Fillable OMB Clearance No: 0970-0571 U.S. DEPARTMENT OF HEALTH

Fill Online, Printable, Fillable, Blank OMB Clearance No: 0970-0571 U.S. DEPARTMENT OF HEALTH Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

OMB Clearance No: 0970-0571 U.S. DEPARTMENT OF HEALTH

On average this form takes 73 minutes to complete

The OMB Clearance No: 0970-0571 U.S. DEPARTMENT OF HEALTH form is 56 pages long and contains:

  • 1 signature
  • 177 check-boxes
  • 207 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2019
LIHWAP Plan: Page 1 of 38
Low Income Household Water Assistance Program
(LIHWAP) Consolidated Appropriations Act of 2021 and
American Rescue Plan
GRANT IMPLEMENTATION PLAN
Grantee Name:
Document Status:
Public Comment Draft
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 2 of 38
Section 1 – Program Needs, Goals and Allocations
Community Needs and Program Goals
1.1 Description of Emergency Household Drinking Water and Wastewater Needs
The OCS priorities are restoration of household water services, reducing arrearages, reducing
rates charged to households. Briefly describe current needs related to these priorities within your
state, territory, or tribal areas. Describe any areas of concentrated need or special issues within
communities served by water utilities within your state, territory, or tribal area.
1.2 Operational Priorities and Emergency Flexibilities
Consistent with goal of the American Rescue Plan to provide immediate relief to the American
people, briefly describe the operational priorities within your state. territory or tribal area
(e.g. immediate restoration of services to households without current water services, immediate
payment of existing arrearages to prevent disconnection of drinking water or wastewater
services after a previous moratorium on water services due to Covid-19).
1.3 Expected Date for Initial Water Payments on Behalf of Households
Provide an estimated date by which payments will be initiated based on the operational
priorities identified above (e.g. first stage of payments to restore services for currently
disconnected households, etc.).
Our goal is to address water utility arrearages for qualifying households. Existing programs address
heating and cooling needs. There are no current water-specific assitance programs. COVID has created
a financial burden on the Muscogee Nation Reservation, leaving many of our Citizens without means to
pay their water utility.
Our goal is to provide assistance to households with water utility cut-off notices and/or shut-offs.
Assistance will begin October 1, 2021.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 3 of 38
Estimated Funding Allocations
1.4 Estimate what amount of available LIHWAP funds will
be used for each component that you will operate:
The total of all percentages must add up to 100%.
The combined total of Administration (State) and
Administration (Subrecipients) must not exceed 15% of
the total for either the Consolidated Appropriations Act or
the American Rescue Plan Award.
Consolidated
Appropriations Act of
2021 Percentage (%)
American Rescue Plan
Grant Percentage %
Household Benefits % %
Outreach/Eligibility Determination % %
Administration - State % %
Administration - Subrecipients % %
Total (each column must equal 100%) % %
Categorical Eligibility
1.5 As outlined in the Terms and Conditions, current recipients the following programs are
categorically-eligible for LIHWAP assistance:
• Low-Income Home Energy Assistance Program (LIHEAP)
• Means-tested Veterans Programs
• Supplemental Security Income (SSI)
• Supplemental Nutrition Assistance Program (SNAP)
• Temporary Assistance for Needy Families (TANF)
Briefly describe your operational plans for enrollment of categorically eligible populations based
on operational priorities outlined in question 1.2 (e.g. automatic enrollment, acceptance of
documentation of enrollment during intake processes). If it will not be possible to include any of
these programs in your intake/eligibility processes, provide a brief explanation.
If a household presents documentation of eligiblity for of any of the qualifying catergorically-eligible
programs, the household income documentation requirement will be bypassed. All other required
documents will then be reviewed to determine eligibility. If the household composition listed on
categorically-eligible documents does not match the household composition on the LIHWAP application,
other documentation will be requested.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 4 of 39
Determination of Eligibility for Direct Enrollment
Note: The information below is focused on eligibility determination for households that are not
categorically eligible based on the enrollment in one of the programs outlined in question 1.5.
