CDC-RFA-CE22-2205 Attach-ments_Final (2).docx

Attachment 1. Sector Table and 12 Coalition Involvement Agreements

Applicants must submit the Sector Table and 12 Coalition Involvement Agreements (CIA) that are signed and dated for each of the 12 individual sector representatives.

Appendix C. Sample Coalition Involvement Agreement provides a sample CIA and may be adapted for your coalition. Be sure to address the roles and responsibilities of the sector representative and the coalition. CIAs must be signed and dated AFTER January 1, 2021.

Instructions for Completing the Sector Table and the CIA Forms

1. Fill in all boxes of the Sector Table. The sector representatives identified on the Sector Table must match the CIAs provided as part of the DFC application. Include the name of the individual, their organization, and a strong rationale describing why the individual was selected to represent that sector. The rationale must adhere to the sector definitions included in the NOFO.

2. Submit an individual CIA for each of the 12 sector representatives listed in the Sector Table. You can use your own agreement forms, or the SAMPLE CIA included in Appendix C.

The CIA is an agreement between the coalition and the selected sector representatives that clearly identifies the agreed upon responsibilities for both the coalition and the sector representative. A CIA is required for each of the 12 sector representatives and must match the names listed in the Sector Table. CIAs must reflect current membership and must be signed and dated AFTER January 1, 2021.

Both the Sector Representative and the Coalition Representative (i.e., Project Director or Project Coordinators, Coalition President, etc.) must sign and date the CIA.

· The Sector Representative and the Coalition Representative are two different people.

· There must be one completed CIA for each sector.

· Submit a total of 12 CIAs for each of the individuals listed on the Sector Table.

Name the file “Attachment 1_Sector Table and 12 CIAs” and upload as a single PDF attachment into grants.gov.

Attachment 1. Sector Table Coalition Name:

Youth

Age of Youth:

Parent

Business

Media

School

Youth Serving Organization

Religious or Fraternal organization

Law enforcement (not retired)

Civic/Volunteer groups

Healthcare professional or organization

State, local, or tribal gov’t agency with expertise in substance abuse

Other organization involved in reducing substance abuse

Attachment 2. Assurance of DFC 10-Year Funding Limit

Under the DFC Act of 1997, a coalition may not receive more than 10 years of DFC funding. This attachment requires the Legal Applicant to read, sign, and date this document to assure that under all situations, the coalition has not received more than 10 years of DFC funding. Specific restrictions are listed below and must be followed.

I. Restrictions on Legal Applicant:

1. A Legal Applicant serving as a Fiscal Agent may not receive DFC funds on behalf of a coalition that has had 10 years of DFC funding.

II. Restrictions on 501(c)(3) coalitions:

1. A coalition applying as is its own Legal Applicant may receive no more than 10 years of DFC funding.

2. A coalition that has received 10 years of DFC funding (through one or more Legal Applicant) may not receive further DFC funding.

3. If additional information is needed to determine your coalition status as a new, unique, and distinct coalition, the Legal Applicant will be notified (see glossary for definition of new coalition).

I hereby certify compliance with the 10-Year Funding Limit and that the applicant coalition has not received more than 10 years of DFC funding. Further, the restrictions provided on this form have not been violated.

Name of Coalition:

Name and Title of Legal Applicant:

Signature:

Date:

The Legal Applicant must sign and date the assurance certifying that the coalition has not received more than 10 years of DFC funding.

Name the file “Attachment 2_Assurance of 10-year Funding Limit”

Attachment 3. Statement of Legal Eligibility By statute, the Legal Applicant must demonstrate that the coalition is a non-profit organization or has made arrangements with a legal entity that is eligible to receive federal grants. Please see Appendix D. Sample MOU between Fiscal Agent and Coalition for a sample Memorandum of Understanding (MOU) and considerations for the relationship between the Coalition and a Fiscal Agent.

To meet this Statutory Eligibility Requirement, applicants must select either Option 1 or Option 2 and submit the signed Statement of Legal Eligibility and the appropriate required documentation described below.

Statement of Legal Eligibility

· OPTION 1. The Coalition is a 501(c)(3) organization.

