COPS Extension Request Form

^Date: XX/XX/20XX

COPS Extension Request Form

OMB Approval Number: 1103- 0093

^{The following COPS award is currently set to expire on:} XX/XX/20XX

^SECTION I:

^{This extension request form will allow your agency the opportunity to request a “no-cost” time extension in order to complete} the project activities under the award listed above. Requesting and/or receiving a time extension will not provide additional funding nor does it approve programmatic or budget modifications.

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

Note: Non-Hiring grants: must complete Sections: IA, IB, IIA and IIB

Hiring grants: must complete Sections: IA, IB, IIA and IIC

A 6-month extension is needed.

A 12-month extension is needed.

A 18-month extension is needed.

Other, provide a new end date below:

New requested end date: 00/00/0000

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

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

Equipment delays (procurement, requests for proposals, installation difficulties, testing/training, not fully operational, etc.). Administrative delays (change in executives/administration, delay in accepting award, environmental assessments, etc.). Delays in implementing applied research project.

Other (please explain):

Title

Title of Requester

Name

Printed Name of Requester

[Email Address of Requester]

00/00/0000

Date Signed

OMB Approval Number: 1103-0093 ORI#:

COPS Extension Request Form Page 2

Legal Name:

Grant Number:

SECTION II: JUSTIFICATION FOR AMOUNT OF TIME REQUESTED

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.

P a p e r w o r k Reduction A c t Notice: T h e public reporting b u r d e n f o r this collection of information is estimated t o b e u p t o one h a l f - h o u r p e r 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 a n d R e g u l a t o r y Affairs, Office o f M a n a g e m e n t a n d B u d g e t, Washington, D. C. 2 0 5 0 3.

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 award. Additionally, please explain how your agency intends to address the delay(s) in order to complete this grant/project.

OMB Approval Number: 1103-0093 ORI#:

COPS Extension Request Form Page 3

Legal Name:

Grant Number:

SECTION II: JUSTIFICATION FOR AMOUNT OF TIME REQUESTED (Non-Hiring Grants Only)

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 time line should be in a monthly and/or quarterly 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.

Example

Jan. 20XX – Mar. 20XX: State Activity

April 20XX – June 20XX: State Activity

July 20XX – September 20XX: State Activity

October 20XX – December 20XX: State Activity

OMB Approval Number: 1103-0093 ORI#:

COPS Extension Request Form

Page 4

Legal Name:

Grant Number:

SECTION II: JUSTIFICATION FOR AMOUNT OF TIME REQUESTED (Hiring Grants Only)

3. For each full-time position under this grant, you are required to provide the information outlined below. Use the format below for your response.

Step 1: In the “Total Months Completed 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 the total amount of time as a single

figure.

Step 2: Indicate if the position listed is currently filled.

Step 3: If a position is currently vacant, please provide us with an expected hire date.

Step 4: Repeat steps 1-4 as needed for all COPS funded positions under this grant.

Type of Position (Sworn)

Total Months Completed Under Grant

Positions Currently Filled(Y/N)

If Position is not Filled, Expected Hire Date