1.6 What type of countable income do you use for eligibility determination? (select one)
Gross Income
Net Income
1.7 List all the applicable forms of countable income used to determine a household's income
eligibility for LIHWAP. Note: The forms of countable income used for benefit eligibility are
generally left to the discretion of the grantee; however, the following sources are not
applicable forms of countable income used to determine a household’s income eligibility
for LIHWAP:
Temporary Assistance for Needy Families (TANF) benets
Supplemental Nutrition Assistance Program (SNAP) benets
Women, Infants, and Children Supplemental Nutrition Program (WIC) benets
Covid-19 Economic Impact Payments (Stimulus Checks)
If any of the above questions require further explanation or clarication that could not be made in the
elds, provide said explanation here.
■
Employment, self-employment income, unemployment insurance, Social Security Administration, retirement
and/or pension benefits, and child support
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 5 of 38
Section 2: Benefits
Eligibility
2.1 Designate the income eligibility threshold used for the water benefit.
Eligibility Threshold (select one) Eligibility Threshold Percent
Federal Poverty Guideline
State Median Income
Hybrid Federal and State
(Based on Household Size)
%
2.2 Do you anticipate additional eligibility requirements beyond the income threshold noted in
2.1 for water assistance? Yes No
If the answer to question 2.2. is “Yes” please provide an explanation below
2.3. How will you support households whose utility payments are included in their rental
payments?
2.4 Check the variables you use to determine your benefit levels. (Check all that apply. Check
both Household Drinking Water Burden and Household Wastewater Burden if households receive
a combined bill for drinking water and wastewater):
Income
Household Size
Household Drinking Water Burden
Household Wastewater Burden
Other (Please describe):
2.5 Describe estimated benefit levels for the project period for which this plan applies
Minimum Benefit $ Maximum Benefit $
60
■
■
Households must meet the following critera:
* The houshold must be located in Muscogee Nation Reservation.
* One household member must be enrolled in Muscogee Nation.
* Household must have a current cut-off notice and/or water is disconnected.
* The water bill must be in a household member's name.
No.
✔
✔
✔
Households with vulnerable populations are given additional points on the benefits matrix that increase
their assistance amount.
190
550
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 6 of 38
2.6 Benefit periods
Is this a one-time benefit? Yes No
If no, please explain the frequency of allowable benefit (e.g., monthly, quarterly, etc.):
2.7 Do you give priority in eligibility to:
People with Disabilities Yes No
Young Children? Yes No
Older Adult/Seniors (60 and over)? Yes No
Households with high water burdens? Yes No
Other? Yes No
2.8 Describe how you prioritize the provision of water assistance to vulnerable populations
(e.g., benefit amounts, early application periods, etc.)
2.9 Do you provide applicants, including those who are physically disabled, the means to
submit applications for benefits without leaving their homes? Yes No
If No, explain.
2.10 For individual who are homebound or physically disabled, do you provide travel to the
sites at which applications for assistance are accepted? Yes No
If No, explain and explain alternative means of intake to those who are homebound or physically
disabled?
■
■
■
■
■
Households with vulnerable populations are given additional points on the benefits matrix that increase
their assistance amount.
■
Applications can be submitted without an in-office visit.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 7 of 38
2.11 Are any of the utility vendors you work with subject to a moratorium on shut offs?
Yes No
If you responded "Yes" to question 2.11, you must respond to question 2.12.
2.12 Describe the terms of the moratorium and any special dispensation received by LIHWAP
clients during or after the moratorium period.
2.13 Do you make payments contingent on vendors taking appropriate measures or maintaining
existing supports to alleviate the water burden of eligible households?
Yes No
If so, describe the measures vendors may take or maintain.
