COPS Application Attachment to the SF-424

COPS
Application
Attachment
to SF-424

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Standard Application Forms

COPS Application Attachment to SF-424

OMB Control Number: 1103-0098
Expiration Date: 2/29/2008

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. Please DO NOT use this form to
apply for multiple programs at one time. A separate application must be completed for each COPS program
for which you are applying. Please ensure that you have 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

Tribal Resources Grant Program
Secure Our Schools
Methamphetamine Initiative

Technology Program
Community Policing Development
Program XX

Program XX
Program XX

SECTION 2: EXECUTIVE INFORMATION
Note: Listing individuals without ultimate programmatic and financial authority for the grant could delay the review of
your application, or remove your application from consideration.
A. Applicant ORI Number:

__ __ __ __ __ __ __

The ORI number is assigned by the FBI and is your agency's unique identifier. The first two letters are your state
abbreviation, the next three numbers are your county's code, and the final 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.

 Check here if your agency has not been assigned an ORI number.
B. Law Enforcement Executive/Program Official Information:
For Law Enforcement Agencies: Enter the law enforcement executive’s name and contact information. This is the
highest ranking law enforcement official within your jurisdiction (e.g. Chief of Police, Sheriff, or equivalent). For NonLaw Enforcement Agencies: Enter the program official’s name and contact information. If the grant is awarded,
this position would be responsible for the programmatic implementation of the award. If your agency is a “start-up”
this section can remain blank.
Title:
First Name:
MI:
Agency Name:
Street Address 1:
Street Address 2:
City:
Telephone:

E-mail:

Last Name:

State:
Fax:

Suffix:

Zip Code:

Type of Agency:
 Municipal  State  County Police Department  Sheriff*  Tribal  Transit*  School*
 Consortium*  University/College* ( Public or  Private)  Public Housing*
 New Start-Up* (please specify):__________________  Non-profit Organization  Profit Organization
 Other* (please specify):________________________
*Agency types that have an asterisk next to them and that are applying for COPS hiring grants must provide additional information.
Please refer to the COPS Application Guide: "Agency Supplemental Information" section for the questions that you will need to
address. Please attach this information to your application.

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C. Government Executive/Financial Official Information:

For Government Agencies: Enter the government executive’s name and contact information. This is the highest ranking
official within your jurisdiction (e.g. Mayor, City Administrator, Tribal Chairman, or equivalent). For Non-Government
Agencies: Enter the financial official’s name and contact information. If the grant is awarded, this position would be
responsible for the financial management of the award. Please note that information for non-executive positions (e.g.
clerk, trustees, etc., are not acceptable).

Title:
First Name:
MI:
Agency Name:
Street Address 1:
Street Address 2:
City:
Telephone:

E-mail:

Last Name:

State:
Fax:

Suffix:

Zip Code:

Type of Government Entity:
 State  City  Town  County  Village  Borough  Township  Territory
 Region  Council  Community  Pueblo  Tribal Nation  School District
 Not applicable. Please check here if applying as a non-law enforcement agency (e.g., non-profit agency)

SECTION 3: GENERAL AGENCY
INFORMATION
A. General Applicant Information
1. Cognizant Federal Agency: _______________________________________
Enter the legal applicant's Cognizant Federal Agency. A Cognizant Federal Agency, generally, is the federal agency
from which your jurisdiction receives the most federal funding. Your Cognizant Federal Agency also may have been
previously designated by the Office of Management and Budget.

2. Fiscal Year: _ _/_ _ /_ _ _ _ to _ _/_ _ /_ _ _ _ (mo/day/yr)
Enter the legal applicant's fiscal year.

3. Population served as of the 2000 U.S. Census: ________________
4. If the population served is not represented by U.S. Census figures (e.g., colleges, special
agencies, school police departments, MSAs, etc.) please indicate the size of the population
served: _________________________________________________________________

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B. Law Enforcement Agency Information
1. Is your agency contracting for law enforcement services?
This question is not applicable to hiring grant programs.

 Yes No
If "yes," the Legal Name and address information listed on the SF-424 under section 8 (Applicant Information) should
be for the jurisdiction that will be contracting to receive law enforcement services, and NOT the law enforcement agency
that will actually provide those services. Also, be sure to enter the name and agency information of the contract law
enforcement department under section 2, part B (law enforcement executive information) of this document. In all
contracting arrangements, the jurisdiction that is applying for assistance is ultimately responsible for ensuring compliance
with all grant requirements. For additional clarification on contracting guidelines, please see the program-specific
section of the COPS Application Guide.

