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Standard Application Forms
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
OMB Control Number:1103-0098
Expiration Date: XXXXXXXX
COPS Application Attachment to SF-424
SECTION 1: COPS PROGRAM REQUEST
Federal assistance is being requested under the following COPS program:
Select the COPS grant program for which you are requesting federal assistance.
A separate application must be completed for each COPS program for which
you are applying. Please ensure that you read, understand, and agree to comply
with the applicable grant terms and conditions as outlined in the COPS
Application Guide before finalizing your selection.
CHECK ONE PROGRAM OPTION ONLY
Child Sexual Predator Program
Community Policing Development
COPS Hiring Program
Meth –Tribal
Secure Our Schools
Targeted - Technology Program
Targeted - Methamphetamine Initiative
Targeted - Safe Schools Initiative
<>
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SECTION 2: Agency Eligibility Information
A. Type of Agency (select one)
□
Law Enforcement
□
Non-Law Enforcement
From the list below, please select the type of agency which best describes the applicant.
Select One...
Law Enforcement Entities <>
Select One...
Non-Law Enforcement Entities <>
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B. Eligibility Questions of Applicants
Q1) Is your agency established and currently operational? Yes_____No_____
A law enforcement agency is established and operational if the jurisdiction has passed authorizing
legislation and it has a current operating budget.
If Yes go to Q2
If No go to Q1a
Q1a) For which of the following are you seeking funds (check one)?
1. To establish or begin operations as a newly authorized law enforcement agency_____
2. To re-establish and resume operations for a previously operational law enforcement
agency_______
If choice 1, go to Q1a1
If choice 2, go to Q1b1
Q1a1) Has your jurisdiction passed legislation which authorizes the creation of a
new law enforcement agency?
If Yes go to Q1a2
If No ELIGIBILITY TBD or go to Q1a2 (depending on program-specific
decisions)
Q1a2) Will your law enforcement agency be operational as of XX/XX/XX
(application close date)?
If Yes go to Q2
If No ELIGIBILITY TBD or go to Q2 (depending on program-specific decisions)
If Don’t Know ELIGIBILITY TBD or go to Q2 (depending on program-specific
decisions)
Q1b1) What was the date that your law enforcement agency was last operational?
__/__/__
ELIGIBILITY TBD if date is before XX/XX/XX (depending on program-specific
decisions) Go to Q1a2.
Q2) Does your agency have primary law enforcement authority?
An agency with primary law enforcement authority is defined as the first responder to calls for
service for all types of criminal incidents within its jurisdiction. Agencies are not considered to
have primary law enforcement authority if they only : respond to or investigate only a specific
type(s) of crime(s); respond to or investigate crimes within a correctional institution; serve
warrants; provide courthouse security; transport prisoners; and/or have cases referred to them
for investigation or investigational support.
If Yes go to Q3
If No ELIGIBILITY TBD or go to Q3 (depending on program-specific decisions)
Q3) Will funds awarded under this grant be used in a written contract for law enforcement services?
Important reminder: Two jurisdictions involved in a contracting relationship may not apply for
funding to support the same officer position(s).
If Yes go to Q3a or ELIGIBILITY TBD (depending on program-specific decisions)
If No DONE
Q3a) For which of the following contracting arrangements are you seeking funds (check
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one)?
1. To provide law enforcement services to another government entity.____
2. To receive law enforcement services provided by another law enforcement
agency to service your jurisdiction.____
If choice 1, go to Q3a1
If choice 2, go to Q3b
Q3a1) Is the government entity that you will be providing services to
located within the geographic boundaries of your jurisdiction (e.g., an
independent city located within your county)?
If Yes go to Q3a2
If No ELIGIBILITY TBD or go to Q3a2 (depending on programspecific decisions)
Q3a2) What is the name of the government entity to which you will be
providing services?________________
DONE
Q3b) What is the name of the law enforcement agency that will be
providing services to your jurisdiction?_____________
DONE
Questions of a subset of Applicants (depending on agency type)
Q4) Is your agency the first responder to all types of criminal incidents within your jurisdiction?
If Yes DONE
If No go to Q4a or ELIGIBILITY TBD (Depending on Program Specific decisions)
Q4a) For what types of incidents is your agency the first responder? _________________________
DONE
Q4) Is your agency the first responder to citizen-initiated calls for service outside of a correctional
institution and/or courthouse setting?
If Yes go to Q5
If No go to Q5 or ELIGIBILITY TBD or DONE (Depending on program-specific decisions)
Q5) Approximately what percentage of your agency’s time is devoted to the following activities:
First response to citizen-initiated calls for service:
Prisoner transport:
______%
Jail operations:
______%
Service of warrants:
______%
Courthouse/bailiff duty:
______%
______%
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Eligibility questions for SOS Applicants only:
The application assurance question must be answered by all SOS applicants and subset questions 1,
2 or 3 should be completed based on agency type checked:
(All SOS Applicants) Application Assurance Question:
Was this application prepared after consultation with individuals not limited to law enforcement officers
(such as school violence researchers, child psychologists, social workers, teachers, principals, and other
school personnel) to ensure that the improvements to be funded under the grant are –
(A) consistent with a comprehensive approach to preventing school violence; and
(B) individualized to the needs of each school at which those improvements are to be made?
Yes
No
(Subset 1 Municipal Police/County Police/Sheriff’s/State Police Agency, Tribal Police etc. (any
agency other than school district police department and university/college))
Is your agency partnering with a school/school district?
Yes
No
(Subset 2 School District Police)
Is your agency a school district which through authorization by its state and/or local legislative authority
has its own police department separate from the local sheriff’s, county police, or municipal police
agency?
Yes
No
(Subset 3 Public or Private University/College Police)
Is your agency a university or college which has a primary or secondary school on its campus?
Yes
No
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(All SOS Applicants)
Does your agency have primary law enforcement authority for the schools/school districts targeted
through this grant proposal?
Note: An agency with primary law enforcement authority is defined as the first responder to calls for service for all types of
criminal incidents within the schools targeted.
Yes
No
Are the schools/school districts targeted through this grant proposal all primary or secondary schools (i.e.,
kindergarten through 12th grade)?
Yes
No
Do these schools all teach the basic school curriculum (e.g., math, science, reading)?
Yes
No
Will the funds awarded solely benefit the primary or secondary schools targeted through this grant proposal?
Yes
No
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Section 3: GENERAL AGENCY INFORMATION
A. Applicant ORI Number: _ _ _ _ _ _ _
The ORI number is assigned by the FBI and is your agency's unique identifier. The
COPS Office uses the first seven characters of this number. The first two letters
are your state abbreviation, the next three numbers are your county's code, and
the next two numbers identify your jurisdiction within your county. If you
do not currently have an ORI number, the COPS Office will assign one to your
agency for the purpose of tracking your grant. ORI numbers assigned to
agencies by the COPS Office may end in “ZZ.”
Check here if your agency has not been assigned an ORI number.
B.Applicant Data Universal Numbering System (DUNS) Number:
_____________
A Data Universal Numbering System (DUNS) Number is required. A DUNS
number is a unique nine or thirteen digit sequence recognized as the
universal standard for identifying and keeping track of entities receiving
federal funds. For more information about how to obtain a DUNS number,
please refer to the "How to Apply" section of the COPS Application Guide.
C.Central Contractor Registration (CCR)
All applicants (other than individuals) are required to maintain current
registrations in the Central Contractor Registration (CCR) database. The
CCR database is the repository for standard information about federal
financial assistance applicants, recipients, and sub-recipients. For more
information about how to register with the CCR, please refer to the "How to
Apply" section of the COPS Application Guide. Please note that applicants
must update or renew their CCR at least once per year to maintain an active
status.
Does your agency have an active registration with the Central Contractor Registration database?
Note: Your Agency must have an active registration with the CCR. If your agency is not registered, please register
now by going to the following web address: https://www.bpn.gov/ccr/default.aspx
Yes _____ No _____
D. Geographic Names Information System (GNIS) ID:_ _ _ _ _ _ _
Please enter your Geographic Names Information System (GNIS) Identification Number. This is a
unique ID assigned to all geographic entities by the U.S. Geological Survey. To look up your GNIS
Feature ID, please go to the website: http://geonames.usgs.gov/domestic/index.html . For more information
about how to obtain a GNIS number, please refer to the “How to Apply” section of the COPS Application
Guide.
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E. Cognizant Federal Agency: Select
___________________
One...
<> full-time officer positions under CHRP. At this time, the
COPS Office must reduce your agency’s request to <> full-time
officer positions. Because we have reduced the total number of officer positions that your agency may
request, we are giving your agency an opportunity to revise its hiring category choices so that it may
prioritize its greatest needs.
It is imperative that applicants understand that the COPS statutory nonsupplanting requirement
mandates that grant funds may only be used to supplement (increase) a grantee’s law enforcement
budget for sworn officer positions and may not supplant (replace) state, local, or tribal funds that a
grantee otherwise would have spent on officer positions if it had not received a grant award. This
means that if your agency plans to:
(a) Hire new officer positions (including filling existing officer vacancies that are no longer funded
in your agency’s budget): It must hire these additional positions on or after the official grant
award start date, above its current budgeted (funded) level of sworn officer positions, and
otherwise comply with the nonsupplanting requirements as described in detail in the Grant
Owner’s Manual.
(b) Rehire officers who have already been laid off (at the time of updated application) as a result of
state, local, or tribal budget cuts: It must rehire the officers on or after the official grant award
start date, maintain documentation showing the date(s) that the positions were laid off and
rehired, and otherwise comply with the nonsupplanting requirement as described in detail in
the Grant Owner’s Manual.
(c) Rehire officers who are (at the time of updated application) currently scheduled to be laid off on
a future date as a result of state, local, or tribal budget cuts: It must continue to fund the officers
with its own funds from the grant award start date until the date of the scheduled lay-off (for
example, if the CHP award start date is September 1 and the lay-off is scheduled for November
1, then the CHP funds may not be used to fund the officers until November 1, the date of the
scheduled lay-off); identify the number and date(s) of the scheduled lay-off(s) in this application
(see below); maintain documentation showing the date(s) and reason(s) for the lay-off; and
otherwise comply with the nonsupplanting requirement as described in detail in the Grant
Owner’s Manual. [Please note that as long as your agency can document the date that the layoff(s) would occur if CHP funds were not available, it may transfer the officers to the CHP
funding on or immediately after the date of the lay-off without formally completing the
administrative steps associated with a lay-off for each individual officer.]