COVID-Specific General (Not COVID-specific)
Disconnection moratorium
No late fees, interest, or penalty
charges
Ability to enter into payment plan
of 6 months or longer
Reconnection of service for
disconnected customers
Enrollment in a discounted rate
Consumer protections regarding shutoffs (e.g.,
minimum notice period, protection of vulnerable
populations, minimum amount overdue before
disconnection allowed, opportunity for payment plan
before disconnection, other procedural or substantive
restrictions on shutoffs)
Data reporting requirements for utilities – on a
permanent basis – e.g., periodic reporting on number
of shutoffs
Percentage of income payment plan other utility-
funded arrearage assistance
Lifeline rates
Water efficiency assistance
Provisions ensuring continued service for a specific
time period (Describe below)
Provisions ensuring reconnection within a specific time
period (Describe below)
■
■
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 8 of 38
If any of the above questions require further explanation or clarification that could not be made in the
fields, provide said explanation here.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 9 of 38
Section 3: Outreach
3.1 Select all outreach activities that you conduct that are designed to assure that eligible
households are made aware of all LIHWAP assistance available:
Place posters/flyers in local and county social service offices, offices of aging, Social Security
offices, VA, etc.
Publish articles or public service announcements in local newspapers or broadcast media
announcements.
Work directly with water utilities to identify potential recipients.
Include inserts in water vendor billings to inform individuals of the availability of all types of
LIHWAP assistance.
Mass mailing(s) to prior-year LIHEAP recipients or recipients of other government benefits:
Automated phone campaigns and/or social media outreach
Multi-lingual announcements in languages spoken by low income households within utility
service area and/or notification in ethnic language news and broadcast media outlets
Inform low income applicants of the availability of all types of LIHWAP assistance at
application intake for other low-income programs.
Execute interagency agreements with other low-income program offices and/or public health
pathways created for Covid-19 outreach to perform outreach to target groups.
Outreach to faith-based institutions, including those serving low-income people and people of
color
Other (specify):
If any of the above questions require further explanation or clarification that could not be made in the
fields, provide said explanation here.
✔
✔
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 10 of 38
Section 4: Coordination
4.1 Describe how you will ensure that the LIHWAP program is coordinated with other
programs available to low-income households (LIHEAP, TANF, SSI, SNAP, EPA,
Emergency Rental Assistance Program, Homeowner Assistance Program, WAP, etc.) etc.).
Joint application for multiple programs:
Intake referrals to/from other programs:
One - stop intake centers:
Other - Describe:
4.2 Describe how you will coordinate with relevant regulatory authorities that govern water
suppliers.
If any of the above questions require further explanation or clarification that could not be made in the
fields, provide explanation here.
✔
All Muscogee Nation Social Services Programs will utilize the same application.
✔
✔
Applications for al Muscogee Nation Social Services programs can be accepted at our three (3) office
sites.
N/A
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 11 of 38
Section 5: Agency Designation
(Required for State grantees and the Commonwealth of Puerto Rico))
5.1 How would you categorize the primary responsibility of your State agency?
Administration Agency
Commerce Agency
Community Services Agency
Energy / Environment Agency
Housing Agency
Human Service Agency
Other - Describe:
5.2 LIHWAP Component
Administration
Drinking Water Service
Wastewater
Service
5.2a Who determines client
eligibility?
5.2b Who processes benefit
payments to water service
providers?
If any of your LIHWAP components are not centrally administered by a State agency, you must
complete questions 5.3, 5.4 and 5.5.
5.3 What is your process for selecting local administering agencies?
5.4 How many local administering agencies do you use?
5.5 What types of local administering agencies do you use?
Community Action Agencies
Local Governments
City Governments
County Governments
Other non-profits
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 12 of 38
If any of the above questions require further explanation or clarification that could not be made in the
fields, provide said explanation here.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 13 of 38
Section 6: Water Suppliers
Note: Water suppliers refers to both drinking and/or wastewater suppliers as they may be different
entities at the local level
6.1 The following question is specific to Tribes (only). Do you charge households drinking
water and wastewater utility services?
Yes If “Yes” please proceed to next questions.
No If “No” please skip to question 6.5.
