Maine F2017
Social Services Block Grant (SSBG)
Intended Use Plan

Grant Administrator:
Ryan Roberts
Maine Department of Health & Human Services
Office of Child and Family Services
Augusta, Maine 04333-0011
Telephone (207) 624-7940
Fax (207) 287-6156
Ryan.Roberts@maine.gov

DUNS#: 809045594
EIN#:1-016000001

Project Period: October 1, 2016 – September 30, 2017

 TABLE OF CONTENTS
Overview
Statutory Authorities
Social Service Block Grant Goals
Social Service Block Grant Administration
Public Participation
Programs and Services
Programs and Services
Definition of Family
Eligibility for Services
Income Guidelines
Availability of Services
Catalog of Programs & Services
Home Based Services/Consumer Directed and Home Based Care
Home Delivered Meals/Nutrition Services
Prevention & Intervention /Domestic Violence and Sexual Assault
Transportation Services/Low Income Transportation
Employment Services/Supported Employment
Housing Services/Shelter Plus Care
Summary of Services and Projected Funding
Summary of Services and Projected Clients
Appendices - Certifications
a. Certification Regarding Drug-Free Workplace Requirements
b. Certification Regarding Environmental Tobacco Smoke
c. Certification Regarding Debarment, Suspension, Other Responsibility
Matters
d. Certification Regarding Lobbying
2

 OVERVIEW
STATUTORY AUTHORITIES
The Social Services Block Grant legislation requires that each state seeking funds under this
program prepare a report on the intended use of the Block Grant funds prior to their distribution.
The pre-expenditure report must include information on the service activities that will be
supported by these funds and the characteristics or categories of persons who will be eligible to
receive the services. The report is submitted to the Secretary of the Federal Department of Health
and Human Services and simultaneously published within the state. Should any substantial changes
occur in the services or use of the funds during the year, a revised report must be submitted to the
Secretary and made public within the state.
This Social Services Block Grant Pre-expenditure Report is intended to briefly explain the social
services available to the citizens of Maine through the federal Social Services Block Grant, other
federal funds, and related state appropriations for the upcoming federal fiscal year.
SOCIAL SERVICE BLOCK GRANT PROGRAM GOALS
In accordance with the Social Services Block Grant legislation, the Maine Department of Health and
Human Services makes available services intended to:
1. Assist individuals in achieving or maintaining economic self-support to prevent, reduce, or
eliminate dependency;
2. Assist individuals in achieving or maintaining self-sufficiency, including reduction or prevention
of dependency;
3. Prevent or remedy neglect, abuse, or exploitation of children and adults unable to protect their
own interests, or preserve, rehabilitate or reunite families;
4. Prevent or reduce inappropriate institutional care by providing for community-based care,
home-based care, or other forms of less intensive care; and
5. Secure referral or admission for institutional care when other forms of care are not appropriate,
or provide services to individuals in institutions.
SOCIAL SERVICES BLOCK GRANT ADMINISTRATION
With passage of the Omnibus Budget Reconciliation Act of 1981 (PL 97-35) creating the block
grants, the Governor of the State of Maine designated the Department of Health and Human
Services as the state's lead agency for the planning and administration of the Social Service Block
Grant. Since 1981, the Office of Child and Family Services has overseen the administering and
monitor of SSBG with consultation from the DHHS financial services center and the DHHS
Commissioner’s Office.
Monitoring is conducted within the Office of Child and Family Services Operations Unit. The
Operations Unit works in teams. There is a team for each service area. In the case of SSBG, the
SSBG team consists of the SSBG Administrator who serves as the Social Services Program Specialist
within the Operations Unit (who monitors program performance) and the Division of Contract
Management Services Agreement Administrator (who writes the contract).
3