Documentation that may be used to prove that scheduled lay-offs are occurring for local economic
reasons that are unrelated to the availability of CHP grant funds may include (but are not limited to)
council or departmental meeting minutes, memoranda, notices, or orders discussing the lay-offs;
notices provided to the individual officers regarding the date(s) of the lay-offs; and/or budget
documents ordering departmental and/or jurisdiction-wide budget cuts. These records must be
maintained with your agency’s CHP grant records during the grant period and for three years
following the official closeout of the CHP grant in the event of an audit, monitoring, or other evaluation
of your grant compliance.
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Instructions:
To continue our application review, your agency must update its request and allocate the number of
positions it needs under each of the hiring categories shown below. Please complete your responses
based on your agency’s current (at the time of application update) needs for funding in the three hiring
categories (new hires, rehires of previously laid off officers, and rehiring officers who are scheduled to
be laid off on a specific future date). CHP grant awards will be made for officer positions requested in
each of these three categories and recipients of CHP awards are required to use awarded funds for the
specific categories awarded.
If your agency’s updated request includes funding for rehires, your agency may request funding to
rehire officers already laid off and/or scheduled to be laid off at the time of application update. If your
agency’s request for officer positions is funded, however, you will have the opportunity after the award
announcement to request a grant modification to move the awarded funding into the category or
categories that meet your agency’s law enforcement needs at that time (including the opportunity to
update your information regarding dates of future scheduled lay-offs). Please also be mindful of the
initial three-year grant period, and your agency’s ability to fill and retain the officer positions awarded,
while following your agency’s established hiring policies and procedures.
Please note that completing this application update in no way indicates that your agency has been
awarded or will be awarded funding under CHP. In addition, if awarded, your agency may not receive
its full current officer request
Example :
Agency A originally requested CHRP funding for a total of 75 officer positions, with 60 positions
requested for new, additional full-time officer positions and 15 positions requested to rehire officers
already laid off. The agency is required to reduce its total request to 50 full-time officer positions. As a
result, the agency has revised its hiring category request to 10 new hires, 25 positions to rehire officers
already laid off, and 15 to rehire officers that are scheduled to be laid off on September 30, 2010.
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Original Request: <> Full-Time Officers Positions
Requested
Updated Request: Your updated request cannot exceed << COPS OFFICER MAXIMUM EST>> Full
Time Officer Positions Requested
Category A: New, additional officer positions (including to fill existing vacancies no longer funded in your
agency’s budget).
Category A Original Request: <>
Category A Updated Request: ____
Category B: Rehire officers already laid off (at the time of application) as a result of state, local, or tribal budget
reductions.
Category B Original Request: <>
Category B Updated Request: ____
Category C: Rehire officers scheduled to be laid off (at the time of application) on a specific
future date as a result of state, local, or tribal budget reductions
Category C Original Request: <> (total)
Category C Updated Request: _____ (total)
Date of the scheduled lay-off for these officers __/__/____ <>
Category C Updated Date of Scheduled Layoffs __ / __/ ____
Category C Original Request for this date: <>
Category C Updated Request for updated date: _____
Date of the scheduled lay-off for these officers __/__/____ <>
Category C Updated Date of Scheduled Layoffs __ / __/ ____
Category C Original Request for this date: <>
Category C Updated Request for updated date: _____
Date of the scheduled lay-off for these officers __/__/____ <>
Category C Updated Date of Scheduled Layoffs __ / __/ ____
Category C Original Request for this date: <>
Category C Updated Request for updated date: _____
Total Updated Applicant Request: <>
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SECTION 6: LAW ENFORCEMENT & COMMUNITY POLICING
STRATEGY
COPS Office grants must be used to reorient the mission and activities of law
enforcement agencies toward the community policing philosophy or enhance their
involvement in community policing. The following is the COPS Office definition of
community policing that emphasizes the primary components of community
partnerships, organizational transformation, and problem solving.
Community policing is a philosophy that promotes organizational
strategies, which support the systematic use of partnerships and problemsolving techniques, to proactively address the immediate conditions that
give rise to public safety issues, such as crime, social disorder, and fear of
crime.
The COPS Office has completed the development of a comprehensive community
policing self-assessment tool for use by law enforcement agencies. Based on this
work, we have developed the following list of primary sub-elements of
community policing. Please refer to the COPS Office web site
(www.cops.usdoj.gov) for further information regarding these sub-elements.
Community Partnerships:
Organizational Transformation:
Problem Solving:
Collaborative par tner ships between
the law enforcement agency and the
individuals and organizations they serve
to both develop solutions to problems and
increase trust in police.
The alignment of organizational
management, structure, personnel and
information systems to support
community partnerships and proactive
problem-solving efforts.
The process of engaging in the
proactive and systematic examination
of identified problems to develop
effective responses that are rigorously
evaluated.
Agency Management
Other Government Agencies
Climate and culture
Community Members/Groups
Leadership
Non-Profits/Service Providers
Labor relations
• Analysis: Analyzing problems
Private Businesses
Decision-making
• Response: Responding to
Media
Strategic planning
• Scanning: Identifying and
prioritizing problems
problems
Policies
• Assessment: Assessing
Organizational evaluations
Transparency
• Using the Crime Triangle
Organizational Structure
Geographic assignment of
officers
Despecialization
Resources and finances
Personnel
Recruitment, hiring and selection
Personnel supervision/evaluations
Training
Information Systems
(Technology)
Communication/access to data
Quality and accuracy of data
problem-solving initiatives
to focus on immediate
conditions (Victim/Offender/Location)
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Proposed Community Policing Plan
COPS grants must be used to initiate or enhance community policing activities, either directly by
your law enforcement agency, or (for non-law enforcement applicants) in collaboration with law
enforcement. Please complete the following questions to describe the types of community
policing activities that you are currently engaged in and that will result from COPS funding.
For each question, answer on behalf of the applicant law enforcement agency, or for non-law
enforcement applicants the law enforcement agency(s) with whom you will collaborate.
You may find more detailed information about community policing at the COPS Office web
site http://www.cops.usdoj.gov/Default.asp?Item=36.
Community Partnerships
Community partnerships are ongoing collaborative relationships between law enforcement and
the individuals and organizations they serve to both develop solutions to problems and increase
trust in the police.
P1) Regularly distributes relevant crime and disorder information to community members.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
P2) Routinely seeks input from the community to identify and prioritize neighborhood
problems (e.g., through regularly scheduled community meetings, annual community
surveys, etc.).
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
P3) Regularly collaborates with local government agencies that deliver public services.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
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If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
P4) Regularly collaborates with non-profit organizations and/or community groups.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
P5) Regularly collaborates with local businesses.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
P6) Regularly collaborates with informal neighborhood groups and resident associations.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
P7) Regularly collaborates with federal government agencies through formal partnerships
(e.g., task forces, working groups, etc.)
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
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□ YES
□ NO
Problem Solving
Problem solving is an analytical process for systematically (1) identifying and prioritizing
problems, (2) analyzing problems, (3) responding to problems, and (4) evaluating problem-solving
initiatives. Problem solving involves an agency-wide commitment to go beyond traditional police
responses to crime to proactively address a multitude of problems that adversely affect quality
of life.
PS1) Routinely incorporates problem-solving principles into patrol work.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
PS2) Identifies and prioritizes crime and disorder problems through the routine
examination of patterns and trends involving repeat victims, offenders, and locations.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
PS3) Routinely explores the underlying factors and conditions that contribute to crime
and disorder problems.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
PS4) Systematically tailors responses to crime and disorder problems to address their
underlying conditions.
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a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
PS5) Regularly conducts assessments to determine the effectiveness of responses to crime and
disorder problems.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
Organizational Transformation
Organizational transformation is the alignment of organizational management, structure, personnel
and information systems to support community partnerships and proactive problem-solving
efforts.
OT1) Incorporates community policing principles into the agency’s mission statement and
strategic plan.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
OT2) Practices community policing as an agency-wide effort involving all staff (i.e., not
solely housed in a specialized unit).
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
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□ YES
□ NO
OT3) Incorporates problem-solving and partnership activities into personnel performance
evaluations.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
Technology
Technology provides agencies with the tools to communicate more effectively externally with the
public and internally with their own staff, and the ability to understand and analyze community
problems.
TEC01) Ensures that agency staff have appropriate access to relevant data (e.g., calls for
service, incident and arrest data, etc.).
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
TEC02) Uses technology (e.g., crime mapping or statistical software) to analyze and
understand problems in the community.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
TEC03) Uses technology (e.g., GIS/GPS for deployment or laptops for field reporting) to
improve the agency’s overall efficiency and effectiveness.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
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□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
TEC04) Provides officers with necessary equipment to better prevent and/or respond to
crime and disorder problems.
a) □ YES
If yes, do you plan to use grant funding to enhance or expand this activity?
□ YES
□ NO
b) □ NO
If no, do you plan to use grant funding to initiate or implement this activity?
□ YES
□ NO
Community Policing Plan Narrative
Please describe your agency’s implementation plan for this program (if awarded), with specific
reference to each of the following elements of community policing: (a) community partnerships
and support, including consultation with community groups, private agencies, and/or other public
agencies; (b) related governmental and community initiatives that complement your agency’s
proposed use of COPS funding; and (c) organizational transformation – how your agency will use
these funds, if awarded, to reorient its mission to community policing or enhance its involvement
in and commitment to community policing. Your organization may be audited or monitored to
ensure that it is initiating or enhancing community policing in accordance with this plan. The
COPS Office may also use this information to understand the needs of the field, and potentially
provide for training, technical assistance, problem solving and community policing
implementation tools.
