged in the
performance of work under the grant and who are on the grantee’s payroll. This
definition does not include workers not on the payroll of the grantee (e.g., volunteers,
even if used to meet a matching requirement; consultants or independent contractors
not on the grantee’s payroll; or employees of subrecipients or subcontractors in
covered workplaces).
Certification Regarding Drug-Free Workplace Requirements
Alternate I. (Grantees Other Than Individuals)
The grantee certifies that it will or will continue to provide a drug-free workplace by:
(a) Publishing a statement notifying employees that the unlawful manufacture,
distribution, dispensing, possession, or use of a controlled substance is prohibited in
the grantee’s workplace and specifying the actions that will be taken against employees
for violation of such prohibition;
(b) Establishing an ongoing drug-free awareness program to inform employees about - -
(1) The dangers of drug abuse in the workplace;
Page 33 of 42
(2) The grantee’s policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs;
and
(4) The penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace;
(c) Making it a requirement that each employee to be engaged in the performance of the
grant be given a copy of the statement required by paragraph (a);
(d) Notifying the employee in the statement required by paragraph (a) that, as a condition
of employment under the grant, the employee will - -
(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a criminal
drug statute occurring in the workplace no later than five calendar days after such
conviction;
(e) Notifying the agency in writing, within 10 calendar days after receiving notice under
paragraph (d)(2) from an employee or otherwise receiving actual notice of such
conviction. Employers of convicted employees must provide notice, including position
title, to every grant officer or other designee on whose grant activity the convicted
employee was working, unless the Federal agency has designated a central point for the
receipt of such notices. Notice shall include the identification number(s) of each
affected grant;
(f) Taking one of the following actions, within 30 calendar days of receiving notice under
paragraph (d)(2), with respect to any employee who is so convicted - -
(1) Taking appropriate personnel action against such an employee, up to and including
termination, consistent with the requirements of the Rehabilitation Act of 1973, as
amended; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local
health, law enforcement, or other appropriate agency;
(g) Making a good faith effort to continue to maintain a drug-free workplace through
implementation of paragraphs (a), (b), (c), (d), (e) and (f).
The grantee may insert in the space provided below the site(s) for the performance of
work done in connection with the specific grant:
Place of Performance (Street address, city, county, state, zip code)
Page 34 of 42
Check if there are workplaces on file that are not identified here. Alternate II. (Grantees
Who Are Individuals)
(a) The grantee certifies that, as a condition of the grant, he or she will not engage in the
unlawful manufacture, distribution, dispensing, possession, or use of a controlled
substance in conducting any activity with the grant;
(b) If convicted of a criminal drug offense resulting from a violation occurring during
the conduct of any grant activity, he or she will report the conviction, in writing,
within 10 calendar days of the conviction, to every grant officer or other designee,
unless the Federal agency designates a central point for the receipt of such notices.
When notice is made to such a central point, it shall include the identification
number(s) of each affected grant.
[55 FR 21690, 21702, May 25, 1990]
8.2 Authorized Tribal Official Signature: I hereby affirm that the Tribe or Tribal
Organization will ensure compliance with the certification above.
Please Note: Effective FY 2020 these assurances will be for 2 years unless there
is a change in the authorizing officials or CSBG administrator.
8.2a Name of Tribe or Tribal Organization:
8.2b Authorized Tribal Official Name:
8.2c Authorized Tribal Official Signature:
(NOTE: Please wait until the CSBG Plan is fully completed before adding all
signatures.)
Delaware Nation
Sylvia Pitner
Sylvia Pitner
Digitally signed by Sylvia Pitner
Date: 2019.08.19 15:46:39 -04'00'
Page 35 of 42
Certification Regarding Debarment, Suspension, and Other Responsibility Matters
Certification Regarding Debarment, Suspension, and Other Responsibility Matters - -
Primary Covered Transactions
Instructions for Certification
(1) By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
(2) The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The
prospective participant shall submit an explanation of why it cannot provide the
certification set out below. The certification or explanation will be considered in
connection with the department or agency’s 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.
(3) The certification in this clause is a material representation of fact upon which reliance
was placed when the department or agency determined to enter into this transaction.
