Attachment A: Application Guidelines for Title VI Grants (Optional) Administration for Community Living/Administration on Aging Application Guidelines for Title VI Grants (Optional) Your application may be presented in any format, but it must meet the criteria specified in the Older Americans Act, Sections 612 (a), 612 (b), and 612 (c) for Title VI, Part A/B and Section 631 for Title VI, Part C. Your application must also meet the criteria specified in Title 45 of the Code of Federal Regulations, Section 1326.19. The following guide may be helpful in drafting your application. Due Date: November 21, 2013 Application Checklist Item Found on page… Completed Program information 2-3 Required Attachments 4-6 Management Assessment 7-9 Program Description: Part A/B 10-18 Program Description: Part C 19-22 Page 1 of 20 Program Information (Please type or print clearly) Tribal Organization: **If Current Grantee - FY2011-13 Grant Number: ______________________________ Address: ______________________________________________________________________ Title VI Director/Contact Person: Phone number: Fax Number: __ Email address: EIN: DUNS Number: Principal Official’s Printed Name and Title __________________________ ___________ Principal Official’s Signature: ____ Principal Official’s email address: __________________________________________________ Please don’t overlook: • EIN – (Employer Identification Number). The Tribal Accounting Office can provide the number. Please include the EIN suffix (for example, A1, D5) if you have received grant awards from ACL/AoA before. • DUNS Number – (Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS)). The Tribal Accounting Office can provide the number. • President, Governor, or Chairperson’s signature. • Both Title VI Director/Contact Person and Principal Official’s email addresses are required. Age of eligibility used by Tribe: Number of eligible elders within the planned service area: Age 60 and older: Under age 60 (if applicable): Total: Under age 60 is included only if the Tribe chooses a different age of eligibility. Page 2 of 20 Source of population statistics used to establish eligibility [Section 614 (b)]: U.S. Census Tribally determined (Include certification.) The law requires that a tribal organization must represent at least 50 persons aged 60 and older in order to be eligible for Title VI funding. Therefore, the number of persons aged 60 and older living in the proposed Title VI service area must be stated in the application. The tr ibal organization may use the Census Bureau population figures, or may develop its own population statistics, but the Bureau of Indian Affairs or your tribal enrollment clerk must certify/approve them in order to establish eligibility, as required in section 614(b) of the OAA, as amended. The amount of the grant is based on this number of Indians, Alaskan Native or Native Hawaiians age 60 and older in the proposed service area. • Proposed service area = number of elders age 60 and older. • All eligible elders, age 60 and older in the proposed service area. The total population census of all tribal members, age 60 and older, cannot be counted unless all the tribal members live in the proposed service area. • If there is overlap between two or more Title VI applicants, as stated under Geographic Location, the eligible elders can only be counted once and included in one application. • The applicants are responsible for determining how the eligible elders will be counted. • More than one applicant may not count the same elder. • This must be stated clearly in the application and signed by the principal official of the tribal organization. As a s eparate matter, the regulations allow a Tribe to define, based on its own criteria, the age at which the Tribe will consider a person to be an “older Indian” for purposes of eligibility to receive Title VI services. If a Tribe selects an age under 60 for an older Indian, the application must state the age selected, and the number of Indians under age 60 eligible to be served. All Tribes in a consortium must use the same age for “older Indian”. This regulation does not apply to Native Hawaiians under Title VI, Part B. Applying for: _____ Part A (or B) only _____ Parts A (or B) and C Page 3 of 20 Required Attachments to the Application Geographic Location (suggested length: 5-10 paragraphs): Sec. 1326.19 of the Older Americans Act states that: “All applications shall include a description of the geographic boundaries of the service area proposed by the tribal organization.” Please provide a short narrative description of the geographical area to be served. Specify how many counties your program covers and include the names of the counties. You may submit a map indicating the geographic boundaries of your program’s service area. Finally, include a description of your program’s procedures that ensure against duplication of services to elders. • Description of the boundaries of the service area. • Number and names of counties the program covers. • May add a map • Explain how you make sure services to elders are not duplicated. Resolutions: The tribal organization representing a Federally-recognized Tribe must submit a current signed and dated copy of the Tribal council resolution authorizing participation in Title VI, Part A or Title VI, Part A and Part C for the grant period April 1, 2014 to March 31, 2017. If the tribal organization represents a consortium of more than one tribe, a resolution is required from each participating tribe, specifically authorizing representation by the tribal organization for the purpose of Title VI of the Older Americans Act for the grant period April 1, 2014 to March 31, 2017. Resolutions needed: • One for the needs assessment. • One for the