If your organization receives this grant funding, these responses, along with the previous
questions, will be considered as your organization’s community policing plan. We understand
that your community policing needs may change during the life of your grant (if awarded), and
minor changes to this plan may be made without prior approval from the COPS Office. We
also recognize that this plan may incorporate a broad range of possible community policing
strategies and activities, and that your agency may implement particular community policing
strategies from the plan on an as-needed basis throughout the life of the grant. If your agency’s
community policing plan changes significantly, however, you must submit those changes in
writing to the COPS Office for approval. Changes are “significant” if they deviate from the
range of possible community policing activities identified and approved in this original
community policing plan submitted with your application.
In the space provided, please address your agency’s implementation plan for this program with
specific reference to each of the following elements of community policing:
(a) Community partnerships and support, including consultation with community groups,
private agencies, and/or other public agencies.
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[Responses are limited to a maximum of 3,000 characters.]
(b) Related governmental and community initiatives that complement your agency’s
proposed use of COPS funding.
[Responses are limited to a maximum of 3,000 characters.]
(c) Organizational transformation – how your agency will use these funds, if awarded, to
reorient its mission to community policing or enhance its involvement in and
commitment to community policing.
[Responses are limited to a maximum of 3,000 characters.]
CP1) To what extent is there community support in your jurisdiction for implementing
the proposed grant activities?
a) High level of support
b) Moderate support
c) Minimal support
CP2) If awarded, to what extent will the grant activities impact the other components of
the criminal justice system in your jurisdiction?
a) Potentially decreased burden
b) No change in burden
c) Potentially increased burden
ORI #:
Standard Application Forms
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SECTION 7: NEED FOR FEDERAL ASSISTANCE
A. Waivers of the Local Match
Please refer to the program-specific Application Guide for information on whether waivers of
the local match are available under the grant program for which you are applying.
Are you requesting a waiver of the local match based upon severe fiscal distress?
Yes
No
B. Explanation of Need for Federal Assistance
All applicants are required to address the need for federal assistance. In the space below, please
provide a brief explanation of your agency's inability to address your public safety needs and
implement this project without federal assistance.
[Please limit your response to a maximum of 3,000 characters.]
C. Fiscal Health
1) Enter your law enforcement agency’s total operating budget for the current AND previous two
fiscal years. Please note: All figures must be rounded to the nearest whole dollar.
CURRENT FISCAL YEAR (2010) $_______________
PREVIOUS FISCAL YEAR (2009) $_______________
PREVIOUS FISCAL YEAR (2008) $_______________
2) Enter the total jurisdictional (city, county, state, tribal, university) locally-generated revenues
for the current AND previous two fiscal years. Locally-generated revenues may include locallygenerated property taxes, sales taxes, and other taxes and revenue sources (e.g., transportation taxes,
transient lodging taxes, licensing fees, other non-property taxes, and franchise taxes). For example,
college/university police departments would include tuition and fees, park police may include
entrance and parking fees, etc. Please note: All figures must be rounded to the nearest whole dollar.
CURRENT FISCAL YEAR (2010) $_______________
PREVIOUS FISCAL YEAR (2009) $_______________
PREVIOUS FISCAL YEAR (2008) $_______________
ORI #:
Standard Application Forms
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3) Since January 1, 2009 , what percentages of the following employees in your jurisdiction
(city, county, state, tribal, university) have been reduced through lay-offs. Please note: All
figures must be rounded to the nearest whole percent.
Civilian Law Enforcement Agency Personnel
Sworn Law Enforcement Agency Personnel
Other Government Agency Personnel
_____%
_____%
_____%
4) Since January 1, 2009, what percentages of the following employees in your jurisdiction
(city, county, state, tribal, university) have been reduced through furloughs that have lasted or are
scheduled to last a minimum of forty hours per affected employee over the course of a fiscal year.
Please note: All figures must be rounded to the nearest whole percent.
Civilian Law Enforcement Agency Personnel
Sworn Law Enforcement Agency Personnel
Other Government Agency Personnel
_____%
_____%
_____%
5) Since January 1, 2009, what percentages of the following authorized positions in your jurisdiction
(city, county, state, tribal, university) are currently unfilled due to official policies and/or decisions
that limit your jurisdiction’s ability to fill vacancies (i.e., hiring freezes). For example, if your
agency has ten authorized sworn positions and one is currently frozen, you would enter 10% on
the sworn personnel line. Please note: All figures must be rounded to the nearest whole percent.
Civilian Law Enforcement Agency Personnel
Sworn Law Enforcement Agency Personnel
Other Government Agency Personnel
_____%
_____%
_____%
6) The U.S. Census Bureau American Community Survey (ACS) provides multi-year poverty
rate estimates for communities. For jurisdictions with a census population greater than 20,000,
please go to the U.S. Census Bureau’s American FactFinder (http://FactFinder.census.gov) to
determine the percentage of families in poverty in your jurisdiction based on the 2006 - 2008
ACS. For jurisdictions below 20,000 in population, please select the nearest best match
for your jurisdiction (for example, the county in which your jurisdiction is located).
For jurisdictions not included in the census (e.g., schools, universities, transit, parks), please
check the box for “Not Applicable.” Please see the program Application Guide for additional
information and help in using the American Fact Finder. Please note: All figures must be rounded
to the nearest whole percent.
Percentage of families in poverty % _______
Not Applicable ____
ORI #:
Standard Application Forms
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
7) The Bureau of Labor Statistics’ Local Area Unemployment Statistics (LAUS) program
provides monthly estimates of unemployment for communities. Please go to the Bureau of
Labor Statistics’ LAUS website (www.bls.gov/lau/data.htm) to find detailed instructions for looking
up your local area's unemployment rate. As with the previous question, it may be necessary to
select the nearest best match to your jurisdiction (for example, a city of fewer than 25,000 people
may report their county level rate). Please see the program Application Guide for additional
information and help in using the LAUS data. For jurisdictions not included in the census (e.g.,
schools, universities, transit, parks), please check the box for “Not Applicable". Please note: All
figures must be rounded to the nearest whole percent.
Percentage unemployed for February 2010 _____%
Not Applicable _____
8) Indicate your jurisdiction's estimated residential property foreclosure rate for calendar
year 2009. This rate should be calculated as the total number of new default and auction
foreclosure filings and new bank-owned foreclosures (REOs) in 2009 divided by the total number
of residential households. Please note: All figures must be rounded to the nearest whole percent.
Bank Owned PCT_____%
_____ Check here if the information necessary to calculate this rate is unavailable
9) Indicate if your jurisdiction has experienced any of the following events since January 1, 2009
(Check all that apply)
_____A declaration of natural or other major disaster or emergency has been made pursuant to the
Robert T. Stafford Disaster Relief and Emergency Assistance Act. (42 U.S.C. 5121 et seq.)
_____A declaration as an economically or financially distressed area by the state in which the
applicant is located.
_____Downgrading of the applicant’s bond rating by a major rating agency.
_____Has filed for or been declared bankrupt by a court of law.
_____Has been placed in receivership or its functional equivalent by the state or federal
government .
10) Enter the total jurisdictional (city, county, state, tribal) operating budget for the current AND
previous two fiscal years. Please note: All figures must be rounded to the nearest whole dollar.
CURRENT FISCAL YEAR (2010)$__________________
PREVIOUS FISCAL YEAR (2009)$_________________
PREVIOUS FISCAL YEAR (2008)$_________________
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
11) Using UCR crime definitions, enter the actual number of incidents reported to your agency in the
previous three calendar years <> for the following crime types. Note that
only those incidents for which your agency had primary response authority should be provided.
UCR Data*
<>
<>
<>
Criminal Homicide
Forcible Rape
Robbery
Aggravated Assault
Burglary
Larceny (except motor vehicle theft)
Motor Vehicle Theft
Please note: Only those incidents for which your agency had primary response authorith should be provided. An agency with primary
response authority is defined as the first responder to calls for service for all types of criminal incidents within its jurisdiction. Agencies
are not considered to have primary response authority if they only: respond to or investigate on a specific type(s) of crime(s); respond to
or investigate crimes within a correctional facility; serve warrants; provide courthouse security; transport prisoners; and/or have cases
referred to them for investigation or investigational support.
*Note: If your agency currently reports to NIBRS, or does not report crime incident totals at all, please ensure that your data is converted to
UCR Summary Data style. Please see the COPS Application Guide or the FBI’s UCR Handbook
(www.fbi.gov/ucr/handbook/ucrhandbook04.pdf ) for more information.
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
SECTION 8: CONTINUATION OF PROJECT AFTER FEDERAL FUNDING
ENDS
If you are applying for a COPS grant with a post-grant retention plan requirement, please complete A. If
you are applying for a COPS grant without a post-grant retention plan requirement, please complete B.
A. Continuation of Project after Federal Funding Ends (for COPS grants with a
retention plan requirement)
Applicants for COPS hiring grants which include a post-grant retention requirement must plan to retain
all positions awarded for a minimum of 12 months at the conclusion of federal funding for each position.
Your responses to the questions below will serve as your agency’s retention plan. The retained COPSfunded positions should be added to your agency’s law enforcement budget with state and/or local funds
at the end of grant funding, over and above the number of locally-funded positions that would have
existed in the absence of the grant. At the time of grant application, applicants must affirm that they
plan to retain the positions and identify the planned source(s) of retention funding. We understand that
your agency’s source(s) of retention funding may change during the life of the grant. Your agency
should maintain proper documentation of any changes in the event of an audit, monitoring or other
evaluation of your compliance.
1. Will your agency plan to retain any additional positions awarded under this grant for a
minimum of 12 months at the conclusion of federal funding for each position?
YES ___ NO___
(If YES, move to the next question)
(If NO: Agencies that do not plan to retain all the positions awarded under the grant are ineligible to
receive COPS funding with a post-grant retention requirement.)
2. Please identify the source(s) of funding that your agency plans to utilize to cover the costs of
retention from the drop-down box listed below: (check all that apply)
______General funds
______Raise bond/tax issue
______Private sources/donations
______Non-federal asset forfeiture funds (subject to approval from the state or local oversight agency)
______Fundraising efforts
______Other (Please provide a brief description of the source(s) of funding not to exceed 350
characters.) __________________________________________________________________
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
B. Continuation of Project after Federal Funding Ends (for other COPS grants
with no retention plan requirement)
Please complete these questions to indicate any plans you may have to continue this program, project, or
activity following the conclusion of federal support?