If it is later determined that the prospective primary participant knowingly rendered
an erroneous certification, in addition to other remedies available to the Federal
Government, the department or agency may terminate this transaction for cause or
default.
(4) The prospective primary participant shall provide immediate written notice to the
department or agency to which this proposal is submitted if at any time the prospective
primary participant learns that its certification was erroneous when submitted or has
become erroneous by reason of changed circumstances.
(5) The terms covered transaction, debarred, suspended, ineligible, lower tier covered
transaction, participant, person, primary covered transaction, principal, proposal, and
voluntarily excluded, as used in this clause, have the meanings set out in the
Definitions and Coverage sections of the rules implementing Executive Order 12549.
You may contact the department or agency to which this proposal is being submitted
for assistance in obtaining a copy of those regulations.
(6) The prospective primary participant agrees by submitting this proposal that, should
the proposed covered transaction be entered into, it shall not knowingly enter into
Page 36 of 42
any lower tier covered transaction with a person who is proposed for debarment
under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or
voluntarily excluded from participation in this covered transaction, unless authorized
by the department or agency entering into this transaction.
(7) The prospective primary participant further agrees by submitting this proposal that it
will include the clause titled “Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusive-Lower Tier Covered Transaction,” provided by
the department or agency entering into this covered transaction, without
modification, in all lower tier covered transactions and in all solicitations for lower
tier covered transactions.
(8) A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that is not proposed for debarment
under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily
excluded from the covered transaction, unless it knows that the certification is
erroneous. A participant may decide the method and frequency by which it
determines the eligibility of its principals. Each participant may, but is not required to,
check the List of Parties Excluded from Federal Procurement and Nonprocurement
Programs.
(9) Nothing contained in the foregoing shall be construed to require establishment of a
system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
(10) Except for transactions authorized under paragraph 6 of these instructions, if a
participant in a covered transaction knowingly enters into a lower tier covered
transaction with a person who is proposed for debarment under 48 CFR part 9,
subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from
participation in this transaction, in addition to other remedies available to the Federal
Government, the department or agency may terminate this transaction for cause or
default.
************
Page 37 of 42
Regarding Debarment, Suspension, and Other Responsibility Matters - -
Primary Covered Transactions
(1) The prospective primary participant certifies to the best of its knowledge and belief,
that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of or
had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction;
violation of Federal or State antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly charged by a
governmental entity (Federal, State or local) with commission of any of the
offenses enumerated in paragraph (1)(b) of this certification; and
(d) Have not within a three-year period preceding this application/proposal had one
or more public transactions (Federal, State or local) terminated for cause or
default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an
explanation to this proposal.
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion -
- Lower Tier Covered Transactions
Instructions for Certification
(1) By signing and submitting this proposal, the prospective lower tier participant is
providing the certification set out below.
(2) The certification in this clause is a material representation of fact upon which reliance
was placed when this transaction was entered into. If it is later determined that the
prospective lower tier participant knowingly rendered an erroneous certification, in
addition to other remedies available to the Federal Government the department or
Page 38 of 42
agency with which this transaction originated may pursue available remedies,
including suspension and/or debarment.
(3) The prospective lower tier participant shall provide immediate written notice to the
person to which this proposal is submitted if at any time the prospective lower tier
participant learns that its certification was erroneous when submitted or had become
erroneous by reason of changed circumstances.
(4) The terms covered transaction, debarred, suspended, ineligible, lower tier covered
transaction, participant, person, primary covered transaction, principal, proposal, and
voluntarily excluded, as used in this clause, have the meaning set out in the
Definitions and Coverage sections of rules implementing Executive Order 12549. You
may contact the person to which this proposal is submitted for assistance in obtaining
a copy of those regulations.
(5) The prospective lower tier participant agrees by submitting this proposal that, should
the proposed covered transaction be entered into, it shall not knowingly enter into
any lower tier covered transaction with a person who is proposed for debarment
under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or
voluntarily excluded from participation in this covered transaction, unless authorized
by the department or agency with which this transaction originated.