If you are a tribal law enforcement agency, instead of providing your own law enforcement services,
does your tribe exclusively contract with a non-BIA local law enforcement agency for services?
 Yes  No
If "yes," please refer to the program-specific section of the COPS Application Guide for additional eligibility
information.
2. Population Served By Law Enforcement Agency
Do officers have primary law enforcement authority for the population to be served?
 Yes  No

An agency with primary law enforcement authority is defined as the first responder to calls for service, and has ultimate
and final responsibility for the prevention, detection, and/or investigation of criminal laws within its jurisdiction.

If "yes," what is the actual population for which your department has primary law enforcement authority?
[In other words, the 2000 Census population minus the incorporated towns and cities that have their own
police departments.] ________________
If "no," please explain. Include the date by which your agency anticipates having primary law enforcement
authority for this population. [Please limit your response to a maximum of 250 words.]

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3. Current Budgeted Sworn Force Strength as of the Date of this Application:
Full-time:____________

Part-time:____________

Enter the budgeted sworn force strength. The budgeted sworn force strength is the number of sworn officer positions your
department has allocated for its budget, including state, Bureau of Indian Affairs, and locally-funded vacancies. Do not
include unpaid/reserve officers, or detention staff.

4. Current Actual Sworn Force Strength as of the Date of this Application:
Full-time:____________

Part-time:____________

Enter the actual sworn force strength. The actual sworn force strength is the actual number of sworn officer positions
employed by your department as of the date of application. Do not include vacant positions or unpaid/reserve positions.

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SECTION 4: 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 problem-solving 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:
Collaborative partnerships between
the law enforcement agency and
the individuals and organizations
they serve to both develop
solutions to problems and increase
trust in police.
•
•
•
•
•

Other Government Agencies
Community Members/Groups
Non-Profits / Service Providers
Private Businesses
Media

Organizational Transformation:
The alignment of organizational
management, structure, personnel
and information systems to support
community partnerships and proactive
problem-solving efforts.
Agency Management
• Climate and culture
• Leadership
• Labor relations
• Decision-making
• Strategic planning
• Policies
• Organizational evaluations
• Transparency
Organizational Structure
• Geographic assignment of officers
• Despecialization
• Resources and finances

Problem Solving:
The process of engaging in
the proactive and systematic
examination of identified problems
to develop effective responses that
are rigorously evaluated.
• Scanning: Identifying and
prioritizing problems
• Analysis: Analyzing problems
• Response: Responding to
problems
• Assessment: Assessing
problem-solving initiatives
• Using the Crime Triangle to
focus on immediate conditions
(Victim/Offender/Location)

Personnel
• Recruitment, hiring and selection
• Personnel supervision/evaluations
• Training
Information Systems (Technology)
• Communication/access to data
• Quality and accuracy of data

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COMMUNITY POLICING PLAN
COPS grants must be used to initiate or enhance community policing. Please complete the following
questions to describe the types of community policing activities that will be initiated or enhanced as a result
of COPS funding. You may find more detailed information about community policing at the COPS Office
web site (www.cops.usdoj.gov).

Community Partnerships
The COPS Office is interested in determining if your organization will use the grant to assist in increasing
the capacity to develop collaborative partnerships with individual and organizational stakeholders in
communities to increase trust and to develop shared solutions to community problems.
If awarded funding, my organization will implement or enhance:
P1- Sharing of relevant crime and disorder information with community members.
 Yes No  Not Sure
P2-Seeking input from the community to identify and prioritize neighborhood problems.
 Yes No  Not Sure
P3-Engagment with the community in the development of responses to community problems.
 Yes No  Not Sure
P4-Collaboration with other agencies that deliver public services (e.g., parks and recreation, social services,
public health, mental health, code enforcement).
 Yes No  Not Sure
Please provide specific examples of the types of activities you plan to engage in to enhance community
partnerships if awarded grant funding (150 word maximum):

Problem Solving
The COPS Office is interested in determining if your organization will use the grant to assist in increasing
the capacity to use 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 problemsolving 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.
If awarded funding, my organization will implement or enhance:
PS1-Integration of problem solving into patrol work.
 Yes No  Not Sure