1. Does your agency plan to obtain necessary support and continue the program, project, or
activity following the conclusion of federal support?
YES______ NO_______
2. Please identify the source(s) of funding that your agency plans to utilize to continue the
program, project, or activity following the conclusion of federal support: (check all that apply)
______General funds
______Raise bond/tax issue
______Private sources/donations
______Non-federal asset forfeiture funds (subject to approval from the state or local oversight agency)
______Fundraising efforts
______Other (Please provide a brief description of the source(s) of funding not to exceed 350
characters.) ____________________________________________________________________
ORI #:
Standard Application Forms
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SECTION9:UCR/SCHOOLINCIDENTDATA
A. UCR Data
1. Using UCR crime definitions, enter the actual number of incidents reported to your agency in the
previous three calendar years <> for the following crime types. Note that
only those incidents for which your agency had primary response authority should be provided.
<>
UCR Data*
<>
<>
Criminal Homicide
Forcible Rape
Robbery
Aggravated Assault
Burglary
Larceny (except motor vehicle theft)
Motor Vehicle Theft
*Note: If your agency currently reports to NIBRS, or does not report crime incident totals at all, please ensure that your data is converted to
UCR Summary Data style. Please see the COPS Application Guide or the FBI’s UCR Handbook
(www.fbi.gov/ucr/handbook/ucrhandbook04.pdf) for more information.
2. Enter the total number of calls for service received by your agency during each year and the
corresponding total resulting in the dispatch of officers. If precise data are not available, provide an estimate
and mark the box below. If none, enter '0'.
<>
Calls
Calls
Received Dispatched
<>
Calls
Calls
Received Dispatched
<>
Calls
Calls
Received Dispatched
Number of Calls for Service
Check Box if Estimate
3. Enter the total number of arrests for each UCR-category listed. If precise data are not available, provide an
estimate and mark the box below. If none, enter '0'.
Offense Category:
Weapons
Driving Under Influence
<>
<>
Check Box if Estimate
<>
Arrests
<>
Arrests
<>
Arrests
B. School Incident Data
1. Crime and school-related incident data may be required as part of your agency’s application for funding.
Please see the program-specific Application Guide for more information. If required, the data reported should
only include incidents that took place on the grounds of partnering schools during the requested timeframe. Do
not report UCR data for the local jurisdiction. The incident data reported should only be for those schools that
will benefit directly from this grant program if awarded. The safety and security of these partnering schools will
be enhanced as a direct result of receiving this grant funding. Please refer to the program-specific Application
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
Guide for specific reporting dates and instructions regarding the data which may be required for this submission.
Type of Crime Incidents Occurring on the
# of Incidents Reported
# of Incidents Reported
Grounds of Partnering School(s) that Were <> <>
Officially Reported to the Applicant Law
Enforcement Agency
Homicide
Sexual Offenses
Aggravated/Major Assaults—for example, an
attack with hands, fist, feet, or weapons on an
individual.
Simple/Minor Assaults—stalking,
intimidation/bullying/coercion, etc.
Thefts (Includes Reports of Stolen Property)
Possession/Sale of Illegal Weapons
Vandalism/Destruction of Property
Alcohol-Related Offenses
Possession, Use or Sale of Drugs
Disorderly Conduct
Type of School-Related Incidents Occurring on
the Grounds of Partnering School(s) that Were
Officially Documented by the School(s)
Truancy
Detentions
Suspensions
Expulsions
Threats to School Property
2. A. Number of schools involved in the project that will benefit directly from this grant funding if
awarded:__________
B. Total student population of partner schools: _______________
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
SECTION 10: EXECUTIVE SUMMARY
Please provide a brief summary of how your agency will use this federal funding. Refer to the
COPS Application Guide for clarification on specific information to include in your summary, and
be sure to provide a description of how you expect this grant to impact public safety and/or crime
prevention in your community. The Executive Summary may be used to keep Congress or other
executive branch agencies informed on law enforcement strategies to deter crime in your
community.
[Responses are limited to a maximum of 3,000 characters.]
SECTION 11: PROJECT DESCRIPTION (NARRATIVE)
Please include in your application an in-depth narrative response detailing your proposed
project. Please refer to the program-specific section of the COPS Application Guide: "How to
Apply" section for information on what should be included in your response, as well as any
additional formatting requirements and page length limitations.
[Responses are limited to a maximum of 3000 characters.]
A. << TBD depending on program>>
B. << TBD depending on program>>
[Responses are limited to a maximum of 3000 characters.]
C. << TBD depending on program>>
[Responses are limited to a maximum of 3000 characters.]
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
D. << TBD depending on program>>
[Responses are limited to a maximum of 3000 characters.]
E. << TBD depending on program>>
[Responses are limited to a maximum of 3000 characters.]
F. << TBD depending on program>>
[Responses are limited to a maximum of 3000 characters.]
G. << TBD depending on program>>
[Responses are limited to a maximum of 3000 characters.]
H. << TBD depending on program>>
[Responses are limited to a maximum of 3000 characters.]
I. << TBD depending on program>>
[Responses are limited to a maximum of 3000 characters.]
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
SECTION 12: OFFICIAL PARTNER(S) CONTACT INFORMATION
An official "partner" under the grant may be a governmental, private, school
district, or other applicable entity that has established a legal, contractual, or
other agreement with the applicant for the purpose of supporting and working
together for mutual benefits of the grant. Please see the COPS Application
Guide for more information on official partners that may be required.
Title: ____________________________________________________________
First Name:___________________ MI:______ Last Name: __________ Suffix:_____
Name of Partner Agency (e.g., Smithville High School): __________________
Type of Partner Agency (e.g., School District): __________________________
Street Address 1: ___________________________________________________
Street Address 2: ___________________________________________________
City: ______________________ State: ____________________ Zip Code:______
Telephone: ____________________________ Fax: _______________________
E-mail: ______________________________
□ Click here to add additional partners.
Person Submitting this Application
□ By clicking this box and typing my name below, I certify that I have been legally and officially
authorized by the appropriate governing body to identify the partner(s) listed above and act on behalf of
the grant applicant entity. I also certify that the above agency (or agencies) is a partner (or are partners)
to the grant project as required by the grant and that our agencies mutually agreed to this partnership as
related to this grant project prior to submission of this grant application. In addition, I certify that the
information provided above regarding the partner(s) is true and accurate to the best of my knowledge. I
understand that false statements or claims made in connection with COPS programs may result in fines,
imprisonment, debarment from participating in federal grants, cooperative agreements, or contracts,
and/or any other remedy available by law to the federal government.
Please type your name here in place of your signature:
___________________________________________
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
SECTION 13: APPLICATION ATTACHMENTS
This section should be used to attach any required or applicable attachments to your grant application
(e.g., a Memorandum of Understanding).
If the program for which you are applying requires a Memorandum of Understanding (MOU), this
document should define the roles and responsibilities of the individuals and partner(s) involved in
your proposed project. Please refer to the program-specific Application Guide to determine if an MOU
or other application attachments are required. The Guide will also specify if optional attachments are
permitted for submission.
ADD ATTACHMENTS
<< Uploaded Attachment 1 Name >>
SelectType...
One...
Select
<< Uploaded Attachment 2 Name >>
SelectType...
One...
Select
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
SECTION 14: BUDGET DETAIL WORKSHEETS
Instructions for Completing the
Budget Detail Worksheets
The following Budget Detail Worksheets are designed to allow all COPS grant and cooperative
agreement applicants to use the same budget forms to request funding. Allowable and unallowable
costs vary widely and depend upon the type of COPS program. The maximum federal funds that can be
requested and the federal/local share breakdown requirements also vary.
Please refer to the program-specific Application Guide to determine the allowable/unallowable costs,
the maximum amount of federal funds that can be requested, and the federal/local share requirements
for the COPS program for which your agency is applying. To assist you, sample Budget Detail
Worksheets are included in each Application Guide.
Please complete each section of the Budget Detail Worksheets applicable to the program for which you
are applying (see the program-specific Application Guide for requirements). If you are not requesting
anything under a particular budget category, please check the appropriate box in that category
indicating that no positions or items are requested.
All calculations should be rounded to the nearest whole dollar. Once the budget for your proposal has
been completed, a budget summary page will reflect the total amounts requested in each category, the
total project costs, and the total federal and local shares.
If you need assistance in completing the Budget Detail Worksheets, please call the COPS Office
Response Center at 800.421.6770.
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
A. SWORN OFFICER POSITIONS
No Sworn Officer Positions Requested
Instructions: This worksheet will assist your agency in reporting your agency’s current entry-level salary
and benefits and identifying the total salary and benefits request per officer position for the length of the
grant term. Please list the current entry-level base salary and fringe benefits rounded to the nearest whole
dollar for one full-time sworn officer position within your agency. Do not include employee contributions.
(Please refer to the program-specific Application Guide for information on the length of the grant term for
the program under which you are applying.)
Special note regarding sworn officer fringe benefits: For agencies that do not include fringe benefits
as part of the base salary costs and typically calculate these separately, the allowable expenditures may
be included under Part 1, Section B. Any fringe benefits that are already included as part of the agency’s
base salary (Part 1, Section A of the Sworn Officer Budget Worksheet) should not also be included in the
separate fringe listing (Part 1, Section B).
Please refer to the program-specific Application Guide for information about allowable and unallowable
fringe benefits for sworn officer positions requested under the program to which your agency is applying.
No Sworn Officer Positions Requested
Enter the second year base
salary for one entry-level
sworn officer position.
$__________________.00
Enter the current first year
entry-level base salary for one
sworn officer position.
$__________________.00
Exempt:
Exempt:
_________________.00
C. Total Year Salary and Benefits (1 Position):
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
% OF BASE
$ _________________.00
(Year 2)
$ _____________________________00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
COST:
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
% OF BASE
$ _________________.00
(Year 3)
$ _____________________________00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
COST:
Year 3 Fringe Benefits
$__________________.00
Enter the third year base
salary for one entry-level
sworn officer position.