6.2 How do you notify the household of the amount of assistance paid, and the timing of the
assistance payment?
6.3 How do you assure that no household receiving assistance under this title will be treated
adversely because of their receipt of LIHWAP assistance?
■
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 14 of 38
6.4 How do you assure that water suppliers are restoring disconnected service or otherwise
maintaining continuity of service due to the benefit payment?
6.5 For Tribes who answered “No” to question 6.1, please describe how you intend to maintain
accurate records to show how LIHWAP funds are expended for drinking water and/or
wastewater utilities on behalf of households. (I.E. Financial expenditure reports).
If any of the above questions require further explanation or clarification that could not be made in the
fields, provide said explanation here.
Payments will be processed in a database tracking all payments and the funding source. Payments are
reviewed and approved by a Supervisor and Program Manager. Finance processes payments and
monitors budget amounts. Finance tracks payments in a financial database. Social Services reconciles
records with Finance.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 15 of 38
Section 7: Program, Fiscal Monitoring, and Audit
7.1 How do you ensure good fiscal accounting and tracking of LIHWAP funds?
Audit Process
7.2 Describe any audit findings rising to the level of material weakness or reportable condition cited
in the Single Audits (as required in the Single Audit Act), Grantee monitoring assessments,
inspector general reviews, or other government agency reviews of the LIHWAP agency from the
most recently audited fiscal year.
No Findings
Finding Type Brief Summary Resolved? Action Taken
1.
2.
3.
4.
5.
6.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
All LIHWAP application documents are scanned into a database. The database also tracks payments, payment
amounts, and the funding source. Muscogee Nation Finance department also tracks payment of assistance
and their funding source in their database.
✔
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 16 of 38
Compliance Monitoring
7.3 Identify the Grantee's strategies for monitoring compliance with the Grantee's and Federal
LIHWAP policies and procedures (e.g. certifications, Terms and Conditions, federal guidance,
nondiscrimination requirements): Select all that apply.
Grantee employees:
Internal program review
Departmental oversight
Secondary review of invoices and payments
Reconciliation of water supplier records
Other program review mechanisms are in place. Describe:
Local Administering Agencies / District Offices:
On - site evaluation
Annual program review
Monitoring through central database
Desk reviews
Client file testing/sampling
Reconciliation of water supplier records
Other program review mechanisms are in place. Describe:
✔
✔
✔
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 17 of 38
7.4 Explain or attach a copy of your local agency monitoring schedule and protocol.
7.5 Describe how you select local agencies for monitoring reviews.
Site visits:
Desk reviews:
7.6 How often will each local agency be monitored? Note: This answer can be prospective.
N/A
N/A
N/A
N/A
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 18 of 38
7.7. How many local agencies are currently on corrective action plans for eligibility and/or benefit
determination issues for LIHEAP or other programs administered by your agency?
7.8. How many local agencies are currently on corrective action plans for financial accounting or
administrative issues for LIHEAP or other programs administered by your agency?
If any of the above questions require further explanation or clarification that could not be made in the fields
provide, said explanation here.
0
0
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 19 of 38
Section 8: Public Participation
8.1 How did you obtain input from the public in the development of your LIHWAP plan?
Select all that apply.
Tribal Council meeting(s)
Public hearing(s)
Enter the dates for Tribal Council meeting(s) or Public hearing(s):
Draft Plan posted to website and available for comment
Hard copy of plan is available for public view and comment
Enter how long draft plan and/or hard copy of plan was available for public view and comment:
Comments from applicants are recorded
Request for comments on draft Plan is advertised
Stakeholder or consultation meeting(s)
Comments are solicited during outreach activities
Other - Describe:
8.2 How many parties commented on your plan?
8.3 Summarize the comments you received on your plan here:
8.4 What changes did you make to your LIHWAP plan as a result of the comments received?
✔
7/20/21 - 8/1/21
✔
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 20 of 38
If any of the above questions require further explanation or clarification that could not be made in the
fields, provide said explanation here.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 21 of 38
Section 9: Fair Hearings
Note: Administrative hearing opportunities will be comparable to and may utilize existing processes,
procedures, and systems currently in place for the State, Territory, or Tribe’s Low Income Home Energy
Assistance grant.