 The Operations Unit is directly responsible for the administration of state purchased services funds
and over a dozen federal grants and programs, including the Community Service Block Grant, Social
Services Block Grant, IV-E and IV-B.
PUBLIC PARTICIPATION
The goal of providing social services is to help families and individuals with challenges that threaten
their well-being or their ability to function self-sufficiently. Input from consumers, community
leaders, providers, and citizens is a critical component to maintaining a viable network of social
services. The SSBG State Plan is available for public review on the State of Maine DHHS website at
the following links http://www.maine.gov/dhhs/ocfs/policy.shtml or
http://www.maine.gov/dhhs/ocfs/aboutus.shtml. Comments on the SSBG state plan may be
submitted to the following email Ryan.Roberts@maine.gov through November 2016.
PROGRAMS AND SERVICES
This report highlights the specific programs and services which the Maine Department of Health
and Human Services has determined be made available in fiscal year 2017, to assist individuals in
attaining the five federal block grant program goals. The Operations Unit in its administration of
multiple social services programs approaches the funding of these programs through the
coordinated use of federal, state, and local funds. Federal Social Services Block Grant funds are
utilized in conjunction with legislatively appropriated state social service funds and other federal
funding sources, to meet a broad range of client needs identified within service programs.
DEFINITION OF FAMILY
For purposes of determining financial eligibility, a family is defined as: A group of related or nonrelated individuals, who are not residents of an institution or boarding house, but who are living as
one economic unit. An economic unit consists of all individuals who share a dwelling unit and
either pool income or share expenses in common. Children in the care or custody of the
Department of Health and Human Services are exempted from the above definition of family, and
are considered a family of one.
ELIGIBILITY FOR SERVICES
While the federal legislation creating the Social Services Block Grant repealed the client income
eligibility requirements of the previous Title XX program, the State of Maine has retained the
concept of income eligibility when maintenance in the community and rehabilitation are the goals
to which services are directed. The Department through its experience in the social, health, and
financial assistance fields regarding individuals with low incomes is acutely aware of the challenges
many of these individuals encounter in their attempts to strengthen themselves financially and
socially. The Department continues to direct its programs and services to those individuals least
able to access needed services on their own.
Further, the Department of Health and Human Services has determined that particular groups of
individuals are to be provided Social Services Block Grant funded services regardless of income
level. Individuals receiving services within the framework of the Department of Health and Human
Services’ Child Protective Services are eligible for service without regard to income when part of a
4

 Department case plan. In addition, sexual assault services, domestic violence services, and nutrition
services for the elderly are available without regard to income.
Except as noted in this section, the Maine Department of Health and Human Services Social Services
Block Grant-funded services and related state-funded services will retain income eligibility
requirements for FY2017. Persons receiving assistance through the Temporary Assistance for
Needy Families (TANF) or Supplemental Security Income (SSI) programs are financially eligible for
needed services based on their income maintenance status. Other persons whose gross family
income does not exceed the limits set forth in this report are also financially eligible to receive
needed services.
In all circumstances, the Department of Health and Human Services assures that there shall be no
discrimination against any applicant for, or recipient of, services on the basis of race, color, sex,
religious creed, ancestry, national origin, or any other factors specified in Title IV of the Civil Rights
Act of 1964, (42 U.S.C. 2000d); Section 504 of the Rehabilitation Act of 1973, et.seq.; the Age
Discrimination Act of 1975, et.seq., and any applicable state statutes.
2016 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT
OF COLUMBIA
PERSONS IN FAMILY/HOUSEHOLD

POVERTY GUIDELINE

For families/households with more than 8 persons, add $4,160 for each additional person.
1

$11,880

2

16,020

3

20,160

4

24,300

5

28,440

6

32,580

7

36,730

8

40,890

SOURCE: https://aspe.hhs.gov/poverty-guidelines

5

 AVAILABILITY OF SERVICES
Social Service Block Grant services are purchased from private, community programs and are
available statewide. Because the need for service often exceeds the limited funds available for
service, agencies may establish waiting lists, priority systems, or limits on the length of or amount of
services that an individual may receive. A list of agencies with which the Department contracts for
services are available upon request from the Office of Child and Family Service or the DHHS Division
of Contract Management.

CATALOG OF PROGRAMS and SERVICES
The following services and programs will be funded, in whole or in part, with federal Social Service
Block Grant funds during Fiscal Year 2017. The following lists are organized by the federal SSBG
service category titles and the corresponding State of Maine’s service area titles.
SSBG Service Category
Prevention and Intervention
Home Delivered Meals
Home Based Services
Transportation Services
Employment Services
Housing Services

State Administered Services
Domestic Violence Services/ Sexual Assault Services
Nutrition Services
Consumer Directed and Home Based Care, Independent
Support Services
Low Income Transportation
Supported Employment
Shelter Plus Care

Charts on the following pages provide overviews of each Maine Department of Health and Human
Services-administered service to be provided. For each service, charts include the service
description, the method of delivery, service/program objective(s), service eligibility criteria, the
service budget allocations, and the projected number of clients to be served.
The method of delivery stated on the charts reflects the manner in which the Department of Health
and Human Services offers each service. Services made available through private, community
agencies are purchased through formal agreements between the Department and each service
provider agency.
Eligibility criteria cited on the charts reflects eligibility for Social Service Block Grant-related services
based upon an individual’s inclusion in particular target groups, income maintenance status,
individual’s presenting problem and/or need, and/or and general income criteria. Unless noted
elsewhere in this report, the eligibility criteria information for the services provided by private
agencies applies to that portion of the services these agencies provide. These are included in their
Department of Health and Human Services service agreement that contains Social Services Block
Grant funding, other federal funds, related state funds, and any required local matching funds.
These private agencies may provide services through other funding arrangements to persons other
than those described in the following charts.
The service funding information presented on the following pages reflect only those other federal
and state funds directly related to SSBG service provision and within the OCFS Operations Unit’s
6

 administrative umbrella. Unless noted in the charts on the following pages, services are available on
a statewide basis.

