By maura.kephart, 2 February, 2026 Introduction Thank you for your interest in applying to the fiscal year (FY) 2025/2026 Small Ambulatory Program (SAP).To streamline the application process IHS is strongly encouraging Tribes/Tribal Organizations to complete the Applicant Eligibility questions of the application kit using this form. After providing your answers to the questions, If you are eligible to move forward with the application process, please click on the link at the end of the form for the next phase. All the requested information is located in the application kit. Please review the application kit before attempting to answer the Applicant Eligibility questions. If you require assistance completing this form, please contact the SAP manager CDR Omobogie Amadasu at Omobogie.Amadasu@ihs.gov or (301) 443-4751Application Kits in Adobe PDF format can be downloaded on or after May 1, 2026 from: https://www.ihs.gov/dfpc/programs/#sap (IHS Division of Facilities Planning and Construction). Contact Information Provide Information Below for the Person Completing the Form First and Last Name Email Address Project Name Tribal Name Applicant’s Eligibility Determination 1. Federally Recognized Tribe. Is applicant included in the Federal Register that provides the Department of Interior, Bureau of Indian Affairs, Notice of Indian Entities Recognized and Eligible to Receive Services for the United States Bureau of Indian Affairs (BIA) (The latest Federal Register edition is Volume 73, Number III - 5 66, dated Friday, April 4, 2008.)? Yes No 2. Different Legal Name. Is the legal name of the applicant other than that appearing in the Federal Register listing of eligible Indian Entities for the BIA? Yes No If YES, provide a name. 3. Status of Project. Has on-site construction started for the project? Yes No If on-site construction has not started, does the applicant plan to award a construction contract for on-site work prior to receipt of a SAP award if selected for an award? Yes No 4. Current Operation. Does the applicant currently operate an Indian health care facility pursuant to an existing health care services Contract, Compact, Annual Funding Agreement (AFA), or Funding Agreement (FA) [referred to hereafter as contract] entered into under The Indian Self-Determination and Education Assistance Act, Public Law (P.L.) 93-638? Yes No 5. Ownership. Provide the legal name of the current owner of the health care facility being operated under the existing P.L. 93-638 services contract: If the IHS is not the current owner, was this facility ever owned or constructed by the IHS? Yes No 6. Non-Receipt of Prior Funding. Has the proposed project, either the entire or a part thereof, received any prior funding under: 1) P.L. 94-437, Section 301, which deals with the IHS Health Facilities Construction Priority System for inpatient, outpatient and staff quarters facilities projects; 2) the expired P.L. 94-437, Section 307, which dealt with the Indian Health Care Delivery Demonstration Program; or 3) P.L. 94-437, Section 306, for a previous SAP award? Yes No 7. Population Certifications We certify that we have more than 500 user population We certify that we have more than 2,000 service population (Please click the link to obtain this data: https://hsp.ihs.gov) 8. Program Assurances. Upon completion of the proposed project, the applicant assures that it will do the following: a. Have adequate financial support available for providing the services at the health care facility. b. Make the health care facility available to eligible Indians, without regard to ability to pay or their source of payment. c. When services, which are feasible and otherwise authorized, are provided to non-eligible persons, such will be done on a cost basis, in accordance with Federal Laws, without diminishing the quality or quantity of services provided to eligible Indians. The applicant hereby certifies the above Yes No 9. Financial Management Systems. In order to comply with the authorizing legislation requirement and to meet the requirements of 25 CFR Parts 900.44 and 900.45 for a SAP contract award, the applicant’s financial management systems have to meet minimum standards. The most recently completed Single-Agency Audit, which is provided annually by Tribes in compliance with 2 CFR 200, Subpart F, will be used to determine compliance. Is the applicant’s latest Single-Agency Audit current in accordance with 2 CFR 200? Yes No 10. Does this audit reflect any substantial unresolved significant and material weaknesses or issues of fraud or misapplication of previously provided Federal funds which would preclude an affirmation determination that the applicant’s financial management systems are in order? Yes No If the answers to the two above questions are such that the applicant is eligible, document the responses by providing:in Application Attachment B, a copy of the auditor’s summary of findings for the same audit; andin Application Attachment C, a copy of the Tribe’s latest Balance Sheet.Any other supporting information, actions, or plans that would mitigate risks to successful completion of the project. 11. Tribal Resolution. Does the Tribal governing body support the proposed project? Yes No If YES, document this statement by providing in Application Attachment D the original or certified true copy of an executed Tribal Resolution containing the following elements and or authorizations: If YES, document this statement by providing in Application Attachment D the original or certified true copy of an executed Tribal Resolution containing the following elements and or authorizations: a. Support of the SAP project and submission of application.b. Statement of the total amount of funds needed for the proposed project, and a breakdown of the portion to be provided by the Tribe, either from Tribal contribution or other sources, and the amount being requested from the SAP. All Tribal funds are to be available at the time the SAP contract is awarded. c. Authorization to enter into a P.L. 93-638 construction contract for the administration, project, as applicable d. Name and position title of Tribal individual authorized to sign all contractual documents. (If a certified copy of the resolution is used, it must contain the original signature of the certifier. Where a project benefits more than one Indian Tribe or Tribal Organization, the approval of each such Tribe or Tribal Organization receiving benefit of the project shall be obtained through consenting Tribal resolutions from each body. {Required by 25 USC §§ 5321(a)(1) and 5304(l) }