Year 3 Salary (As applicable)
D. Total Salary and Benefits for Years 1, 2, and 3 (1 Position): $______________________ X _____# of Positions = $_____________________________
(Year 1)
$ _____________________________00
_______%
_______%
Benefits Sub-Total Per Year (1 Position)
$ _____________.00
_______%
_______%
_______%
_______%
$ _____________.00
Select One...
Other
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
_______%
_______%
_______%
_______%
_______%
_______%
% OF BASE
Other_______________________________
Select One...
Exempt:
Unemployment Insurance
Other
Fixed Rate:
Exempt:
Worker’s Compensation
Fixed Rate:
Fixed Rate:
Retirement
Number of Hours Annually: _________
Sick Leave
$ _____________.00
$ _____________.00
Number of Hours Annually: _________
$ _____________.00
Vacation
Fixed Rate:
$ _____________.00
$ _____________.00
$ _____________.00
Family:
Fixed Rate:
Fixed Rate:
COST:
Year 1 Fringe Benefits
Life Insurance
Individual:
Health Insurance
Cannot exceed 1.45% of Total Base Salary.
Medicare
Cannot exceed 6.2% of Total Base Salary.
Social Security
FRINGE BENEFITS:
Year 2 Fringe Benefits
Year 2 Salary (As applicable)
Year 1 Salary
B. Fringe benefit costs should be calculated for each year of the grant term.
A. Base Salary Information
As applicable per the program-specific Application Guide, you may also be required to project Year 2 and Year 3 salaries.
Part 1: Instructions: Please complete the questions below based on your agency’s entry-level salary and benefits package for one locally-funded officer position.
Full-Time Entry-Level Sworn Officer Base Salary Information
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
Part 2: Sworn Officer Salary Information
If your agency's second and/or third-year costs for salaries and/or fringe benefits increase after the
first year, check the reason(s) why in the space below:
Cost of living adjustment (COLA)
Step raises
Change in benefit costs
Other - please explain briefly: ______________________________________________
Part 3: Federal/Local Share Costs (for Hiring Grants)
If the COPS Hiring Grant Program requires a local match, the grantees are required to pay a
progressively larger share of the cost of the grant with local funds over the grant period. Please refer
to the program-specific Application Guide to determine if this section is applicable. This means that
your local match must increase each year, while the federal share must decrease. Please project in the chart
below how your agency plans to assume a progressively larger share of the grant costs during each year
of the program. The chart is a projection of your plans; while your agency may deviate from these specific
projections during the grant period, it must still ensure that the federal share decreases and the local share
increases.
Year 1
Year 2
Year 3
Federal Share
$___________________
$___________________
$___________________
Local Share
$___________________
$___________________
$___________________
Totals
$___________________
$___________________
$___________________
(Pre-populated)
(Pre-populated)
(Pre-populated)
Total salary and benefits for years 1, 2 & 3 (all positions):
$ (Pre-populated from budget)
Total federal share:
$ (Pre-populated from budget)
Total local share required (sworn officer costs):
(Based on Years 1, 2 & 3 costs for all sworn positions)
$ (Pre-populated from budget)
Exempt:
Exempt:
_______%
_______%
$ _____________.00
$ _____________.00
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
% OF BASE
$_____________.00 (A+B)
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
COST:
Year 2 Fringe Benefits
Year 2 Salary (As applicable)
Enter the second year base
salary for one civilian/
non-sworn position.
$_______________
x________% of time on project =
$__________________.00
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
% OF BASE
$_____________.00 (A+B)
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
$ _____________.00
COST:
Year 3 Fringe Benefits
Year 3 Salary (As applicable)
Enter the third year base salary
for one civilian/
non-sworn position.
$_______________
x________% of time on project =
$__________________.00
Civilians/Non-Sworn Personnel Total $ ___________________
If requesting additional positions with exact budget check here Indicate # of positions_____ If requesting other position(s) with different budget(s), check here
D. Total Salary and Benefits for Years 1, 2, and 3 (1 Position): $________________
$_____________.00(A+B)
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
_______%
$ _____________.00
Total (A+B)
Fixed Rate:
Unemployment Insurance Exempt:
Other Select One...
Other Select One...
Other_______________________________
$ _____________.00
$ _____________.00
Fixed Rate:
Exempt:
Worker’s Compensation
$ _____________.00
%
Benefits Sub-Total Per Year (1 Position)
Fixed Rate:
Retirement
Number of Hours Annually: _________
Sick Leave
$ _____________.00
$ _____________.00
Number of Hours Annually: _________
$ _____________.00
Vacation
Fixed Rate:
$ _____________.00
$ _____________.00
$ _____________.00
Family:
Fixed Rate:
Fixed Rate:
COST:
BASE
Year 1 Fringe Benefits
Life Insurance
Individual:
Health Insurance
Cannot exceed 1.45% of Total Base Salary.
Medicare
Cannot exceed 6.2% of Total Base Salary.
Social Security
FRINGE BENEFITS:
OF
(base salary x percent = adjusted Year-1
salary)
Year 1 Salary
Enter the current first year base
salary for one civilian/
non-sworn position.
$_______________
x________% of time on project =
$__________________.00
B. Fringe benefit costs should be calculated for each year of the grant term.
(One position per worksheet)
Description
Position Title
A. Base Salary Information
No Civilian/Non-Sworn Positions Requested
Part 1: Instructions: Please complete the questions below for one non-sworn position salary and benefits package. As applicable per the program-specific Application
Guide, you may also be required to project Year 2 and Year 3 salaries.
B. Base Salary and Fringe Benefits for Civilian/Non-Sworn Personnel
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
C. EQUIPMENT/TECHNOLOGY
No Equipment/Technology Requested
Instructions: List non-expendable items that are to be purchased. Provide a specific description for each item and
explain how the item supports the project goals and objectives as outlined in your application. Non-expendable
equipment is tangible property (e.g., technology) having a useful life of more than one year and an acquisition cost of
$5,000 or more per unit. Expendable items should be included either in the “SUPPLIES” or “OTHER” categories. Applicants
should analyze the cost benefits of purchasing versus leasing equipment, especially for high-price items and those subject
to rapid technical advances. Rented or leased equipment costs should be listed in the “CONTRACTS / CONSULTANTS”
category.
Please be advised that, to the greatest extent practical, all equipment and products purchased with these funds must
be American-made.
For agencies purchasing items related to enhanced communications systems, the COPS Office expects and
encourages that, wherever feasible, such voice or data communications equipment should be incorporated into
an intra- or interjurisdictional strategy for communications interoperability among federal, state, and local law
enforcement agencies.
See the program-specific Application Guide for a list of allowable/unallowable costs for this program. Agencies are
limited to 10 lines for each category. If your agency has more than 10 items, please group similar items together so that
all items are accounted for on the budget worksheet.
Item Name
Computation
Per Item Subtotal
(# of Items/Units X Unit Cost)
More Equipment Entries
Required
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
Equipment/Technology $ _______________
Total:
Description
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
D. SUPPLIES
No Supplies Requested
Instructions: List items by type (office supplies; postage; training materials; copying paper; books; hand-held tape recorders;
etc). Provide a specific description for each item and explain how it supports the project goals and objectives outlined in
your application. Generally, supplies include any materials that are expendable or consumed during the course of the project.
See the program-specific Application Guide for a list of allowable/unallowable costs for this program. Agencies are limited to 10
lines for each category. If your agency has more than 10 items, please group similar items together so that all items are accounted
for on the budget worksheet.
Item Name
Computation
Per Item Subtotal
(# of Items/Units X Unit
Cost)
More Supplies Entries Required
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
Supplies Total: $______________
Description
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
E. TRAVEL/TRAINING
No Travel/Training Requested
Instructions: Itemize grant-related travel expenses of grantee personnel (excluding consultants, whose expenses are listed in
Section F) by event (e.g., mandatory training, staff to training, field interviews, advisory group meetings). Identify the location
of travel whenever possible, and show the number of staff expected to attend each event. Training fees, transportation, lodging
and per diem rates for trainees should be listed as separate travel items. Grantee travel costs specific to the grant project may be
based on the grantee's written travel policy, assuming the costs are reasonable. Grantees without a written travel policy must
follow the established federal rates (found at www.gsa.gov) for lodging, meals, and per diem. For all grantees (with or without a
written travel policy), airfare travel costs must be one of the following: the lowest discount commercial airfare, standard coach
airfare, or the federal government contract airfare (if authorized and available). Note: Any local training costs (within a 50-mile
radius) should be listed under Section G ("Other Costs").
See the program-specific Application Guide for a list of allowable/unallowable costs for this program. Agencies are limited to 10
lines for each category. If your agency has more than 10 items, please group similar items together so that all items are accounted
for on the budget worksheet.
Event Title and Location
More Travel/Training
Entries Required
Event Costs
Number of
Staff
Per Event
Subtotal
Registration
Transportation
Lodging
Per diem
$___________
$___________
$___________
$___________
$
Registration
Transportation
Lodging
Per diem
$___________
$___________
$___________
$___________
$
Registration
Transportation
Lodging
Per diem
$___________
$___________
$___________
$___________
$
Registration
Transportation
Lodging
Per diem
$___________
$___________
$___________
$___________
$
Registration
Transportation
Lodging
Per diem
$___________
$___________
$___________
$___________
$
Registration
Transportation
Lodging
Per diem
$___________
$___________
$___________
$___________
$
Travel/ $___________
Training
Total:
Description
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
F. CONTRACTS/CONSULTANTS
No Contracts/Consultants Costs Requested
Instructions: See the program-specific Application Guide for a list of allowable/unallowable costs for the particular program to
which you are applying.
1. Contracts: Provide a description of the product or service to be procured by contract and an estimate of the cost. Applicants are
encouraged to promote free and open competition in awarding contracts. If awarded, requests for sole source procurements
of equipment, technology, or services in excess of $100,000 must be submitted to the COPS Office for prior approval.
(See Application Guide for more information on the required submission.)