7

 HOME BASED SERVICES
Consumer Directed Home Based Care, Home Based Care, and Independent Support Services
Program/Service Definition:
Consumer Directed Home Based Care (CDHBC) delivers services to elders and adults with disabilities
that allow them to maximize independent living opportunity at home, to remain in the community,
and avoid or delay placement in higher cost settings. Consumer Directed Home Based Care services
include the following: service coordination, personal assistance services, transitional services,
transportation, and personal emergency response (assistive technology). Home Based Care (HBC)
serves individuals who are at greatest risk of institutionalization through the provision of service
coordination, personal care, nursing, therapies, respite, adult day health, home modifications,
personal emergency response (assistive technology), and limited transportation to activities
covered in the plan of care. Independent Support Services (ISS) delivers services to individuals
assessed as needing assistance at home with Independent Activities of Daily Living (IADL). Activities
supported include meal preparation, light household cleaning, laundry, grocery shopping, and
limited transportation.
Method of Delivery:

Purchased - private agencies
Contracted through DHHS, Office of Aging and Disability Services

Service Objectives:
The overall goal is to assist eligible consumers with services needed to avoid or delay placement in
higher cost settings. Consumers receiving Home Based Care services will retain or increase their
level of independent living, receiving the quality and quantity of services needed to remain at
home.
Client Eligibility:
 The Assessing Services Agency (ASA) conducts a face-to-face assessment to determine
medical eligibility and the need for CDHBC and HBC services covered.
 The ASA develops an authorized plan of care that specifies all services to be delivered based
on the assessment, within the service level boundaries established in the policy referenced
above.
 The contracted Provider of ISS conducts a face-to-face assessment to determine medical
eligibility and the need for ISS.
 Reassessments which follow the same procedures are conducted annually or sooner when
the client’s medical condition changes.
-------------------------------------------------------------------------------------------------------FFY2017 SERVICE BUDGET ALLOCATION:
SSBG Funds

Funds Transferred Other Federal
into SSBG
Funds

State Funds

Total

$2,350,099

$0

$5,314,875

$9,215,204

$1,550,230

FFY2017 SERVICE RECIPIENT PROJECTIONS:
Total Clients – 1,000
8

 HOME DELIVERED MEALS
Nutrition Services

Program/Service Definition:
Home-delivered meals provide a hot meal that includes one third the minimum daily adult
requirements and may be supported by nutritional education, counseling, and socialization. Meals
are delivered to the residence of individuals who are homebound.

Method of Delivery:

Purchased - private agencies
Contracted through DHHS, Office of Aging and Disability Services

Service Objectives:


To prevent institutionalization, malnutrition, and feelings of isolation of adults living in the
community.

Client Eligibility:




Adults in public guardianship and active adult protective cases, when part of the Department
case plan.
Elderly persons who are Area Agency on Aging case management clients, when part of a case
plan.
Physically handicapped adults and elderly individuals residing in the community.
-------------------------------------------------------------------------------------------------------FFY2017 SERVICE BUDGET ALLOCATION:

SSBG Funds
$521,278

Funds Transferred Other Federal
into SSBG
Funds

State Funds

$5,924,054

Total
$6,445,332

FFY2017 SERVICE RECIPIENT PROJECTIONS:
Total Clients – 5,650

9

 PREVENTION and INTERVENTION
Domestic Violence and Sexual Assault Services
Program/Service Definition:
Domestic Violence services include prevention and intervention, emergency shelter, crisis response,
and individual advocacy services to abused women and their children. Services also include
individual; family and group counseling; children's services; employment counseling; housing
assistance; accompaniment and support with law enforcement, legal, and court systems; and
transportation.
Training, technical assistance, and consultation with DHHS TANF Regional Office staff on domestic
violence issues are also available services for individual clients.
Sexual Assault Services include crisis support to victims of rape or sexual assault and their families
through maintenance of 24-hour crisis hotlines; victim counseling; family counseling;
accompaniment to and support with law enforcement, medical, and legal procedures;
transportation; training of crisis counselors; and community education.
Method of Delivery:

