COPS Standard Extension Worksheet

U.S. Department of Justice

Office of Community Oriented Policing Services (COPS)

COPS Extension Request Form OMB Approval Number: 1103-0093

Expiration Date: 05/31/2009

The following COPS [grant program type] grant/cooperative agreement is currently set to expire on mm/dd/yyyy:

ORI #: [Full-time Officers Awarded: ##] Project Start Date: mm/dd/yyyy

Grant #: [Part-time Officers Awarded: ##] Original Project End Date: mm/dd/yyyy

[Supplement #: #] Federal Funds Awarded: $$$$$

SECTION I: This extension request form will allow your agency the opportunity to request a “no-cost” time extension in order to complete the federal funding period and requirements for the grant/cooperative agreement award listed above. Requesting and/or receiving a time extension will not provide additional funding. Please read the enclosed “Frequently Asked Questions” document for more information on extending your grant/cooperative agreement.

A. Please select the option below that best meets your agency’s needs:

[NOTE: If the extension request you indicate below (or a combination of the current request and a previously approved extension for this award) exceeds [18] months from the original end date of this grant, you are required to complete Section II on the following page(s).] Months this award has already been extended: [0]

(OMB Note: options will vary according to program—some programs may need to complete section II earlier than others.)

O An extension is NOT needed; we will complete the grant/cooperative agreement by the current end date.

O [A 6-month extension is needed. (You are [not] required to complete Section II.)]

O [A 12-month extension is needed. (You are [not] required to complete Section II.)]

O [An 18-month extension. (You are [not] required to complete Section II.)]

O [For requests of more than 18 months, provide a new end date: __/__/____ (You are required to complete Section II.)]

Please check the reason(s) below that best describe why this extension is being requested (check all that apply):

O Hiring delays (initial hiring delays, extended vacancies, lack of qualified candidates, scheduled academy, etc.).

O Equipment delays (procurement, requests for proposals, installation difficulties, testing/training, not fully operational, etc.).

O Administrative delays (change in executives/administration, delay in accepting award, environmental assessments, etc.).

O Delays in implementing applied research project.

O Other (please explain):_______________________________________________________________________________

B.

/ /

Printed Name of Requester Title of Requester Signature of Requester Date Signed

C. Indicate any change to the agency information listed below (Chief, Sheriff, Program Official, phone number, etc.).

4. Return this request to us via fax at (202) [XXX-XXXX] or mail the completed form(s) to COPS at the address listed below:

U.S. Department of Justice, COPS Office

1100 Vermont Avenue, N.W.

Washington, DC 20530 [20005 if using an overnight carrier]

Attn: [Program Team] Control Desk

C urrent Agency Information Listed in COPS Files: Changes to COPS Current Agency Information:

[Law Enforcement Executive]: [Law Enforcement Executive]:

Legal Name: Legal Name:

Address 1: Address 1:

Address 2: Address 2:

City/State/Zip: City/State/Zip:

Phone #: Phone #:

Fax #: Fax #:

OMB Approval Number: 1103-0093

COPS Extension Worksheet Legal Name:

ORI#: Grant Number:

Page 2 [Supplement # #]

SECTION II: JUSTIFICATION FOR AMOUNT OF TIME REQUESTED

(OMB Note: Section II is sent to grantees that request more than a set amount of time as defined by the choice they select under Section I A . Hiring grantees that are required to fill out Section II will complete Section II A and the first section B that is on this page. COPS grantees with other types of grants will be required to fill out Section II A and the second section B that is on the next page. Grantees will only receive the Section B appropriate to their grant. The form is only two pages in length.)

If the amount of time you requested in Section I indicated that you must complete Section II, please respond to the questions below. Please respond as thoroughly and completely as possible. Failure to answer all questions thoroughly could delay processing of your extension request, or result in your request being denied.

1. Please use the space below to explain the specific issues or problems that have caused delays in the implementation and/or completion of this grant/cooperative agreement. Additionally, please explain how your agency intends to address the delay(s) in order to complete this grant/project.

______________________________________________________________________________________________________­­­­­

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

B.

For each position under this specific grant that has not yet completed the full 36 months of federal funding, you are required to provide us with the information requested below. Be sure to include any positions that have never been filled under this grant. Use the format below for your response.

Step 1: Indicate the type of position (full or part-time) for which 36 months of funding has not yet been expended.

Step 2: In the “Total Months Under Grant” column, indicate the total amount of time, in months, that the position has been filled from the grant award start date to present. If multiple officers have held a COPS-funded position due to turnover, please determine the cumulative number of months for all officers that have been employed in that position, and then indicate that total amount of time as a single figure.

Step 3: Indicate if the position listed is currently filled.

Step 4: If a position is currently vacant, please provide us with an expected hire date.

Step 5: Repeat steps 1-4 as needed for each additional position under this grant that has not utilized 36 months of funding.

Type of Position Total Months Under Grant Position Currently Filled? Expected Hire Date*

Example: Full-Time 24 Yes N/A

Part-Time 10 No 10/1/06

Your Agency:

____________ _____ _____ ____________

____________ _____ _____ ____________

____________ _____ _____ ____________

____________ _____ _____ ____________

Paperwork Reduction Act Notice: A person is not required to respond to a collection of information unless it displays a valid OMB control number. The public reporting burden for this collection of information is estimated to be up to one half-hour per response, depending upon the COPS program being extended, which includes time for 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 COPS Office; and to the Public Use Reports Project, Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

If additional space is needed to answer the questions below, please continue your response on department letterhead.

Reminder: If you do not intend to fill a position in the near future, you may wish to consider a grant modification or withdrawal to eliminate that position. Additionally, your agency is entitled to a maximum of 36 months of grant funding for each position awarded. At the conclusion of this period, your agency must implement the retention period for each awarded position using local funds.

OMB Approval Number:

COPS Extension Worksheet Legal Name:

ORI#: Grant Number:

Page 2 [Supplement # #]

B.

In the space below, please provide a new timeline that reflects when your agency plans to complete any steps or phases of the project that are not currently finished. This timeline should be in a monthly format, and indicate up to the newly requested end date what tasks your agency will be working on. During months in which you anticipate no activity taking place, please indicate that as well.

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Paperwork Reduction Act Notice: A person is not required to respond to a collection of information unless it displays a valid OMB control number. The public reporting burden for this collection of information is estimated to be up to one half-hour per response, depending upon the COPS program being extended, which includes time for 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 COPS Office; and to the Public Use Reports Project, Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.