Sample Letter Of Intent To Apply Template

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SAMPLE Letter of Intent to Apply
STATE INNOVATION MODELS: ROUND 2 OF FUNDING FOR DESIGN AND TEST
ASSISTANCE
Please submit a Letter of Intent electronically to
Leah.Nash@cms.hhs.gov
by June 6, 2014. States may use
this sample letter or create their own that provides similar information.
1. Name of State: ______________________________________________________________________
2. State/Governing Agency/Public-Private Partnership Organization: _____________________________
_____________________________________________________________________________________
3. Contact/Representative Name and Title: __________________________________________________
4. Address: ___________________________________________________________________________
5. Phone: _________________________ Fax: _______________________________________________
6. E-mail address: ______________________________________________________________________
7. Model (indicate Test or Design): ________________________________________________________
Signature:
____________________________________________________
Authorized Organizational Representative
FOR NON-STATE APPLICANTS:
Only if an outside organization will be submitting the application (i.e. a non-profit affiliate of the State, or a
public-private partnership supported by the Governor’s Office), per the Funding Opportunity
Announcement the intended applicant MUST submit an official request from the Governor along with
this Letter of Intent. A justification must be included with the request as well as an attestation that the state
will actively participate in all activities described in the proposal. Approval of such requests will be at the
sole discretion of CMS. Only one application supported by the Governor will be allowed per state.
This non-binding letter of Intent to Apply must be submitted to CMS by June 6, 2014. Entities which do
not submit a Letter of Intent by this deadline will not be eligible to apply. Only one application supported
by the Governor will be allowed per state. All approvals are at the sole discretion of CMS.

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