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PS2-Identification and prioritization of crime and disorder problems by examining patterns and trends
involving repeat victims, offenders, and locations.
 Yes No  Not Sure
PS3-Exploring the underlying factors and conditions that contribute to crime and disorder problems.
 Yes No  Not Sure
PS4-Developing tailored responses to crime and disorder problems that address the underlying conditions
that contribute to them.
 Yes No  Not Sure
Please provide specific examples of the types of activities you plan to engage in to enhance problemsolving activities if awarded grant funding (150 word maximum):

Organizational Transformation
The COPS Office is interested in determining if your organization will use the grant to assist in increasing
the capacity to transform organizational environment, organizational structure, personnel, practices, and
policies to support the community policing philosophy and community policing activities.
If awarded funding, my organization will implement or enhance:
OC1-Institutionalization of organizational changes that support the implementation of community policing
strategies.
 Yes No  Not Sure
OC2-Incorporation of community policing principles into the agency’s mission/vision statement and strategic
plan.
 Yes No  Not Sure
OC3-Institutionalization of community policing principles into a corresponding set of policies, practices and
procedures.
 Yes No  Not Sure
OC4-Institutionalization of community policing agency-wide.
 Yes No  Not Sure
Please provide specific examples of the types of activities you plan to engage in to enhance organizational
alignment towards community policing if awarded grant funding (150 word maximum):

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Technology
The COPS Office is interested in determining if your organization will use the grant to assist in increasing
technological capacity to better prevent and/or respond to crime and disorder incidents.
If awarded funding, my organization will implement or enhance:
T1- Ensuring that agency staff have proper access to relevant data (e.g., calls for service, incident and
arrest data, etc.).
 Yes No  Not Sure
T2- Analysis and understanding of problems in the community.
 Yes No  Not Sure
T3- Improvements to the agency’s overall efficiency and effectiveness.
 Yes No  Not Sure
T4- Providing officers with necessary equipment to better prevent and/or respond to crime and disorder
incidents.
 Yes No  Not Sure
Please provide specific examples of the types of activities you plan to engage in to enhance alignment of
technology towards community policing if awarded grant funding (150 word maximum):

If your organization receives this COPS grant funding, it should use your responses to these
questions as your organization’s community policing plan. Your organization may be audited or
monitored to ensure that it is initiating or enhancing community policing in accordance with this
plan.
We understand that your community policing needs may change during the life of your COPS grant
(if awarded), and we welcome minor changes to this plan without prior approval. 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.

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SECTION 5: CONTINUATION OF PROJECT
AFTER FEDERAL FUNDING ENDS
Retention for COPS Hiring Grants
This section is applicable to COPS applicants applying for sworn officer positions. In FYXXX, this
section is not applicable to any COPS applicants.

 Check here if not applying for a hiring grant
Hiring grantees are required to retain all additional officer positions awarded for at least one full local budget
cycle following the expiration of COPS grant funding for each COPS-funded officer position. The additional
officer positions should be added to your agency's law enforcement budget with state, local, or tribal funds for
at least one full local budget cycle, over and above all other locally-funded officer positions (including other
school resource officers) that would have existed regardless of the grant, from the time that the thirty-six (36)
months of grant funding for each COPS position expires. Absorbing COPS-funded officers through attrition
(rather than adding the extra positions to your budget with additional funding) does not meet the retention
requirement. Please be aware that if your agency has additional sworn officer hiring grants that are active
when one hiring grant expires, the officer positions that were awarded under the expired grant are added to
your baseline of locally-funded officer positions and must be maintained throughout the implementation of all
additional hiring grants.
Use the space below to explain how your agency currently plans to retain any additional officer positions
awarded. Please be as specific as possible about the source(s) of retention funding (General Fund revenues,
local ballot item, etc.) your agency plans to utilize. A missing or incomplete response could affect your ability
to receive funding.

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SECTION 6: NEED FOR FEDERAL
ASSISTANCE
All applicants are required to provide a brief explanation of their agency's public safety needs and an
explanation of their agency's inability to implement this project and/or address these public safety
needs without federal assistance.
In the space below, please provide a brief explanation of your agency's inability to implement this project
without federal assistance. [Please limit your response to a maximum of 250 words.]

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SECTION 7: WAIVERS OF THE LOCAL
MATCH
Please refer to the Application Guide for information on whether waivers of the local match, when
applicable, are available under the grant program for which you are applying.

 Check here if not applicable
Are you requesting a waiver of the local match based upon severe fiscal distress?
 Yes  No
If requesting a waiver, you will be required to attach a detailed waiver justification to your application. Please refer to the
COPS Application Guide - "Waiver of the Local Match" section for information on what to include in your justification, as
well as the program-specific portion of the Guide to review the local match requirements.

