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Equitable Sharing
Agreement and
Certification
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OMB Number 1123-0011
Expires9-30-2014
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Police Department ~ Sheriff's Office ~ Task Force(Complete Table A)
0Prosecutor's Office ~ National Guard Counterdrug Unit
0Other
*Please fill each required field. Hover mouse over any fillable field for pop-up instructions.
Agency Name:
NCIC/ORI/Tracking Number:
Mailing Address:
City:
State:
Finance Contact: First:
Last:
E-mail:
Phone:
Preparers
Last:
First:
❑Same as
Finance Contact
Zip:
E-mail:
Phone:
Independent Public Accountant:
E-mail:
Agency Current FY Budget:
Last FY End Date:
O New Participant:
Read the Equitable Sharing Agreement and sign the Affidavit.
O Existing Participant:
Complete the Annual Certification Report, read the Equitable Sharing Agreement, and sign
the Affidavit.
O Amended Form:
Revise the Annual Certification Report, read the Equitable Sharing Agreement, and sign
the Affidavit.
Annual Certification Report
Summary of Eauitable Sharing Activity
Justice Funds'
Treasury Fundsz
~
Beginning Equitable Sharing Fund Balance (must match
Ending Equitable Sharing Fund Balance from prior FY)
2
Federal Sharing Funds Received
3
Federal Sharing Funds Received from Other Law Enforcement
Agencies and Task Forces (To populate, complete Table B)
4
Other Income
5
Interest Income Accrued
6
Total Equitable Sharing Funds (total of lines 1 - 5)
$0.00
$0.00
7
Federal Sharing Funds Spent (total oflines a - m below)
$0.00
$0.00
8
Ending Balance (difference between line 7 and line 6)
$0.00
$0.00
Non-Interest Bearing
Interest Bearing
Justice Agencies are: FBI, DEA, ATF, USPIS, USDA, DCIS, DSS, and FDA.
Z Treasury Agencies are: IRS, ICE, CBP, TTB, USSS, and USCG.
Page 1 of 5
July 2012
Version 2.1
Justice Funds
Summary of Shared Funds Snent
a
Total spent on salaries under permitted salary exceptions
b
Total spent on overtime
c
Total spent on informants,"buy money",and rewards
d
Total spent on travel and training
e
Total spent on communications and computers
f
Total spent on weapons and protective gear
g
Total spent on electronic surveillance equipment
h
Total spent on buildings and improvements
~
Total transfers to other participating state and local law
enforcement agencies(To populate, complete Table C)
~
Total spent on other law enforcement expenses(To populate,
complete Table D)
k
Treasury Funds
Total Expenditures in Support of Community-Based Programs
(To populate, complete Table E)
Total Windfall Transfers (To populate, complete Table F)
m
Total spent on matching grants (To populate, complete
Table G)
n
o
Total
$0.00
$0.00
Did your agency receive non-cash assets? ~ Yes ~ No If yes, complete Table H.
Please fill out the following tables, if applicable.
Table A: Members of Task Force
NCIC/ORI/Tracking Number
Agency Name
Table B: Equitable Sharing Funds Received from other Agencies
Transferring Agency Name,Gty,and State
justice Tunas
i reasury Tunas
Justice Funds
Treasury Funds
agency Name:
~CIC/ORI/Tracking Number:
Table C: Equitable Sharing Funds Transferred to Other Agencies
Receiving Agency Name, City, and State
agency Name:
VCIC/ORI/Tracking Number:
Page 2 of 5
July 2012
Version 2.1
Table D: Other Law Enforcement Expenses
Justice Funds
Description of Expense
Treasury Funds
Table E: Expenditures in Support of Community-Based Programs
Justice Funds
Recipient
Table F: Windfall Transfers
Recipient
Justice Funds
Treasury Funds
Justice Funds
Treasury Funds
Table G: Matching Grants
Matching Grant Name
Table H: Other Non-Cash Assets Received
Source
Description of Asset
Justice
Treasury
Table I: Civil Rights Cases
Name of Case
Race
Type of Discrimination Alleqed
~ National ~ Gender
~ Color
Origin
Disability ~ Age
~ Other
Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information
unless it displays a valid OMB control number. We try to create accurate and easily understood forms
that impose the least possible burden on you to complete. The estimated average time to complete this
form is 30 minutes. If you have comments regarding the accuracy of this estimate, or suggestions for
making this form simpler, please write to the Asset Forfeiture and Money Laundering Section,
1400 New York Avenue, N.W., Washington, DC 20005.
Page 3 of 5
July 2012
Version 2.1
Equitable Sharing Agreement
This Federal Equitable Sharing Agreement, entered into among (1)the Federal Government,(2) the above-stated law
enforcement agency("Agency"),and (3) the governing body, sets forth the requirements for participation in the
federal Equitable Sharing Program and the restrictions upon the use of federally forfeited cash, property, proceeds,
and any interest earned thereon, which are equitably shared with participating law enforcement agencies.
By its signatures, the Agency agrees that it will be bound by the statutes and guidelines that regulate shared assets
and the following requirements for participation in the federal Equitable Sharing Program. Receipt of the signed
Equitable Sharing Agreement and Certification (this "Document") is a prerequisite to receiving any equitably shared
cash, property, or proceeds.