Contract Name
Per Contract Subtotal
Description
$
$
$
Contracts Subtotal: $
2. Consultant Fees: For each consultant enter the name (if known), service to be provided, hourly or daily fee (based upon an
8-hour day), and estimated length of time on the project. Unless otherwise approved by the COPS Office, approved consultant
rates will be based on the salary a consultant receives from his or her primary employer. Consultant fees in excess of $550 per
day require additional written justification and must be pre-approved in writing by the COPS Office if the consultant is hired
via a noncompetitive bidding process.
Consultant Name/Title
Service Provided
Computation
( Cost X # Days or
# Hours)
Per Consultant
Fee
Subtotal
( _________ X _____)
$
( _________ X _____)
$
( _________ X _____)
$
Description
Consultant Fees Subtotal: $
3. Consultant Travel: List all travel-related expenses to be paid from the grant to the individual consultants (e.g.,
transportation, meals, lodging) separate from their consultant fees.
Consultant Name/
Event Title
Event Costs
Number of Staff
Per Consultant
Travel Subtotal
Registration
Transportation
Lodging
Per diem
$_________
$_________
$_________
$_________
$
Registration
Transportation
Lodging
Per diem
$_________
$_________
$_________
$_________
$
Description
Consultant Travel Subtotal:
4. Consultant Expenses: List all travel-related expenses to be paid from the grant to the individual consultants separate from
their consultant fees and travel expenses (e.g., computer equipment and office supplies).
Consultant Name/Title
Item(s)
Per Consultant
Subtotal
Consultant Expenses Subtotal: $
Contracts/Consultants Total:
Contracts (F1) + Consultant Fees (F2) + Consultant Travel (F3) + Consultant Expenses (F4)
More Contracts/Consultants Entries Required
$_______________
Description
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
G. OTHER COSTS
No Other Costs Requested
Instructions: List other requested items that will support the project goals and objectives as outlined in your application.
Provide a specific description for each item and explain how the item supports the project goals and objectives as
outlined in your application.
Please be advised that, to the greatest extent practical, all equipment and products purchased with these funds must be
American-made.
See the program-specific Application Guide for a list of allowable/unallowable costs for this program. Agencies are limited to
10 lines for each category. If your agency has more than 10 items, please group similar items together so that all items are
accounted for on the budget worksheet.
Item Name
Computation
Per Item Subtotal
(# of Items/Units X Unit Cost)
More Other Costs Entries Required
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
(
X
)
$
Other Costs Total: $ __________________
Description
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
H. INDIRECT COSTS
No Indirect Costs Requested
Instructions: Indirect costs are allowed under a very limited number of specialized COPS programs. Please see the
program-specific Application Guide for a list of allowable/unallowable costs for the particular program to which you are
applying.
If indirect costs are requested, a copy of the agency's fully-executed, negotiated Federal Rate Approval Agreement must be
attached to this application.
Indirect Cost Description
Approved Indirect Cost Rate
Per Indirect
Cost Subtotal
$
$
$
$
$
$
$
Indirect Cost Total: $
_______________
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
BUDGET SUMMARY
Instructions: Please review the category totals and the total project costs below. If the category totals and
project amounts shown are correct, please continue with the submission of your application. Should you
need to make revisions to a budget category, click the “Edit” button for that category.
Budget Category
Category Total
A.
Sworn Officer Positions
$ _______________. 00
B.
Civilian/Non-Sworn Personnel
$ _______________. 00
C.
Equipment/Technology
$ _______________. 00
D.
Supplies
$ _______________. 00
E.
Travel/Training
$ _______________. 00
F.
Contracts/Consultants
$ _______________. 00
G.
Other Costs
$ _______________. 00
H.
Indirect Costs
$ _______________. 00
Total Project Amount:
$ _______________. 00
Total Federal Share Amount:
(Total Project Amount X Federal Share Percentage Allowable)
$ _______________. 00
Total Local Share Amount (If applicable):
(Total Project Amount - Total Federal Share Amount)
$ _______________. 00
Edit
____%
____%
Contact Information for Budget Questions
Please provide contact information of the financial official that the COPS Office may contact with
questions related to your budget submission.
Authorized Official’s Typed Name: _____________________________________________________
Title:
__________________________________________________________________________
Phone:
___________________________________________________________________________
Fax:
____________________________________________________________________________
E-mail Address: ______________________________________________________________________
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
SECTION 15A: ASSURANCES
Several provisions of federal law and policy apply to all grant programs.
The Office of Community Oriented Policing Services needs to secure your
assurance that the applicant will comply with these provisions. If you would
like further information about any of these assurances, please contact your
state’s COPS Grant Program Specialist at 800.421.6770.
8.
By the applicant’s authorized representative’s signature, the applicant assures
that it will comply with all legal and administrative requirements that govern
the applicant for acceptance and use of federal grant funds. In particular, the
applicant assures us that:
1. It has been legally and officially authorized by the appropriate governing
body (for example, mayor or city council) to apply for this grant and
that the persons signing the application and these assurances on its
behalf are authorized to do so and to act on its behalf with respect to
any issues that may arise during processing of this application.
2. It will comply with the provisions of federal law, which limit certain
political activities of grantee employees whose principal employment
is in connection with an activity financed in whole or in part with
this grant. These restrictions are set forth in 5 U.S.C. § 1501, et seq.
3.
It will comply with the minimum wage and maximum hours provisions
of the Federal Fair Labor Standards Act, if applicable.
4.
It will establish safeguards, if it has not done so already, to prohibit
employees from using their positions for a purpose that is, or gives
the appearance of being, motivated by a desire for private gain for
themselves or others, particularly those with whom they have family,
business or other ties.
5.
It will give the Department of Justice or the Comptroller General access
to and the right to examine records and documents related to the grant.
6.
It will comply with all requirements imposed by the Department
of Justice as a condition or administrative requirement of the grant,
including but not limited to: the requirements of 28 CFR Part 66 and
28 CFR Part 70 (governing administrative requirements for grants and
cooperative agreements); 2 CFR Part 225 (OMB Circular A-87), 2 CFR
220 (OMB Circular A-21), 2 CFR Part 230 (OMB Circular A-122)
and 48 CFR Part 31.000, et seq. (FAR 31) (governing cost principles);
OMB Circular A-133 (governing audits) and other applicable OMB
circulars; the applicable provisions of the Omnibus Crime Control and
Safe Streets Act of 1968, as amended; 28 CFR Part 38.1; the current
edition of the COPS Grant Monitoring Standards and Guidelines; the
applicable COPS Grant Owner's Manuals; and with all other applicable
program requirements, laws, orders, regulations, or circulars.
7.
If applicable, it will, to the extent practicable and consistent with
applicable law, seek, recruit and hire qualified members of racial
and ethnic minority groups and qualified women in order to further
effective law enforcement by increasing their ranks within the sworn
positions in the agency.
It will not, on the ground of race, color, religion, national origin, gender,
disability or age, unlawfully exclude any person from participation
in, deny the benefits of or employment to any person, or subject any
person to discrimination in connection with any programs or activities
funded in whole or in part with federal funds. These civil rights
requirements are found in the non-discrimination provisions of the
Omnibus Crime Control and Safe Streets Act of 1968, as amended (42
U.S.C. § 3789d); Title VI of the Civil Rights Act of 1964, as amended
(42 U.S.C. § 2000d); the Indian Civil Rights Act (25 U.S.C. §§ 13011303); Section 504 of the Rehabilitation Act of 1973, as amended (29
U.S.C. § 794); Title II, Subtitle A of the Americans with Disabilities
Act (ADA) (42 U.S.C. § 12101, et seq.); the Age Discrimination Act
of 1975 (42 U.S.C. § 6101, et seq.); and Department of Justice NonDiscrimination Regulations contained in Title 28, Parts 35 and 42
(subparts C, D, E, G and I) of the Code of Federal Regulations.
A. In the event that any court or administrative agency makes a finding
of discrimination on grounds of race, color, religion, national origin,
gender, disability or age against the applicant after a due process
hearing, it agrees to forward a copy of the finding to the Office for Civil
Rights, Office of Justice Programs, 810 7th Street, NW, Washington,
D.C. 20531.
B. If your organization has received an award for $500,000 or more and
has 50 or more employees, then it has to prepare an Equal Employment
Opportunity Plan (EEOP) and submit it to the Office for Civil Rights
(“OCR”), Office of Justice Programs, 810 7th Street, N.W., Washington,
DC 20531, for review within 60 days of the notification of the award.
If your organization received an award between $25,000 and $500,000
and has 50 or more employees, your organization still has to prepare an
EEOP, but it does not have to submit the EEOP to OCR for review.
Instead, your organization has to maintain the EEOP on file and
make it available for review on request. In addition, your organization
has to complete Section B of the Certification Form and return it to
OCR. If your organization received an award for less than $25,000;
or if your organization has less than 50 employees, regardless of the
amount of the award; or if your organization is a medical institution,
educational institution, nonprofit organization or Indian tribe, then
your organization is exempt from the EEOP requirement. However,
your organization must complete Section A of the Certification Form
and return it to OCR.
9.
Pursuant to Department of Justice guidelines (June 18, 2002 Federal
Register (Volume 67, Number 117, pages 41455-41472)), under Title
VI of the Civil Rights Act of 1964, it will ensure meaningful access to
its programs and activities by persons with limited English proficiency.
10. It will ensure that any facilities under its ownership, lease or supervision
which shall be utilized in the accomplishment of the project are not
listed on the Environmental Protection Agency’s (EPA) list of Violating
Facilities and that it will notify us if advised by the EPA that a facility to
be used in this grant is under consideration for such listing by the EPA.
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
11. If the applicant’s state has established a review and comment
procedure under Executive Order 12372 and has selected this
program for review, it has made this application available for
review by the state Single Point of Contact.
12. It will submit all surveys, interview protocols, and other
information collections to the COPS Office for submission to
the Office of Management and Budget for clearance under the
Paperwork Reduction Act of 1995 if required.
13. It will comply with the Human Subjects Research Risk
Protections requirements of 28 CFR Part 46 if any part of
the funded project contains non-exempt research or statistical
activities which involve human subjects and also with 28 CFR
Part 22, requiring the safeguarding of individually identifiable
information collected from research participants.