9.1 Describe your fair, independent hearing procedures for households whose applications are
denied or where the applicant disputes the benefit amount.
9.2 When and how are applicants informed of these rights?
9.3 Describe your fair hearing procedures for households whose applications are not acted on
in a timely manner.
All required documentation must be received in order for eligibility to be determined. In the event of
denial, if the applicant feels the decision of the Social Services staff is in error, he/she may file a written
appeal within 10 days from the date on the letter of denial. The Human Services Director will review and
forward the appeal letter to an Appeals Team for review and a decision will be made within 10 days days
from receiving the appeal letter. All decisions will be based according to Tribal and Federal Law, our
approved Model Plan, and the program policy and procedures.
At the time of application, the right to appeal a decison is provided in writing on the application.
Additionally, all applicants are informed of these righs in writing on all denial letters.
If a client feels the application was not acted on in a timely manner, he or she may appeal this action
following the same guidelines previously stated for denials. A response will be issued to the client within 5
business days.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 22 of 38
9.4 When and how are applicants informed of these rights?
If any of the above questions require further explanation or clarification that could not be made in the
fields, provide said explanation here.
At the time of application the right to appeal a decison is provided in writing on the application. In addition,
it is also explained on all denial letters. Further, with a client speaks with a Social Worker, Supervisor, or
Manager, these rights can also be verbally explained.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 23 of 38
Section 10: Training
10.1 Training Strategy - Briefly describe the anticipated training strategy for ensuring that
grantee staff, local administering agencies, and participating water utilities understand
requirements outlined in the Terms and Conditions as well eligibility requirements and
procedures described in this plan. Indicate any technical assistance or resources
needed by the State, Territory or Tribe to carry out this training strategy.
Training will be as follows:
* Formal training on grantee policies and procedures will be conducted as needed.
* Employees will be provided with a copy of the approved LIHWAP Model Plan.
* Formal training conferences (if/when developed) will be attended as needed.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 24 of 38
Section 11: Performance Management
11.1 Describe any challenges you anticipate with collecting and reporting data to ACF each
year regarding how you implemented your LIHWAP. Examples of data may include, but
are not limited to, the number of households assisted, the average benefit amount
provided, the number of households whose water or wastewater services were restored
because of the benefit, demographics of applicants and beneficiaries, and the number of
imminent disconnections of water or wastewater services avoided because of the benefit.
11.2 List any technical assistance resources you request of ACF related to data collection,
analysis and reporting on your LIHWAP.
N/A
N/A
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 25 of 38
If any of the above questions require further explanation or clarification that could not be made in the
fields, provide said explanation here.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 26 of 38
Section 12: Program Integrity
12.1 Fraud Reporting Mechanisms
a. Identify all mechanisms that will be available to the public for reporting cases of
suspected LIHWAP waste, fraud, and abuse. Select all that apply.
Online fraud reporting
Dedicated fraud reporting hotline
Report directly to local agency/district office or Grantee office
Report to State Inspector General or Attorney General
Forms and procedures in place for local agencies/district offices and vendors to report
fraud, waste, and abuse
Other - Describe:
b. Identify strategies that will be used for advertising the above-referenced resources.
Select all that apply
Printed outreach materials
Addressed on LIHWAP application
Website
Other - Describe:
12.2. Identification Documentation Requirements
a. Indicate which of the following forms of identification will be required or requested to be
collected from LIHWAP applicants or their household members. Note: The types of
documentation required is left to the discretion of the grantee. The types of documentation
included in the list below are examples of documentation required by LIHEAP grantees for
some or all household members based on policies within the State, Territory or Tribe.
Comparable documentation and procedures may be instituted for LIHWAP households or may
be modified or simplified for households that are categorically eligible based on enrollment in
programs identified in question 1.5.
