Impaired Driving Adjudication Court Application

SECTION A: General Information. This section must be completed for all applicants.
Name of Tribe:
Address
City:						State:		Zip:
Telephone Number:						Fax Number:
Name of Person Completing Application:								Title:
E-mail Address:
Number where you can be reached for questions regarding the application:
Tribal agency applying for this grant:
If grant is awarded, please identify the Project Director or person who will be responsible for the grant administration.
Name:					Title:			Phone:
E-mail Address:
How many years has your Tribe received funding for the project you are proposing?
Has the Tribe applied for and received other traffic safety related grants from other agencies in the last 3 years?
If yes, please list the agencies:
Is there another traffic safety (focused) grant currently in place? (i.e. CDC, Indian Health, State, college, etc)
If yes, please list the funding agency or agencies:
Reservation Size:				Acres				Square Miles
Reservation Population:						Total Number of Road Miles:
Total number of Police Officers:					Total number of officers who work traffic:
Name of Chief of Police:							Contact Number:
Can your Tribal law enforcement agency conduct checkpoints?							Is your Enforcement:
Do you have cross commission agreements with any other law enforcement agencies?
Are the other agencies able to arrest and appear in your court on DUI/DWI/OWI arrests?
(A narrative section is is included on the last page for you to add any information you feel that would make this application stronger)
SECTION B: Data. This section must be filled out completely for all project applications.
ONLY Fiscal Year (October 1 - September 30) data will be accepted.
Data is the cornerstone of all highway safety related problems. It allows you to demonstrate the extent of the problem. In order to apply for a grant utilizing highway safety funds, you must provide a data breakdown utilizing the most recent data available for your reservation.
Does your Tribe capture crash and/or citation data electronically?
If yes, what system is used to capture this data?
Are Tribal DUI/DWI/OWI arrest data and court adjudication data linked?
If yes, how or what program is used to link the data?
What is the last year of completed data that you have available?							What is the Tribe's BAC law?
Is the data:			Year
	Total number of crashes:				(Each incident is counted as 1 crash regardless of number of vehicles involved)
	Total number of fatal crashes:				(each incident is counted as 1 crash regardless of number of vehicles involved)
	Total number of injury crashes:				Total number of property damage only crashes:
	Of the total number of crashes, how many were single vehicle crashes?
	Of the total number of crashes, how many involved 2 or more vehicles?
	Total number of crashes that involved alcohol:
	Total number of fatal crashes that involved alcohol:
	Total number of people killed:					Males:		Females:
	Of those killed, how many were not wearing seat belts:
	Of those killed, how many drivers were impaired (.08 or more BAC)
	Of those injured, how many were:						Males		Females
	Total number of crashes that involved pedestrians:
	Total number of pedestrians killed:
	Total number of intoxicated pedestrians involved in crashes:
	Total number of crashes that involved motorcycles:
	Total number of motorcyclists killed:
	Total number of un-helmeted motorcyclist fatalities:
Does the Tribe have a Seat Belt Law?					If Yes, is it:
Does the Tribe have a formal traffic code:
Total number of traffic citations issued in the data year being reported:
	Total number of DUI/DWI/OWI arrests?
Does the Tribe have a DUI Court?					What is the conviction rate for DUI's in the Tribal Courts?
SECTION C. Targets/Performance Measures/Strategies: This section must be completed for all project applications.
The Indian Highway Safety Program (IHSP) is a performance-based program. In order to apply for a grant, you must provide information on the targets/performance measures you are trying to reach. Select ONLY those that are appropriate to the traffic safety problem you are trying to address.
TARGETS:
To reduce the number of motor vehicle crashes involving alcohol by							from the		(year) number of
	to		by the end of FY2013	of FY2015
To decrease the average BAC in impaired drivers from						in		(year) to		by the end
of FY2015.
OTHER - PLEASE SPECIFY
To reduce the number of					by		from the		(year) number of
	to		by the end of FY2015.
To increase the number of					by		from the		(year) number of
	to		by the end of FY2015.
In order to reach the target(s) that have been identified above, select from the following list of performance measures that you will do during the project year.
PERFORMANCE MEASURES:
Increase the number of DUI/DWI/OWI arrest adjudicated from							to		in FY2015.
Increase the number of DUI/DWI/OWI convictions from						to		in FY2015.
Increase the number of cases filed by the Tribal Prosecutor from							to		in FY2015.
Decrease the number of DUI/DWI/OWI dismissals by						from		to		in FY2015.
Decrease adjudication time from the average of						days	to		days	in FY2015.
Increase the number of first offenders referred to							by		from
to		in FY2015.
OTHER:
OTHER:
STRATEGIES:
Please provide information on your work plan:
SECTION D: Training. This section must be completed for any training that is requested or needed in order to properly execute the grant being requested.
Training can a vital part to any project/program. Training, in order to qualify for funding, must be applicable to the project or enhance the project that is being proposed. If the application for funding is approved, approved training will be listed in the project grant agreement.
