Under the Paperwork Reduction Act of 1995, as amended, and 5 C.F.R. § 1320.5(b)(2)(i), persons are not required to respond to this collection of information unless it
displays a currently valid OMB control number. The OMB control number for this collection is 0945-0008. In lieu of completing this hard copy form and mailing it in,
the Applicant/Recipient may provide this assurance via the U.S. Department of Health and Human Services’ Assurance of Compliance online
portal at https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf.
Burden Statement
Public reporting burden for the collection of information on this Assurance of Compliance form is estimated to average 4 hours (240 minutes) per response,
including the time for reviewing instructions, gathering the data needed and entering and reviewing the information on the completed Assurance of Compliance form.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden,
to: HHS/OS Reports Clearance Officer, Office of Information Resources Management, 200 Independence Ave. S.W., Room 531H, Washington, D.C. 20201.
Please do not mail the HHS Form 690 (Assurance of Compliance) to this address.
ASSURANCE OF COMPLIANCE WITH TITLE VI OF THE CIVIL RIGHTS ACT OF 1964, SECTION 504 OF THE REHABILITATION ACT OF 1973,
TITLE IX OF THE EDUCATION AMENDMENTS OF 1972, THE AGE DISCRIMINATION ACT OF 1975, SECTION 1557 OF THE PATIENT PROTECTION
AND AFFORDABLE CARE ACT, AND FEDERAL CONSCIENCE AND RELIGIOUS NONDISCRIMINATION LAWS
The Applicant/Recipient provides this assurance in consideration of and for the purpose of obtaining federal grants, loans, contracts, property,
discounts, or other federal financial assistance from the U.S. Department of Health and Human Services.
THE APPLICANT/RECIPIENT HEREBY AGREES THAT IT WILL COMPLY WITH:
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Title VI of the Civil Rights Act of 1964, as amended (codified at 42 U.S.C. § 2000d et seq.), and all requirements imposed by
or pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 80), to the end that, in accordance
with Title VI of that Act and the Regulation, no person in the United States shall, on the ground of race, color, or national
origin (including limited English proficiency) be excluded from participation in, be denied the benefits of, or be otherwise
subjected to discrimination under, any program or activity for which the Applicant/Recipient receives federal
financial assistance from the Department.
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Section 504 of the Rehabilitation Act of 1973, as amended (codified at 29 U.S.C. § 794), and all requirements imposed by or pursuant
to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 84), to the end that,
in accordance with Section 504 of that Act and the Regulation, no otherwise qualified individual with a disability in
the United States shall, solely by reason of their disability, be excluded from participation in, be denied the benefits of,
or be subjected to discrimination under, any program or activity for which the Applicant/Recipient receives federal financial assistance
from the Department.
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Title IX of the Education Amendments of 1972, as amended (codified at 20 U.S.C. § 1681 et seq.),
and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 86),
to the end that, in accordance with Title IX and the Regulation, no person in the United States shall,
on the basis of sex (including pregnancy), be excluded from participation in, be denied the benefits of,
or be otherwise subjected to discrimination under, any education program or activity for which the Applicant/Recipient receives
federal financial assistance from the Department.
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The Age Discrimination Act of 1975, as amended (codified at 42 U.S.C. § 6101 et seq.), and all requirements imposed by or
pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 91), to the end that,
in accordance with the Act and the Regulation, no person in the United States shall, on the basis of age, be denied the benefits of,
be excluded from participation in, or be subjected to discrimination under, any program or activity
for which the Applicant/Recipient receives federal financial assistance from the Department.
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Section 1557 of the Patient Protection and Affordable Care Act, as amended (codified at 42 U.S.C. § 18116),
and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 CFR Part 92),
to the end that, in accordance with Section 1557 and the Regulation, no person in the United States shall, on the ground of race, color,
national origin (including limited English proficiency), age, disability, or sex be excluded from participation in,
be denied the benefits of, or be subjected to discrimination under, any health program or activity
for which the Applicant/Recipient receives federal financial assistance from the Department.