Type of Identification Collected
Collected from Whom?
Applicant Only All Adults in Household All Household Members
Social Security Card is photocopied
and retained
Required Required Required
Requested Requested Requested
Social Security Number (Without
Actual Card)
Required Required Required
Requested Requested Requested
Government-issued identification
card (i.e.: driver's license, State ID,
Tribal ID, passport, etc.)
Required Required Required
Requested Requested Requested
Other (Describe Below) Required Required Required
Requested Requested Requested
✔
✔
Muscogee (Creek) Nation Citizenship
Verification
✔
✔
✔
✔
✔
✔
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 27 of 38
b. Describe any exceptions to the above policies.
12.3 Identification Verification
Identify what methods will be used to verify the authenticity of identification documents provided
by clients or household members. Select all that apply
Verify SSNs with Social Security Administration
Match SSNs with death records from Social Security Administration or State agency
Match SSNs with State eligibility/case management system (e.g., SNAP, TANF)
Match with State Department of Labor system
Match with State and/or federal corrections system
Match with State child support system
Verification using private software (e.g., The Work Number)
In-person certification by staff (for Tribal grantees only)
Match SSN/Tribal ID number with Tribal database or enrollment records
(for Tribal grantees only)
Other - Describe:
12.4. Citizenship/Legal Residency Verification
What are your procedures for ensuring that household members are U.S. citizens or permanent
residents who are qualified to receive LIHWAP benefits? Select all that apply.
Clients sign an attestation of citizenship or legal residency
Client's submission of Social Security cards is accepted as proof of legal residency
Noncitizens must provide documentation of immigration status
Citizens must provide a copy of their birth certificate, naturalization papers, or passport
Noncitizens are verified through the SAVE system
Tribal members are verified through Tribal enrollment records/Tribal ID card
Other - Describe:
* Social Security Cards maybe waived for minor children twelve (12) and younger.
* Household member who don't have a government-issued identification card may submit a birth
certificate in lieu. Hospital birth certificates will be accepted for children twelve (12) and younger.
* At least one household member must be an enrolled member of the Muscogee (Creek) Nation
✔
✔
✔
✔
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 28 of 38
12.5. Income Verification Note: Income verification applies only to households that have not
been determined to be categorically eligible based on enrollment in other programs
identified in question 1.5 above. Methods of income verification are left to the discretion
of grantees and should be consistent with any sources of countable income identified in
question 1.7 above.
What methods will your agency utilize to verify household income? Select all that apply.
Require documentation of income for all adult household members
Bank statements
Pay stubs
Social Security award letters
Tax statements
Unemployment insurance letters
Zero-income statements
Other - Describe:
Computer data matches
Income information matched against state computer system (e.g., SNAP, TANF)
Proof of unemployment benefits verified with state Department of Labor
Social Security income verified with SSA
Utilize state directory of new hires
Other - Describe:
12.6. Protection of Privacy and Confidentiality
Identify the financial and operating controls that will be in place to protect client information
against improper use or disclosure. Select all that apply.
Policy in place prohibiting release of information without written consent
Grantee LIHWAP database includes privacy/confidentiality safeguards
Employee training on confidentiality for:
Grantee employees Local agencies/district offices
Employees must sign confidentiality agreement
Grantee employees Local agencies/district offices
Physical files are stored in a secure location
Other - Describe:
✔
✔
✔
✔
* For self-employed individuals an income ledger will be required.
* Income verified by the Department of Human Services will be accepted as income.
* Eighteen (18) year old household members still attending high schol will be counted as
minors and income will not be required for these members. Proof of current school enrollment
will be required.
✔
✔
✔
✔
✔
✔
✔
✔
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 29 of 38
12.7 Verifying the Authenticity
What policies will be in place for verifying vendor authenticity? Select all that apply.
All vendors must register with the State/Tribe.