SECTION 8: EXECUTIVE SUMMARY
This section is applicable to COPS applicants applying under the COPS Methamphetamine Initiative,
Secure Our Schools, Technology Program, and Community Policing Development Programs.

 Check here if not applicable
Please attach to your application a brief summary of how your agency will use this federal funding. Be sure
to include a description of how you expect this grant to impact public safety and/or crime prevention in your
community. Please refer to the COPS Application Guide for clarification on specific information to include in
your summary. 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. [Please limit your response to a
maximum of 400 words.]

SECTION 9: PROJECT DESCRIPTION
(NARRATIVE)
This section is applicable to COPS applicants applying for all COPS programs in FYXXX.

 Check here if not applicable
Please attach to 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.

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SECTION 10: BUDGET NARRATIVE
(EXCLUDING SWORN OFFICER
POSITIONS)
This section is applicable to COPS applicants applying under Community Policing Development
Programs, the Methamphetamine Initiative, Secure Our Schools, the Tribal Resources Grant Program,
and the Technology Program.

 Check here if not applicable
In the Budget Narrative, you must attach a brief description of each item proposed for purchase, its purpose,
and how the items relate to the overall project. Like items may be grouped together for ease of reporting.
The structure of the Budget Narrative must mirror the structure of the Budget Detail Worksheet included in this
application. In other words, each item reported in the Budget Narrative must fall under one of the following
budget categories: Civilian/Other Personnel, Equipment/Technology, Other Costs, Supplies, Travel/Training,
Contracts/Consultants, and Indirect Costs. For your information, a sample Budget Narrative and a sample
Budget Detail Worksheet are included in the COPS Application Guide. Every item included on the Budget
Detail Worksheet must be included in the Budget Narrative.
Note that allowable/unallowable costs will vary widely between different COPS grant programs and cooperative
agreements. Please ensure that you refer to the program-specific portion of the COPS Application Guide "Federal Funding: Allowable & Unallowable Costs" section for a complete list of the allowable and unallowable
costs associated with the particular program for which you are applying. Including unallowable items on
your application may delay the processing of your application and could ultimately result in the denial of your
request.

SECTION 11: MEMORANDUM OF
UNDERSTANDING
This section is applicable to COPS applicants applying under XXX.

 Check here if not applicable
Please attach a Memorandum of Understanding (MOU) to your application that defines the roles and
responsibilities of the individuals and partner(s) involved in your proposed project. Please refer to the programspecific portion of the Guide for a complete description of information pertaining to the required MOU.

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SECTION 12: OFFICIAL PARTNER(S)
CONTACT INFORMATION
This section is applicable to COPS applicants applying under XXX.

 Check here if not applicable
An official "partner" under the grant may be a governmental or private 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 refer to the Application Guide for a complete description of
partnership requirements under the grant program for which you are applying.
Please attach additional partner information pages to your application, if necessary.
Title:
First Name:

MI:

Last Name:

Suffix:

Name of Partner Agency (e.g., School District):
Type of Partner Agency (e.g., School District):
Street Address 1:
Street Address 2:
City:

Telephone:

State:

Zip Code:
Fax:

E-mail:
Title:
First Name:

MI:

Last Name:

Suffix:

Name of Partner Agency (e.g., School District):
Type of Partner Agency (e.g., School District):
Street Address 1:
Street Address 2:
City:

Telephone:

State:

Zip Code:
Fax:

E-mail:

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Title:
First Name:

MI:

Last Name:

Suffix:

Name of Partner Agency (e.g., School District):
Type of Partner Agency (e.g., School District):
Street Address 1:
Street Address 2:
City:

Telephone:

State:

Zip Code:
Fax:

E-mail:
Title:
First Name:

MI:

Last Name:

Suffix:

Name of Partner Agency (e.g., School District):
Type of Partner Agency (e.g., School District):
Street Address 1:
Street Address 2:
City:

Telephone:
E-mail:

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State:

Zip Code:
Fax:

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SECTION 13: INCIDENT DATA
Incident data is required for the <>, <>, and <> grant programs. The
data reported should cover the time period of <> to <> and should only include incidents
that took place at <>. Please refer to the program guide for specific information and
instructions regarding the data required for this submission.