Purchased - private agencies
Contracted through DHHS, Office of Child and Family Services

Service Objective:
 To ensure the safety of victims of domestic violence and their children.
 To assist victims of domestic violence in attaining self-sufficiency and/or self-support.
 To assist victims of rape and sexual assault and their families to cope with the subsequent legal
and medical procedures and the trauma of personal violence.
Client Eligibility:
 Without regard to income, individuals and their children who are in imminent fear of, or who
have received physical injury or psychological abuse from a domestic partner.
 Without regard to income, all victims and potential victims of rape or sexual assault.
---------------------------------------------------------------------------------------------------FFY2017 SERVICE BUDGET ALLOCATION:
SSBG Funds
$1,220,584

Funds Transferred Other Federal
into SSBG
Funds
$4,138,310

State Funds

Total

$1,925,418

$7,284,312

FFY2017 SERVICE RECIPIENT PROJECTIONS:
Total Clients –20,000
10

 TRANSPORTATION SERVICES
Low Income Transportation
Program/Service Definition:
Transportation services consist of the provision of or arrangement for the conveyance of individuals
from one location to another via means of public and/or private vehicle.

Method of Delivery:

(Purchased - private agencies)
Contracted through DHHS, Office of Child and Family Services

Service Objective:
 To enable persons who have no other reasonable means of transportation available to access
necessary and critical social and medical services.
Client Eligibility:


When part of a Department case plan, the following groups are eligible without regard to
income: child protective case(s); children in the care and custody of the Department; adult
protective cases; and adults in public guardianship/conservatorship.



When division financial eligibility standards are met, the following groups are eligible: elderly
persons at risk of institutionalization or needing preventive services; physically handicapped
persons; persons with intellectual disabilities living in the community; persons with mental
illness living in the community; and families with low incomes that have medical, social and
employment needs.
---------------------------------------------------------------------------------------------------------

FFY2017 SERVICE BUDGET ALLOCATION:

SSBG Funds
$1,321,226

Funds Transferred Other Federal
into SSBG
Funds

State Funds

$3,304,614

Total
$ 4,625,839.95

FFY2017 SERVICE RECIPIENT PROJECTIONS:
Total Clients – 5,100

11

 Employment Services
Supported Employment
Program/Service Definition: Supported employment is an evidenced-based practice to assist
individuals to maintain employment in the community.
Method of Delivery:
(Purchased - private agencies)
Contracted through DHHS, Office of Substance Abuse and Mental Health Services
Service Objective: One of the core principles is “follow along supports are continuous and provided
on a time-unlimited basis, allowing the individual to become as independent as possible at the
place of employment.” .Employment Services are included as a core service in the Consent Decree
Client Eligibility:
 Long Term Supported Employment (LTSE) services are provided to persons working in
integrated community-based employment setting and who require support to keep that job.
 The individual receiving services shall be working currently in a competitive employment
setting. The LTSE provider will facilitate the development of natural supports in order for the
individual to gain greater independence.

---------------------------------------------------------------------------------------------------------

FFY2017 SERVICE BUDGET ALLOCATION:

SSBG Funds
$401,434

Funds Transferred Other Federal
into SSBG
Funds
$ 35,000

State Funds

Total

$725,597

$ 1,162,031

FFY2017 SERVICE RECIPIENT PROJECTIONS:
Total Clients – 200

12

 Housing Services
Shelter Plus Care

Program/Service Definition: Shelter Plus Care (SPC) program, more recently known as the
Continuum of Care (CoC) program, which is a federally-funded, housing voucher program governed
under 24 C.F.R. Part 582 and 24 C.F.R. Part 578 respectively through the U.S. Department of
Housing and Urban Development (HUD).
Method of Delivery:
Purchased - private agencies
Contracted through DHHS, Office of Substance Abuse and Mental Health Services
Service Objectives:
This permanent supported housing voucher program provides homeless persons suffering from
Sever and Persistent Mental Illness (SPMI), Substance Use Disorders, Dual Diagnosis, or HIV/AIDS,
with Permanent Supportive Housing Vouchers (PSHVs) and referrals to health care, mental health,
and substance abuse treatment services.
Client Eligibility:
a. Ensure that the following components of the S+C/CoC eligibility requirements below are met
before an Applicant is considered to receive S+C/CoC Services. All Recipients must be Adults
who are Homeless, as defined in 24 C.F.R. Part 578.3 and 24 C.F.R. Part 582.5, and be
diagnosed with at least one (1) of the following Disabilities:
i. Severe and Persistent Mental Illness (SPMI);
ii. Dual-Diagnosis; and/or
iii. HIV/AIDS.
b. Perform the following verifications for each Applicant:
i. Homelessness verification, according to 24 C.F.R. Part 576.500(b);
ii. Disability verification, according to 24 C.F.R. Part 582.301(c);
c. Ensure that all S+C/CoC funds are provided to individuals according to how they are categorized
on the following Priority List, on a ranked basis (as numbered below; 1 being the highest priority
and 5 being the lowest priority):
i. Chronically Homeless, as defined in 24 C.F.R. Part 578.3;
ii. Long-term Stayer;
iii. Literally Homeless;
iv. Graduating/moving from Transitional Housing, as defined in 24 C.F.R. Part 578.3; and
v. All other Applicants.