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The Conscience Protection Statutes,
including the Church Amendments, as amended (codified at 42 U.S.C. § 300a-7),
the Coats-Snowe Amendment (codified at 42 U.S.C. § 238n), the Weldon Amendment
(Consolidated Appropriations Act, 2026, Pub. L. No. 119-75, div. B, tit. V, § 507(d), 140 Stat 170, 317 (Feb. 3, 2026),
Section 1553 of the Patient Protection and Affordable Care Act, as amended (codified at 42 U.S.C. § 18113),
and Section 1303(b)(4) of the Patient Protection and Affordable Care Act, as amended (codified at 42 U.S.C. § 18023(b)(4)),
among others, and 45 C.F.R. Part 88, to the extent that the rights of conscience are protected and associated discrimination and
coercion are prohibited, in any program or activity for which the Applicant/Recipient receives certain federal financial assistance.
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The Religious Nondiscrimination authorities
including block or formula grant funds, such as Projects for
Assistance in Transition from Homelessness (PATH), (42 U.S.C. 290cc-21, 33),
Preventative Health and Services Block Grants (42 U.S.C. 300w), Maternal and Child Health Services Block Grant (42 U.S.C. 701, 708),
Family Violence Prevention and Services (42 U.S.C. 10401, 10406); the Charitable Choice Provisions,
which includes the Community Services Block Grant (42 U.S.C. 8621, 8625), Temporary Assistance for
Needy Families (TANF) (42 U.S.C. 601, 604a), SAMHSA Grants (42 U.S.C. 290aa, 290kk-290kk-3, 300x-57, 65);
other laws prohibiting discrimination based on religion such as The Head Start Act (42 U.S.C. 9831, 9849),
Programs for All-Inclusive Care for the Elderly Services (42 U.S.C. 1395eee), (42 C.F.R. 460.112),
the Equal Treatment Rule (45 CFR Part 87), among others.
The Applicant/Recipient agrees that compliance with this assurance constitutes a material condition of continued receipt of federal financial assistance,
and that it is binding upon the Applicant/Recipient, its successors, transferees, and assignees for the period during which such assistance is provided.
The Applicant/Recipient acknowledges that a subsequent finding of violation under the authorities contained in this assurance may give rise to
liability under the False Claims Act, 31 U.S.C. § 3729.
The Applicant/Recipient acknowledges that the term “program or activity” is defined expansively in statute to cover all of the
operations of certain entities receiving federal funds, even if only part of the entity receives the funds.
See, e.g., 42 U.S.C. 2000d-4a (Title VI), 20 U.S.C. 1687 (Title IX), 29 U.S.C. 794 (Section 504), 42 U.S.C. 6107 (Age Discrimination Act).
This expansive definition applies to agencies of a State or local government; colleges or universities; and local educational agencies.
For a private corporation, partnership, or organization, the entire entity is covered if it is—for example—principally engaged
in certain activities, such as education or health care, or if other statutory conditions are met. If the Applicant/Recipient is subject to
Section 1557 of the Affordable Care Act as a “health program or activity,” there is a similarly broad scope of coverage.
See 42 U.S.C. 18116; 45 C.F.R. Part 92.
If any real property or structure thereon is provided or improved with the aid of federal financial assistance extended to the Applicant/Recipient
by the Department, this assurance shall obligate the Applicant/Recipient, or in the case of any transfer of such property, any transferee,
for the period during which the real property or structure is used for a purpose for which the federal financial assistance is extended
or for another purpose involving the provision of similar services or benefits. If any personal property is provided,
this assurance shall obligate the Applicant/Recipient for the period during which it retains ownership or possession of the property.
The Applicant/Recipient further recognizes and agrees that the United States shall have the right to seek judicial enforcement of this assurance.
The person whose signature appears below is authorized to sign this assurance and commit the Applicant/Recipient to the above provisions.
The Applicant/Recipient may provide this assurance via the U.S. Department of Health and Human Services’ Assurance of Compliance online portal at
https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf or mail the signed form to:
U.S. Department of Health & Human Services
Office for Civil Rights
200 Independence Ave., S.W. Room 509F
Washington, D.C. 20201