1. Submission. This Document must be submitted to [email protected] within 60 days of the end of the
Agency's fiscal year. This Document must be submitted electronically with the Affidavit/Signature submitted by fax.
This will constitute submission to the Department of Justice and the Department of the Treasury.
2. Signatories. This agreement must be signed by the head of the Agency and the head of the governing body.
Examples of Agency heads include police chief, sheriff, director, commissioner,superintendent, administrator,
chairperson, secretary, city attorney, county attorney, district attorney, prosecuting attorney, state attorney,
commonwealth attorney, and attorney general, The governing body's head is the person who allocates funds or
approves the budget for the Agency. Examples of governing body heads include city manager, mayor, city council
chairperson, county executive, county council chairperson, director, secretary, administrator, commissioner, and
governor.
3. Uses. Any shared asset shall be used for law enforcement purposes in accordance with the statutes and guidelines
that govern the federal Equitable Sharing Program as set forth in the current edition of the Department of Justice's
Guide to Equitable Sharing forState and Local Law Enforcement(Justice Guide), and the Department of the Treasury's
Guide to Equitable Sharing for Foreign Countries and Federal, State, and Local Law EnforcementAgencies (Treasury
Guide).
4. Transfers. Before the Agency transfers cash, property, or proceeds to other state or local law enforcement
agencies, it must first verify with the Department of Justice or the Department of the Treasury, depending on the
source of the funds, that the receiving agency is a current and compliant Equitable Sharing Program participant.
5. Internal Controls. The Agency agrees to account separately for federal equitable sharing funds received from the
Department of Justice and the Department of the Treasury. Funds from state and local forfeitures and other sources
must not be commingled with federal equitable sharing funds. The Agency shall establish a separate revenue
account or accounting code for state, local, Department of Justice, and Department of the Treasury forfeiture funds.
Interest income generated must be accounted for in the appropriate federal equitable sharing account.
The Agency agrees that such accounting will be subject to the standard accounting requirements and practices
employed for other public funds as supplemented by requirements set forth in the current edition of the Justice Guide
and the Treasury Guide, including the requirement in the Justice Guide to maintain relevant documents and records for
five years.
The misuse or misapplication of shared resources or the supplantation of existing resources with shared assets is
prohibited. Failure to comply with any provision of this agreement shall subject the recipient agency to the sanctions
stipulated in the current edition of the Justice orTreasuryGuides,depending on the source of the funds/property.
6. Audit Report. Audits will be conducted as provided by the Single Audit Act Amendments of 1996 and OMB
Circular A-133. The Department of Justice and Department of the Treasury reserve the right to conduct periodic
random audits.
Page 4 of 5
July 2012
Version 2.1
Affidavit
Under penalty of perjury, the undersigned officials certify that they have read and understand their obligations under
the Equitable Sharing Agreement and that the information submitted in conjunction with this Document is an accurate
accounting of funds received and spent by the Agency under the Justice and/or TreasuryGuides during the reporting
period and that the recipient Agency is in compliance with the National Code of Professional Conduct for Asset Forfeiture.
The undersigned certify that the recipient Agency is in compliance with the nondiscrimination requirements of the
following laws and their Department of Justice implementing regulations: Title VI of the Civil Rights Act of 1964(42 U.S.C.
§ 2000d etseq.), Title IX of the Education Amendments of 1972(20 U.S.C. § 1681 eTseq.), Section 504 of the Rehabilitation
Act of 1973(29 U.S.C. § 794), and the Age Discrimination Act of 1975 (42 U.S.C. § 6101 eTseq.), which prohibit
discrimination on the basis of race, color, national origin, disability, or age in any federally assisted program or activity, or
on the basis of sex in any federally assisted education program or activity. The Agency agrees that it will comply with all
federal statutes and regulations permitting federal investigators access to records and any other sources of information as
may be necessary to determine compliance with civil rights and other applicable statutes and regulations.
During the past fiscal year: (1) has any court or administrative agency issued any finding,
judgment,or determination that the Agency discriminated against any person or group in
violation of any of the federal civil rights statutes listed above;or(2) has the Agency entered
into any settlement agreement with respect to any complaint filed with a court or
administrative agency alleging that the Agency discriminated against any person or group in
violation of any of the federal civil rights statutes listed above? 0
Yes Q NO
If you answered yes to the above question, complete Table
Agency Head
Governing Body Head
Signature:
Signature:
Name:
Name:
Title:
Title:
Date:
Date:
E-mail:
E-mail:
Subscribe to Equitable Sharing Wire:
The Equitable Sharing Wire is an electronic newsletter that
gives you important, substantive, information regarding
Equitable Sharing policies, practices, and procedures.
Final Instructions:
Step 1: Click to save for your records
Step 2: Click to save in XML format
Save as PDF
Save as XML
Step 3: E-mail the XML file to [email protected]
Step 4: Fax THIS SIGNED PAGE ONLY to (202)616-1344
FOR AGENCY USE ONLY
Entered by
Entered on
p FY End:
~ NCIC:
O
State:
Agency:
Phone:
Finance Contact:
E-mail:
Page # of ##
July 2012
version z.~
| File Type | application/pdf |
| Author | scanuser ( CRM ) |
| File Modified | 2012-07-11 |
| File Created | 2012-06-28 |