-------------------------------------------------------------------------------------------------------FFY2017 SERVICE BUDGET ALLOCATION:
13

 SSBG Funds
$ 514,800

Funds Transferred Other Federal
into SSBG
Funds
$8,461,854

State Funds

Total

$70,735.00

$9,047,389

FFY2017 SERVICE RECIPIENT PROJECTIONS:
Total Clients –1,779

14

 Maine Department of Health & Human Services Social Services Block Grant
Summary of Services and Projected Funding Federal Fiscal Year 2017
Service Categories

SSBG Funds

Home Based Services
Home Delivered Meals
Prevention &
Intervention
Transportation Services
Employment Services
Housing Services
SERVICE TOTAL
DHHS Administration
ADMINISTRATIVE
TOTAL
GRAND TOTAL

SSBG/
TANF
Transfer

$ 2,350,099
$ 521,278
$ 1,220,584

Other Federal

$1,550,230
$5,186,453
$5,933,189

State Funds

Total Funds

$5,314,875
$737,601
$130,539

$9,215,204
$6,445,332
$7,284,312

$ 1,321,226
$ 401,434
$514,800
$6,329,421 TBD
$249,712
$249,712

$3,304,614
$35,000
$8,461,854
$24,471,340

$725,597
$70,735
$6,979,347

$4,625,840
$1,162,031
$9,047,389
$37,780,108

$6,579,133

$24,471,340

$6,979,347

$37,780,108

Service Categories
Home Based Services
Home Delivered Meals
Prevention & Intervention
Transportation Services
Employment Services
Housing Services
Total

Total Clients
1,000
5,650
20,000
5,100
200
1,779
34,258

15

 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 No procurement Suspension and Debarment common rule and DrugFree Workplace common rule apply to this certification. Grantees' attention is called, in particular,
to the following definitions from these rules:
16

 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 sub recipients 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);
17

 (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:
Place of Performance (Street address, city, county, state, zip code)
221 State Street Augusta, Maine 04330 Kennebec County
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
18

 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.

Signature
Chief Operating Officer
Title

_

Maine Department of Health and Human Services
Organization

19

 CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE
The Pro-Children Act of 2001, 42 U.S.C. 7181 through 7184, imposes restrictions on smoking in
facilities where Federally-funded children’s services are provided. HHS grants are subject to these
requirements only if they meet the Act’s specified coverage. The Act specifies that smoking is
prohibited in any indoor facility (owned, leased, or contracted for) used for the routine or regular
provision of kindergarten, elementary, or secondary education or library services to children under
the age of 18. In addition, smoking is prohibited in any indoor facility or portion of a facility
(owned, leased, or contracted for) used for the routine or regular provision of federally funded
health care, day care, or early childhood development, including Head Start services to children
under the age of 18. The statutory prohibition also applies if such facilities are constructed,
operated, or maintained with Federal funds. The statute does not apply to children’s services
provided in private residences, facilities funded solely by Medicare or Medicaid funds, portions of
facilities used for inpatient drug or alcohol treatment, or facilities where WIC coupons are
redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil
monetary penalty of up to $1,000 per violation and/or the imposition of an administrative
compliance order on the responsible entity.

Signature
Chief Operating Officer
Title

_

Maine Department of Health and Human Services
Organization

20

 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
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 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 Non procurement 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.
************
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.

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 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
whom 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, [[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 Non procurement 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.
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 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.

Signature
Chief Operating Officer
Title

_

Maine Department of Health and Human Services
Organization

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 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 sub awards at all tiers (including subcontracts, sub grants, and contracts under
grants, loans, and cooperative agreements) and that all sub recipients 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.

Signature
Chief Operating Officer
Title

_

Maine Department of Health and Human Services
Organization
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