14. Pursuant to Executive Order 13043, it will enforce on-the-job
seat belt policies and programs for employees when operating
agency-owned, rented or personally-owned vehicles.
15. It will not use COPS funds to supplant (replace) state, local, or
Bureau of Indian Affairs funds that otherwise would be made
available for the purposes of this grant, as applicable.
16. If the awarded grant contains a retention requirement, it will
retain the increased officer staffing level and/or the increased
officer redeployment level, as applicable, with state or local
funds for a minimum of 12 months following expiration of the
grant period.
17. It will not use any federal funding directly or indirectly to
influence in any manner a Member of Congress, a jurisdiction,
or an official of any government, to favor, adopt, or oppose,
by vote or otherwise, any legislation, law ratification, policy
or appropriation whether before or after the introduction of
any bill, measure, or resolution proposing such legislation, law,
ratification, policy or appropriation as set forth in the AntiLobby Act, 18 U.S.C. 1913.
18. In the event that a portion of grant reimbursements are seized
to pay off delinquent federal debts through the Treasury Offset
Program or other debt collection process, it agrees to increase
the non-federal share (or, if the awarded grant does not contain
a cost sharing requirement, contribute a non-federal share)
equal to the amount seized in order to fully implement the
grant project.
False statements or claims made in connection with COPS grants (including cooperative agreements) may result in fines,
imprisonment, disbarment from participating in federal grants or contracts, and/or any other remedy available by law.
I certify that the assurances provided are true and accurate to the best of my knowledge.
Elections or other selections of new officials will not relieve the grantee entity of its obligations under this grant.
______________________________________________________________
___________________________
Signature of Law Enforcement Executive/Agency Executive
Date
______________________________________________________________
______________________________
Signature of Government Executive/Financial Official
Date
Rev. 01/2010
e08097228
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
SECTION 15B: CERTIFICATIONS
Regarding Lobbying; Debarment, Suspension and Other Responsibility Matters; Drug-Free Workplace Requirements;
Coordination with Affected Agencies.
Although the Department of Justice has made every effort to simplify the application process, other provisions of federal law require us to seek
your agency’s certification regarding certain matters. Applicants should read the regulations cited below and the instructions for certification
included in the regulations to understand the requirements and whether they apply to a particular applicant. Signing this form complies with
certification requirements under 28 CFR Part 69, “New Restrictions on Lobbying,” 2 CFR Part 2867, “Nonprocurement Debarment and
Suspension” 28 CFR Part 83 Government-Wide Requirements for Drug-Free Workplace (Grants),” and the coordination requirements of the
Public Safety Partnership and Community Policing Act of 1994. The certifications shall be treated as a material representation of fact upon
which reliance will be placed when the Department of Justice determines to award the covered grant.
1. Lobbying
As required by Section 1352, Title 31 of the U.S. Code, and
implemented at 28 CFR Part 69, for persons entering into a grant or
cooperative agreement over $100,000, as defined at 28 CFR Part 69,
the applicant certifies that:
A. 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 any agency,
a member of Congress, an officer or employee of Congress, or
an employee of a member of Congress in connection with the
making of any federal grant; the entering into of any cooperative
agreement; and the extension, continuation, renewal, amendment
or modification of any federal grant or cooperative agreement;
B. 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 grant
or cooperative agreement, the undersigned shall complete
and submit Standard Form - LLL, “Disclosure of Lobbying
Activities,” in accordance with its instructions; and
C. The undersigned shall require that the language of this
certification be included in the award documents for all
subawards at all tiers (including subgrants, contracts under
grants and cooperative agreements, and subcontracts) and that
all sub-recipients shall certify and disclose accordingly.
2.
Debarment, Suspension and Other Responsibility Matters
(Direct Recipient)
As required by Executive Order 12549, Debarment and Suspension,
and implemented at 2 CFR Part 2867, for prospective participants in
primary covered transactions, as defined at 2 CFR Part 2867.20(a)A. The applicant certifies that it and its principals:
(i) Are not presently debarred, suspended, proposed for debarment,
declared ineligible, sentenced to a denial of federal benefits by
a state or federal court, or voluntarily excluded from covered
transactions by any federal department or agency;
(ii) Have not within a three-year period preceding this application
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) or private agreement or transaction;
violation of federal or state antitrust statutes or commission of
embezzlement, theft, forgery, bribery, falsification or destruction
of records, making false statements, tax evasion or receiving
stolen property, making false claims, or obstruction of justice, or
commission of any offense indicating a lack of business integrity
or business honesty that seriously and directly affects your
present responsibility;
(iii) 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 (A)
(ii) of this certification; and
(iv) Have not within a three-year period preceding this application
had one or more public transactions (federal, state or local)
terminated for cause or default.
B. Where the applicant is unable to certify to any of the statements
in this certification, he or she shall attach an explanation to this
application. Please check here if an explanation is attached
to this application.
3.
If applicable, an applicant who receives an award in excess of
$5,000,000 certifies that, to the best of its knowledge and belief,
the applicant has filed all Federal tax returns required during the
three years preceding the certification, has not been convicted of
a criminal offense under the Internal Revenue Code of 1986, and
has not, more than 90 days prior to certification, been notified
of any unpaid Federal tax assessment for which the liability
remains unsatisfied, unless the assessment is the subject of an
installment agreement or offer in compromise that has been
approved by the Internal Revenue Service and is not in default,
or the assessment is the subject of a non-frivolous administrative
or judicial proceeding.
4.
Drug-Free Workplace (Grantees Other Than Individuals)
As required by the Drug-Free Workplace Act of 1988, and
implemented at 28 CFR Part 83, for grantees/recipients, as defined
at 28 CFR Part 83.660 A. The applicant certifies that it will, or will continue to, provide a
drug- free workplace by:
(i) 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;
(ii) Establishing an on-going drug-free awareness program to inform
employees about (a) The dangers of drug abuse in the workplace;
(b) The grantee’s policy of maintaining a drug-free workplace;
(c) Any available drug counseling, rehabilitation and employee
assistance programs; and
(d) The penalties that may be imposed upon employees for
drug-abuse violations occurring in the workplace;
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
(iii) 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 (i);
(iv) Notifying the employee in the statement required by paragraph
(i) that, as a condition of employment under the grant, the
employee will (a) Abide by the terms of the statement; and
(b) 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;
(v) Notifying the agency, in writing, within 10 calendar days after
receiving notice under subparagraph (iv)(b) from an employee or
otherwise receiving actual notice of such conviction. Employers
of convicted employees must provide notice, including position
title, to: COPS Office, 1100 Vermont Ave., NW, Washington,
D.C. 20530. Notice shall include the identification number(s)
of each affected grant;
(vi) Taking one of the following actions, within 30 calendar days of
receiving notice under subparagraph (iv)(b), with respect to any
employee who is so convicted (a) 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
(b) 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;
(vii) Making a good faith effort to continue to maintain a drug-free
workplace through implementation of paragraphs (i), (ii), (iii),
(iv), (v), and (vi).
Grantee Agency Name and Address:
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)
_______________________________________________
_______________________________________________
Check if there are workplaces on file that are not identified here.
5.
Coordination
The Public Safety Partnership and Community Policing Act of
1994 requires applicants to certify that there has been appropriate
coordination with all agencies that may be affected by the applicant’s
grant proposal if approved. Affected agencies may include, among
others, the Office of the United States Attorney, state or local
prosecutors, or correctional agencies. The applicant certifies that there
has been appropriate coordination with all affected agencies.
Grantee Agency Name and Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Grantee IRS/ Vendor Number: ______________________________
False statements or claims made in connection with COPS grants (including cooperative agreements) may result in
fines, imprisonment, disbarment from participating in federal grants or contracts, and/or any other remedy available
by law.
I certify that the assurances provided are true and accurate to the best of my knowledge.
Elections or other selections of new officials will not relieve the grantee entity of its obligations under this grant.
Typed Name and Title of Law Enforcement Executive/Agency Executive:
______________________________________________________________________________________
Signature: _______________________________________________________ Date: ________________
Typed Name and Title of Government Executive/Financial Official:
Signature: ________________________________________________________ Date: ________________
Rev. 01/2010
e08097228
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
SECTION 16: Disclosure of Lobbying Activities
Instructions for Completion of SF-LLL, Disclosure of Lobbying Activities
This disclosure form shall be completed by the reporting entity, whether subawardee or prime federal recipient,
at the initiation or receipt of a covered federal action, or a material change to a previous filing, pursuant to title 31
U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying
entity 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 a covered federal
action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing
guidance published by the Office of Management and Budget for additional information.
1. Identify the type of covered federal action for which
lobbying activity is and/or has been secured to influence
the outcome of a covered federal action.
2. Identify the status of the covered federal action.
3. Identify the appropriate classification of this report. If
this is a follow-up report caused by a material change to
the information previously reported, enter the year and
quarter in which the change occurred. Enter the date of
the last previously submitted report by this reporting
entity for this covered federal action.
4. Enter the full name, address, city, state and zip code
of the reporting entity. Include Congressional District
number, if known. Check the appropriate classification
of the reporting entity that designates if it is, or expects
to be, a prime or subaward recipient. Identify the tier of
the subawardee, e.g., the first subawardee of the prime
is the 1st tier. Subawards include but are not limited
to subcontracts, subgrants and contract awards under
grants.
5. If the organization filing the report in item 4 checks
"Subawardee," then enter the full name, address, city,
state and zip code of the prime federal recipient.
Include Congressional District, if known.
6. Enter the name of the federal agency making the
award or loan commitment. Include at least one
organizational level below agency name, if known. For
example, Department of Transportation, United States
Coast Guard.
7. Enter the federal program name or description for the
covered federal action (item 1). If known, enter the full
Catalog of federal Domestic Assistance (CFDA) number
for grants, cooperative agreements, loans and loan
commitments.
8. Enter the most appropriate federal identifying
number available for the federal action identified
in item 1 (e.g., Request for Proposal (RFP) number;
Invitation for Bid (IFB) number; grant announcement
number; the contract, grant, or loan award number; the
application/proposal control number assigned by the
federal agency). Include prefixes, e.g., "RFPD E-90-001."