						Number Needing			Number Currently
Name of Training						Training			Trained
SECTION E: Equipment. This section must be completed for any type of equipment being requested to carry out the grant being applied for. Please note: The federal guidelines require equipment to be necessary for the project. All equipment requested must be approved by the BIA IHSP and must be used specifically for the project.
Equipment, if requested must be essential to the success of this project and not for general purposes or general use. Please identify equipment and how it is vital to this project.
		Number	Justification
Type		Requested
If you are requesting the purchase of specialty software, please identify the software and it purpose and anticipated use.
Name of Software:
Use:
Name of Software:
Use:
Name of Software:
Use:
SECTION F: BUDGET. This section must be completed for all project applications. Please only complete those sections that are pertinent to the project being requested.
Budgets must support the project that is being proposed. Please be as accurate and reasonable as possible when filling out the budget section. Federal guidelines for these grants require that costs be reasonable and necessary in order to carry out and/or operate the grant. Budgets should be completed by the finance office for the Tribe.
Name of Finance Officer completing this section:
E-mail Address:								Phone :
Personnel, including fringe benefits: Include all personnel, program role, percentage of time each will work on this project, base salary and fringe. *Amounts entered will automatically calculate based on base, percentage of time and estimated fringe. If approved fringe will be paid based on documented actual rates.
Personnel Title		Role in Project		% of Time	Hourly Salary	# of Hours	Sub-total	Fringe	Line Total
							$0.00		$0.00
							$0.00		$0.00
							$0.00		$0.00
							$0.00		$0.00
							$0.00		$0.00
							$0.00		$0.00
							$0.00		$0.00
TOTALS									$0.00
Indirect costs up to 20% can be applied to salary, OT salaries and fringe benefits, If the Tribe has a rate lower than 20%, that rate will be applied if the application is accepted for funding.
Actual Rate		Actual will be calculated up to 20%						TOTAL:	$0.00
Training: List all costs associated with each type of training identified above.
			Cost/Fee	Number					Line
Type/name of Training			Per Person	of People					Totals
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
TOTALS									$0.00
Travel: List all costs associated with travel. These costs may include: airfare, registration, hotel, per diem, mileage, parking, and other travel related items.
			Number of		Approx. cost				Line
Purpose			People		per Person				Totals
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
TOTALS									$0.00
Equipment: Please list the cost for each piece of equipment identified.
Equipment			# requested		Cost (each)				Line Total
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
									$0.00
Totals:									$0.00
Supplies: Please list all supplies that will be needed in order to successfully carry out the grant.
Item		Cost	Quantity	Purpose						Line Total
										$0.00
										$0.00
										$0.00
										$0.00
										$0.00
										$0.00
										$0.00
										$0.00
TOTALS:										$0.00
Personnel			$0.00
Travel			$0.00
Training			$0.00
Equipment			$0.00
Supplies			$0.00
Indirect Costs			$0.00
Other
TOTAL		$0.00
SECTION G: ADDITIONAL INFORMATION. Please add additional information here that may not be covered in the application above.
SECTION H: TERMS, CONDITIONS AND RESPONSIBILITIES. Please read and initial to acknowledge each of the items listed. Applications received without initials to acknowledge this section will be considered incomplete and will not be considered for funding.
	Requests for reimbursements and a written narrative report must be submitted to the BIA IHSP monthly.
	Tribe understands this program is a Reimbursable Grant program. Tribe use expend its funds and seek reimbursement based on an approved budget and application.
	A copy of the Tribe's most recent Indirect Cost Letter must be sent to the BIA IHSP in order to claim ID Costs.
	Tribe must participate in the national enforcement mobilizations and the "Indian State" mobilization.
	All travel must be approved in advance by the BIA IHSP.
	Any equipment purchased must be used for the project applied for.
	A current approved Tribal Resolution must be attached. If not attached, it must be received if project is
	selected for funding.
	In order to comply with the provisions of MAP-21, and the required State Certifications and Assurances, the BIA IHSP will allocate funds on behalf of the Tribes to meet certain conditions and comply with all applicable rules and regulations for administering a traffic safety program.
	Tribes participating in the federal grant processes must comply with the Single Audit Act of 1984.
	If requesting full time personnel, 100% of the employee's time must be spent on the project.
I,					do hereby state and affirm:
I have authority to submit this application on behalf of the Tribal government named herein. I further understand and affirm that I have obtained all necessary approvals, and have discussed this application with the necessary and appropriate people. I understand by submitting this application, I am hereby electronically signing my name.
Name							Date Submitted:
Title:
			APPLICATION CHECKLIST
Please use the checklist below to ensure that your application is complete and ready to submit.
Have you included a current Tribal Resolution?
Have you attached the latest copy of your Tribe's Indirect Cost Rate?
Is the application signed in the appropriate place?
Have all Conditions been checked and initialed?
Has someone from the budget office looked at or approved the proposed budget?