application. • The signed tribal resolution from each tribe in the consortium must be included in the application. Note: Examples can be found on www.olderindians.aoa.gov Program Assurances: The Title VI, Part A/B Program Assurances are those provisions identified in Section 614 (a) of the Older Americans Act, and in the Title 445 of the Code of Federal Page 4 of 20 Regulations section 1326.19 (d), issued August 31, 1988. The tribal organization must state that it agrees to abide by all the provisions for the entire project period, April 1, 2014 to March 31, 2017. Please don’t overlook: • Signature of President, Governor, or Chairperson. Certification Forms: Certifications are required of the applicant regarding lobbying, debarment, suspension, and other responsibility matters; and drug-free workplace requirements. Please note that a duly authorized representative of the tribal organization (typically the Chairperson of your tribe) must attest to the applicant’s compliance with these certifications by signing and dating the forms. Please don’t overlook: • Signature of President, Governor, or Chairperson. Page 5 of 20 If applying as a consortium, list all Tribes/Villages within the consortium. There must be a signed resolution and certification of population numbers included in the application from each participating Tribe/Village included in this application. Tribe/Village Age 60 and over Under 60 1. ___________________________________ ________ _______ 2. ____________________________________ ________ _______ 3. ____________________________________ ________ _______ 4. ____________________________________ ________ _______ 5. ____________________________________ ________ _______ 6. ____________________________________ ________ _______ 7. ____________________________________ ________ _______ 8. ____________________________________ ________ _______ 9. ____________________________________ ________ _______ 10. ____________________________________ ________ _______ 11. ____________________________________ ________ _______ 12. ____________________________________ ________ _______ 13. ____________________________________ ________ _______ 14. ____________________________________ ________ _______ Page 6 of 20 Management Assessment The following five questions are designed to help you think about how you can most successfully manage your program, your budget and ensure accurate reporting. 1) Please describe the results obtained from your program’s needs assessment: • A needs assessment is required as part of the application. • The proposed plans must incorporate the results of your needs assessment to address the needs of your community. • The National Resource Center on Native American Aging (NRCNAA) at the University of North Dakota has developed a needs assessment for Title VI grantees to use. They help you plan for your survey, teach you how to conduct the survey, and do the analysis for you. 2) Please describe the results and benefits you expect from your Title VI program(s): • The application must describe the results or benefits expected from each of the core services proposed. • For example: o the number of individuals served; o the number of meals served; o the number of home and community-based support services provided, etc. Page 7 of 20 3) Please describe how you plan to evaluate your program, and how often: Evaluation Criteria • Discuss the criteria to evaluate the objective results and successes of the program. • Explain the methods to determine if the results of your needs assessment to address the needs of your community are being achieved. Page 8 of 20 4) Please describe any financial systems your program has in place to ensure correct use of Title VI funds: 5) Please describe your system of record keeping (how you ensure an unduplicated count of elders, how you keep track of home-delivered meals or information services, etc.): NOTE: The ACL/AoA Title VI Manual located on http://olderindians.aoa.gov/ appendix has sample record keeping logs. And reporting guidance can be found at: http://olderindians.aoa.gov/reporting.cfm Keep track on a regular basis an unduplicated list of the names of eligible participants who receive meals and supportive services. A participant’s name will only go on the list one time each year. Start the list April 1st and end the list March 31st. Each program must keep a separate unduplicated list for: congregate, home-delivered, and supportive services. A name can go on more than one list, but can only appear once on each list. Page 9 of 20 Program Description (Part A/B): Nutrition & Supportive Services Section A: Nutrition • Nutrition services are required. • Include a description of the methods, facilities, and staff to be used in preparing, serving, and delivering meals, and the estimated number of persons to be served. • The nutrition services provided, either directly or by contract, must be substantially in compliance with the provisions of Part C, Title III. • If no Title VI funds are to be used for nutrition services, the application must state how such services are provided in other ways, and how they are financed. • Menus must meet the Dietary Guidelines. 1) Will the tribal organization provide nutrition services directly? ____Yes ____No 1a) If no, who will provide nutrition services? ____Other Tribal Department ____Outside Contracted Vendor ____Outside Service Agency ____Other: ______________ Congregate Meal program 2) How many meal sites does your program operate? ____1 ____2 ____3 ____4 ____5 or more 3) How many days per week, and what meals are provided at each site? Number of days Site meals are Breakfast Lunch Dinner Snack served 1 2 3 4 5 4) Do you require elders to register for congregate meals in advance? ____Yes ____No Page 10 of 20