9. For a covered federal action where there has been an
award or loan commitment by the federal agency, enter
the federal amount of the award/loan commitment for
the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city, state and zip
code of the lobbying entity engaged by the reporting
registrant identified in item 4 to influence the covered
federal action.
(b) Enter the full name(s) of the individual(s) performing
services, and include full address if different from 10 (a).
Enter Last Name, First Name, and Middle Initial (MI).
11. The certifying official shall sign and date the form,
print his/her name, title and telephone number.
Public reporting burden for this collection of information
is estimated to average 30 minutes per response, including
time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information.
Send comments regarding the burden estimate or any
other aspect of this collection of information, including
suggestions for reducing this burden, to the Office of
Management and Budget, Paperwork Reduction Project
(0348-0046), Washington, D.C. 20503.
37
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
Disclosure of Lobbying Activities
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352.
Not Applicable ___
1. Type of Federal Action: _____________
2. Status of Federal Action: _____
3. Report Type: _____
a. contract
a. bid/offer/application
a. initial filing
b. grant
b. initial award
b. material change
c. cooperative agreement
c. post-award
For Material Change Only:
d. loan
Year: __________
e. loan guarantee
Quarter: _______
Date of last report _______
f. loan insurance
4. Name and Address of Reporting Entity:
Prime Subawardee
Tier _____, if known:
5. If Reporting Entity in No. 4 is Subawardee, Enter
Name and Address of Prime:
Congressional District (number), if known: _____
Congressional District (number), if known: _____
6. Federal Department/Agency:
7. Federal Program Name/Description:
CFDA Number, if applicable: _______________
8. Federal Action Number, if known:
9. Award Amount, if known:
$
10. a. Name and Address of Lobbying Registrant
(if individual, last name, first name, MI):
10. b. Individuals Performing Services
(including address if different from No.10a)
(last name, first name, MI):
11. Information requested through this form is
authorized by Title 31 U.S.C. Section 1352. This
disclosure of lobbying activities is a material
representation of fact upon which reliance was
placed by the tier above when this transaction was
made or entered into. This disclosure is required
pursuant to 31 U.S.C. 1352. This information will be
reported to the Congress semi-annually and will be
available for public inspection. Any person who fails
to file the required disclosure shall be subject to a
civil penalty of not less than $10,000 and not more
than $100,000 for each such failure.
Signature: ____________________________________
Federal Use Only:
Authorized for Local Reproduction, Standard Form - LLL
38
Print Name: __________________________________
Title: ________________________________________
Telephone No.: ___________________ Date: ______
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
SECTION 17: CERTIFICATION OF REVIEW AND REPRESENTATION OF
COMPLIANCE WITH REQUIREMENTS
Certification of Review of 28 C.F.R. Part 23/Criminal Intelligence Systems
Please review the COPS Application Guide: Legal Requirements Section for additional information.
Please check one of the following, as applicable to your agency’s intended use of
this grant:
□ No, my agency will not use these COPS grant funds (if awarded) to operate
an interjurisdictional criminal intelligence system.
□ Yes, my agency will use these COPS grant funds (if awarded) to operate an
interjurisdictional criminal intelligence system. By signing below, we assure that our
agency will comply with the requirements of 28 C.F.R. Part 23.
The signatures of the Law Enforcement Executive/Agency Executive and Government
Executive/Financial Official on the Certification of Review and Representation of Compliance with
Requirements:
1) Assures the COPS Office that the applicant will comply with all legal, administrative, and
programmatic requirements that govern the applicant for acceptance and use of federal funds as outlined
in the applicable COPS Application Guide; AND
2) Attests to the accuracy of the information submitted with this application (including the Budget Detail
Worksheets).
The signatures on this application must be made by the actual executives named on this application
unless there is an officially documented authorization for a delegated signature. If your jurisdiction has
such an official document, it must be attached to this application. Applications with missing, incomplete,
or inaccurate signatories or responses may not be considered for funding.
Signatures shall be treated as a material representation of fact upon which reliance will be placed when
the Department of Justice determines to award the covered grant.
Please be advised that a hold may be placed on this application if it is deemed that the applicant agency is
not in compliance with federal civil rights laws, and/or is not cooperating with an ongoing federal civil
rights investigation, and/or is not cooperating with a COPS Office compliance investigation concerning a
current grant award.
Person Submitting this Application
□ By clicking this box and typing my name below, I certify that I have been legally and officially
authorized by the appropriate governing body to submit this application and act on behalf of the
grant applicant entity. I certify that I have read, understand, and agree, if awarded, to abide by all
of the applicable grant compliance terms and conditions as outlined in the COPS Application
Guide, the COPS Grant Owner’s Manual, assurances, certifications and all other applicable
program regulations, laws, orders, or circulars. In addition, I certify that the information provided
on this form and any attached forms is true and accurate to the best of my knowledge. I
understand that false statements or claims made in connection with COPS programs may result in
fines, imprisonment, debarment from participating in federal grants, cooperative agreements, or
contracts, and/or any other remedy available by law to the federal government.
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
Please type your name here in place of your signature:
______________________________________________
Law Enforcement Executive/Agency Executive
□ By clicking this box and typing my name below, I certify that I have been legally and officially
authorized by the appropriate governing body to submit this application and act on behalf of the
grant applicant entity. I certify that I have read, understand, and agree, if awarded, to abide by all
of the applicable grant compliance terms and conditions as outlined in the COPS Application
Guide, the COPS Grant Owner’s Manual, assurances, certifications and all other applicable
program regulations, laws, orders, or circulars. In addition, I certify that the information provided
on this form and any attached forms is true and accurate to the best of my knowledge. I
understand that false statements or claims made in connection with COPS programs may result in
fines, imprisonment, debarment from participating in federal grants, cooperative agreements, or
contracts, and/or any other remedy available by law to the federal government.
Please type your name here in place of your signature:
_______________________________________________
Government Executive/Financial Official
□ By clicking this box and typing my name below, I certify that I have been legally and officially
authorized by the appropriate governing body to submit this application and act on behalf of the
grant applicant entity. I certify that I have read, understand, and agree, if awarded, to abide by all
of the applicable grant compliance terms and conditions as outlined in the COPS Application
Guide, the COPS Grant Owner’s Manual, assurances, certifications and all other applicable
program regulations, laws, orders, or circulars. In addition, I certify that the information provided
on this form and any attached forms is true and accurate to the best of my knowledge. I
understand that false statements or claims made in connection with COPS programs may result in
fines, imprisonment, debarment from participating in federal grants, cooperative agreements, or
contracts, and/or any other remedy available by law to the federal government.
Please type your name here in place of your signature:
______________________________________________
ONLINE NOTE: The only electronic signature submitted online with this application will be the
individual registered with the user name and password. However, the signatures of both the Law
Enforcement Executive/Agency Executive and the Government Executive/Financial Official are
REQUIRED for Sections 14, 15 and 17 of this application. Original, signed hard copies of the
Certification of Review and Representation of Compliance with Requirements, Assurances, and
Certifications must be kept in the agency's files and furnished upon request.
□ By clicking this box, I have read and understand this requirement.
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
SECTION 18: COPS HIRING PROGRAM (CHP)
Amendment of COPS Hiring Recovery Program (CHRP) Application Certifications
Part I
I have read, understand and agree to the following:
the information my agency provides on this form is an official amendment to our original CHRP
application, and supersedes our original program request;
my agency’s CHRP application will be considered for funding in FY10 under the COPS Hiring
Program (CHP);
any new elections or other selections of new officials since the original application does
not relieve my agency of its obligations under its 2010 CHP grant;
I received the Application Update Letter sent to my agency dated <>, and certify
that the items specified by the COPS Office as needing review and/or update have been
thoroughly reviewed by my agency, and are accurate.
Typed Name of Person Completing this Form
Date Completed
Part II
I have read, understand and agree to the following:
I am authorized by the appropriate governing body to act on behalf of the grant applicant entity in
submitting this application amendment;
my agency’s representations on this form are subject to all the statements and signatures
in our original CHRP application.
my agency’s request for CHRP sworn officer positions has been updated as reflected above;
if my agency receives a CHP grant, we are required to use grant funds for the specific hiring
category(s) awarded; and
if after receiving the CHP grant, my agency needs to change the hiring category(s) it received
funding under, we will request a post-award grant modification so that the COPS Office may
accurately track the numbers of officers funded in each category.
Typed Name of Person Completing this Form
Date Completed
In order for your agency to be considered for CHP grant funding, all application updates must be submitted
through the COPS website (www.cops.usdoj.gov) by <> E.D.T. on <>. For technical
assistance with submitting your updates, please call the COPS Office Response Center at 800.421.6770.
If your agency no longer wishes to be considered for funding and wants to withdraw its application from
consideration, please call the COPS Office Response Center at 800.421.6770.
Submit
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
Paperwork Reduction Act Notice
The public reporting burden for this collection of information is estimated to be up to 11 hours per response, depending
upon the COPS program being applied for, which includes time for and reviewing instructions. Send comments regarding
this burden estimate or any other aspects of the collection of this information, including suggestions for reducing this
burden, to the Office of Community Oriented Policing Services, U.S. Department of Justice, 1100 Vermont Avenue, N.W.,
Washington, DC 20530; and to the Public Use Reports Project, Office of Information and Regulatory Affairs, Office of
Management and Budget, Washington, DC 20503.
You are not required to respond to this collection of information unless it displays a valid OMB control number.
The OMB control number for this application is 1103-0098 and the expiration date is MM/DD/YYYY.
ORI#:_________________________________________________________________________________________________________________ Standard Application Forms
FOR MORE INFORMATION:
U.S. Department of Justice
Office of Community Oriented Policing Services
1100 Vermont Avenue, N.W.
Washington, DC 20530
To obtain details on COPS programs, call the
COPS Office Response Center at 800.421.6770
Visit COPS Online at www.cops.usdoj.gov.
e011011250
Revised Date: April 2010
| File Type | application/pdf |
| File Modified | 2010-04-16 |
| File Created | 2010-04-16 |