All vendors must supply a valid SSN or TIN/W-9 form
Vendors are verified through water bills provided by the household
Grantee and/or local agencies/district offices perform physical monitoring of vendors
Other - Describe and note any exceptions to policies above:
12.8 Benefits Policy - Water and Wastewater Utilities
What policies will be in place to protect against fraud when making benefit payments to water
utilities on behalf of clients? Select all that apply.
Applicants required to submit proof of physical residency
Applicants must submit current water or wastewater bill
Centralized computer system/database tracks payments to all water suppliers
Centralized computer system automatically generates benefit level
Computer databases are periodically reviewed to verify accuracy and timeliness of payments
made to water suppliers
Data exchange with utilities that verifies:
Account is properly credited with benefit
Account ownership
Balances
Consumption
Payment history
Other - Describe:
Payments coordinated among other water and wastewater assistance programs to avoid
duplication of payments
Payments to water suppliers and invoices from water suppliers are reviewed for accuracy
Procedures are in place to require prompt refunds from utilities in cases of account closure
Separation of duties between intake and payment approval
Vendor agreements specify requirements selected above, and provide enforcement
mechanism
Other - Describe:
✔
✔
✔
✔
✔
✔
✔
Data exchange with water companies discussing blances are conducted for processing
arrearage payments.
✔
✔
✔
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 30 of 38
12.9 Investigations and Prosecutions
Identify the Grantee's procedures for investigating and prosecuting reports of fraud, and any
sanctions placed on clients/staff/vendors found to have committed fraud. Select all that apply.
Clients found to have committed fraud are banned from LIHWAP assistance. For how long is
a household banned?
Contracts with local agencies require that employees found to have committed fraud are
reprimanded and/or terminated
Grantee attempts collection of improper payments. If so, describe the recoupment process
Local agencies/district offices or Grantee conduct investigation of fraud complaints from public
Refer to local prosecutor or State Attorney General
Refer to State Inspector General
Refer to US DHHS Inspector General (including referral to OIG hotline)
Vendors found to have committed fraud may no longer participate in LIHWAP
Other - Describe:
If any of the above questions require further explanation or clarification that could not be made in the
fields, provide said explanation here.
✔
One (1) year
✔
✔
Collection of improper payments: Written notice will be sent to the client or vendor notifying of
improper payment and requesting repayment of funds. Client will be inelgible for assistance until
repayment is remedied. Office Clerk will continue to follow up with vendors until repayment of
improper payment is received.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 31 of 38
Section 13: 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 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 Exclusion-
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 it 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.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 32 of 38
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.
Certification 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 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.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 33 of 38
5. The prospective lower tier participant agrees by submitting this proposal that, [[Page 33043]] 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 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 5 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 an 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.
By checking this box, the prospective primary participant is providing the certification set out above.
✔
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 34 of 38
Section 14: 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 pint 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 not 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).
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;
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 35 of 38
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;
(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 ten 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).
(B) The grantee may insert in the space provided below the site(s) for the performance of work done in
connection with the specific grant:
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 36 of 38
Place of Performance (Street address, city, county, state, zip code)
Address Line 1:
Address Line 2:
Address Line 3:
City:
Zip Code:
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]
By checking this box, the prospective primary participant is providing the certification set out above.
State:
✔
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 37 of 38
Section 15: Certification Regarding Lobbying
The submitter of this application 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 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.
By checking this box, the prospective primary participant is providing the certification set out above.
✔
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES
OMB Clearance No: 0970-0571
Expiration Date: 12-31-2021
LIHWAP Plan: Page 38 of 38
Signature of Tribal Chairperson’s Authorized Official
Name of Tribe:
LIHWAP Tribal Lead Agency:
I certify that the LIHWAP Plan is complete and that LIHWAP grant project will be implemented in
compliance with the certifications contained herein.
Print Name
Muscogee (Creek) Nation
Social Services
Terra Branson-Thomas
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

OMB Clearance No: 0970-0571 U.S. DEPARTMENT OF HEALTH

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 February 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document