The Coalition is a 501(c)(3) organization applying on its own behalf. The Coalition’s name is listed on the SF- 424 in Box #8a with the Coalition’s Employer/Taxpayer Identification Number (EIN/TIN). As the legal applicant, the Coalition must submit:

a. Proof of 501(c)(3) status; and

b. Signed Statement of Legal Eligibility.

· OPTION 2. The Coalition is not a 501(c)(3) organization.

The Coalition MUST use a Fiscal Agent to apply on its behalf. The Fiscal Agent’s name is listed on the SF-424 in Box #8a with the Fiscal Agent’s Employer/Taxpayer Identification Number (EIN/TIN). As the legal applicant, the fiscal agent must submit:

a. Signed Memorandum of Understanding (MOU); and

b. Signed Statement of Legal Eligibility.

I hereby certify that the organization applying for this grant is legally eligible to receive federal funding in accordance with the requirements listed above.

Name of Coalition:

Name and Title of Legal Applicant:

Signature:

Date:

The Legal Applicant must sign and date the Statement of Legal Eligibility to certify that they are legally eligible to receive federal funds. Upload the Statement of Legal Eligibility AND either the proof of 501(c)3 status OR the MOU. Name the file “Attachment 3_Statement of Legal Eligibility”

Attachment 4. General Applicant Information

Applicants must provide responses to the required information below.

Key Personnel

1. Program Director/Principal Investigator (PD/PI) Name/Title Address (No P.O. Boxes) City/State/ZIP Phone Number E-mail Address

2. Authorized Organization Representative (AOR) Name/Title Address (No P.O. Boxes) City/State/ZIP

3. Project Coordinator Name/Title Address (No P.O. Boxes) City/State/ZIP

Statutory Requirement: Mission Statement and Multiple Drugs of Misuse

4. Provide the coalition’s Mission Statement. The mission statement must focus on the prevention and reduction of youth substance use in the community served.

5. List the substances of use by youth addressed in this application.

Coalition and Community Information

6. What is the date that the Coalition was established?

Provide month, day, and year.

7. List all zip codes served by the coalition. Go to: https://tools.usps.com/go/ZipLookupAction!input.action

YES – Please upload a Letter of Mutual Cooperation signed by both parties

9. What is the population size of the community served by the coalition?

10. What is the median income in the community the coalition intends to serve?

11. What is the racial/ethnic demographic make-up of the community being served by the coalition? Please provide percentages, which are available from the US Census.

https://www.census.gov/acs/www/data/data-tables-and-tools/data-profiles/

YES - list the name of tribe here.

YES - list the representative’s name and organizational entity here.

14. Enter your SAM registration date.

NOTE: Failure to have an active registration will make your application ineligible.

DATE of SAM Registration:

Applicants must provide responses to each of the questions.

Name the file “Attachment 4_General Applicant Information”

Attachment 5. Congressional Notification

Applicants must follow the exact format below and include the completed Congressional Notification with the application. The Project Description for the Congressional Notification must not exceed 35 lines nor exceed more than one page. If the application is funded this information will be shared with members of Congress and the media and may be posted to the DFC website.

Template Grant Award Number (if applicable) Coalition Name:

Legal Applicant Organization:

Coalition Community:

Legal Applicant Contact Name:

Legal Applicant Contact Mailing Address:

Legal Applicant Contact E-Mail Address:

Legal Applicant Contact Phone:

Coalition Contact Name:

Coalition Contact Mailing Address:

Coalition Contact E-Mail Address:

Coalition Contact Phone:

[Name of State] Serving Federal Congressional District(s): [ ] Coalition Located in Federal Congressional District: [ ]

Project Description

The [Coalition Name] was awarded a FY2022 Drug-Free Communities Support Program grant in the amount of $ [fill in amount requested] by the White House Office of National Drug Control Policy, in cooperation with the Centers for Disease Control and Prevention. The Coalition serves [Community/Town], [State], a community of [total population]. The goals of the coalition are to establish and strengthen community collaboration in support of local efforts to prevent youth substance use. The coalition will achieve its goals by implementing these strategies [Provide a one-sentence description on your strategies. Coalitions may also provide a description of special efforts, initiatives, and/or approaches (i.e., drugged driving, opioid prevention, etc.)].

Applicants must follow the exact format of the template and not exceed 35 lines nor exceed more than one page.

Name the file “Attachment 5_Congressional Notification”