□ Check here if not applicable.
Type of Incident

# of Incidents Reported

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

School Data

Totals

Truancy
Detentions

Suspensions

Expulsions

Threats to School Property
# of Schools Involved in Project

Total Student Population for Involved Schools

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SECTION 14: CERTIFICATION OF
REVIEW AND REPRESENTATION OF
COMPLIANCE WITH REQUIREMENTS
Certification of Review of 28 C.F.R. Part 23/Criminal Intelligence Systems
You must answer this question regardless of the type of COPS grant you are applying for. 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/Program Official and Government Executive/Financial
Official, and any applicable program partners 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 the reverse side of this page 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 signatures or responses may not be considered for funding. Stamped or electronic signatures
(unless applying online via Grants.gov) also will not be accepted. Original signatures are required. Faxed
copies will not be accepted. Applications postmarked after the final application deadline date 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.
By signing on the reverse side of this page, 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. 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.

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Law Enforcement Executive/Program Official's Signature:
_______________________________________________
(Signature of person named in Section 2 of this form)

Date: ______________

Government Executive/Financial Official's Signature:
_______________________________________________
(Signature of person named in Section 2 of this form)

Date: ______________

Official Partner(s) Signature:
_______________________________________________ Date: ______________
(Signature of person(s) named in Section 12 of this form, if applicable)
_______________________________________________ Date: ______________
(Signature of person(s) named in Section 12 of this form, if applicable)
_______________________________________________ Date: ______________
(Signature of person(s) named in Section 12 of this form, if applicable)
_______________________________________________ Date: ______________
(Signature of person(s) named in Section 12 of this form, if applicable)

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SECTION 15: ASSURANCES
Several provisions of federal law and policy apply to all grant programs. We (the Office of Community Oriented Policing Services) need 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.
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, or the Federal Acquisition Regulations, as applicable (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; 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.
8. 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. § 3789(d)); Title
VI of the Civil Rights Act of 1964, as amended (42 U.S.C. § 2000d); the

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Indian Civil Rights Act (25 U.S.C. §§ 1301-1303); 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 Non-Discrimination Regulations
contained in Title 28, Parts 35 and 42 (subparts C, D, E and G) 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 of Civil Rights, Office of Justice Programs, 810 7th Street, NW,
Washington, D.C. 20531.
B. Grantees that have 50 or more employees and grants over
$500,000 (or over $1,000,000 in grants over an eighteen-month
period), must submit an acceptable Equal Employment Opportunity
Plan ("EEOP") or EEOP short form (if grantee is required to submit an
EEOP under 28 CFR 42.302), that is approved by the Office of Justice
Programs, Office for Civil Rights within 60 days of the award start
date. For grants under $500,000, but over $25,000, or for grantees
with fewer than 50 employees, the grantee must submit an EEOP
Certification. (Grantees of less than $25,000 are not subject to the
EEOP requirement.)
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.
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.

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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.

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 Anti-Lobby Act, 18 U.S.C. 1913.

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.

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.

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.

I certify that the assurances provided are true and accurate to the best
of my knowledge.

16. 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
Elections or other selections of new officials will not relieve the grantee entity of its obligations under this grant.
_______________________________________________
Signature of Official with Programmatic Authority (or Law
Enforcement Executive, as applicable)
_______________________________________________
Signature of Official with Financial Authority (or Government
Executive, as applicable)

_______________________
Date
_______________________
Date

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Standard Application Forms

ORI #: ­­

SECTION 16: 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," 28 CFR Part 67, "Government-Wide Debarment and Suspension (Nonprocurement),” 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;
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 28 CFR Part 67, for prospective participants in
primary covered transactions, as defined at 28 CFR Part 67, Section
67.440 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;

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(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; and
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.
3. 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, as defined at 28 CFR Part 83,
Sections 83 and 83.510 A. The applicant certifies that it will, or will continue to, provide a drugfree 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 -

Standard Application Forms
(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 drugabuse violations occurring in the workplace;
(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).
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.
4. 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 (or Official with Programmatic Authority, as applicable):
________________________________________________________________________________
Signature: ______________________________________________ Date: ____________________
Typed Name and Title of Government Executive (or Official with Financial Authority, as applicable): ____________________________________
____________________________________________
Signature: _______________________________________________ Date: ___________________

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Standard Application Forms

PAPERWORK REDUCTION ACT NOTICE
The public reporting burden for this collection of information is estimated to be up to 10 average hours per
response, depending upon the COPS program being applied for, including time for searching existing data
sources, gathering the data needed, and completing and reviewing the application. 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, D.C. 20530; and to the Public Use Reports Project, Office of Information
and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 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 2/29/2008.

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