(6) The prospective lower tier participant further agrees by submitting this proposal that
it will include this clause titled “Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,” without
modification, in all lower tier covered transactions and in all solicitations for lower
tier covered transactions.
(7) A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that it is not proposed for debarment
under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily
excluded from covered transactions, unless it knows that the certification is
erroneous. A participant may decide the method and frequency by which it
determines the eligibility of its principals. Each participant may, but is not required to,
check the List of Parties Excluded from Federal Procurement and Nonprocurement
Programs.
(8) Nothing contained in the foregoing shall be construed to require establishment of a
system of records in order to render in good faith the certification required by this
Page 39 of 42
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
(9) Except for transactions authorized under paragraph five of these instructions, if a
participant in a covered transaction knowingly enters into a lower tier covered
transaction with a person who is proposed for debarment under 48 CFR part 9,
subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from
participation in this transaction, in addition to other remedies available to the Federal
Government, the department or agency with which this transaction originated may
pursue available remedies, including suspension and/or debarment.
************
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion -
- Lower Tier Covered Transactions
(1) The prospective lower tier participant certifies, by submission of this proposal, that
neither it nor its principals is presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from participation in this
transaction by any Federal department or agency.
(2) Where the prospective lower tier participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an
explanation to this proposal.
8.3 Authorized Tribal Official Signature: I hereby affirm that the Tribe or Tribal
Organization will ensure compliance with the certification above.
Please Note: Effective FY 2020 these assurances will be for 2 years unless there
is a change in the authorizing officials or CSBG administrator.
8.3a Name of Tribe or Tribal Organization:
8.3b Authorized Tribal Official Name:
8.3c Authorized Tribal Official Signature:
(NOTE: Please wait until the CSBG Plan is fully completed before adding all signatures.)
Delaware Nation
Sylvia Pitner
Sylvia Pitner
Digitally signed by Sylvia Pitner
Date: 2019.08.19 15:47:00 -04'00'
Page 40 of 42
Certification Regarding Environmental Tobacco Smoke
Public Law 103227, Part C Environmental Tobacco Smoke, also known as the Pro Children
Act of 1994, requires that smoking not be permitted in any portion of any indoor routinely
owned or leased or contracted for by an entity and used routinely or regularly for 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 $1000 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 the children’s services and that
all subgrantees shall certify accordingly.
8.4 Authorized Tribal Official Signature: I hereby affirm that the Tribe or Tribal
Organization will ensure compliance with the certification above.
Please Note: Effective FY 2020 these assurances will be for 2 years unless there
is a change in the authorizing officials or CSBG administrator.
8.4a Name of Tribe or Tribal Organization:
8.4b Authorized Tribal Official Name:
8.4c Authorized Tribal Official Signature:
(NOTE: Please wait until the CSBG Plan is fully completed before adding all
signatures.)
Delaware Nation
Sylvia Pitner
Sylvia Pitner
Digitally signed by Sylvia Pitner
Date: 2019.08.19 15:47:19 -04'00'
Page 41 of 42
SECTION 9
ANNUAL REPORT
9.1 Mandatory Annual Report:
All renewing grantees must submit an Annual Report each year (including grantees with
previously-approved two-year CSBG Tribal Plans).
Please Note: Starting FY19 all Annual Reports will be due on December 30 of each year.
The Annual Report is a narrative description of how the grantee met its CSBG goals and
objectives and provides information on the types of projects supported with CSBG
funding awarded in the previous fiscal year.
☐ The Tribe or Tribal Organization will complete and submit a FY19 CSBG
Annual Report by December 30, 2019
✔
Page 42 of 42
END OF FORM
Please save your PDF form. Then review and confirm that that you have provided all of the
necessary information before adding the required signatures. (Instructions regarding
signatures can be found in the CSBG Tribal Plan & Application Tool Guide.) Once signatures
have been added, save your final signed PDF file. It will be ready to be submitted as part
of your official FY2020 CSBG Tribal Plan & Application package. Please refer to the CSBG
Tribal Plan & Application Tool Guide for detailed instructions on how to submit your
official FY 2020 CSBG Tribal Plan & Application package to OCS.
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Completed 27 January 2021

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