Law Enforcement Grant Application

Indian Highway Safety Grants

Law Enforcement Grant Application & Instructions

Law Enforcement Grant Application

OMB: 1076-0190

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OMB Control. No. 1076-0190
Expiration Date XX/XX/XX

Instructions for Completion of
Bureau of Indian Affairs
Indian Highway Safety Program
Law Enforcement Grant Application

The Highway Safety Act of 1966, U.S.C. Title 23, Section 402, provides U.S. Department of
Transportation funding to assist Indian tribes in implementing traffic safety projects. These
projects are designed to reduce the high number of traffic crashes, motor vehicle crash fatalities,
injuries and property damage within Indian Country. These 402 funds are intended to
supplement an existing traffic safety program on the reservation.
The Bureau of Indian Affairs (BIA) Office of Justice Services (OJS) Indian Highway Safety
Program (IHSP) offers data driven performance based grant opportunities. Tribes can apply for
straight time or overtime hour law enforcement grants with this application; use the drop down
menu to select the grant the Tribe is interested in applying for. A traffic safety problem must be
identified; all applications must contain measurable targets/performance measures, and be
justified by confirm-able data. Insufficient data to justify a traffic safety problem will
significantly reduce the possibility of funding for the tribe. Complete the application in its
entirety; do not leave any blank spaces/fields.
IHSP grants are funded in the form of reimbursements. Tribes must first expend their funds and
submit documentation for reconciliation and reimbursement each month. Monthly report and
financial reports (requests for reimbursement) are required. A Tribal Resolution and the Tribe’s
most current approved Indirect Cost Rate Agreement letter must be submitted with the
application. Please contact the IHSP at (505)563-3139 to inquire about BIA IHSP Grant Writing
Training.
Grant applications are due by May 1 of the current year for the next fiscal year award. Grant
applications and attachments can be e-mailed to [email protected] or
submitted by mail to:
Bureau of Indian Affairs
Office of Justice Services
Indian Highway Safety Program
1001 Indian School Road NW, Suite 251
Albuquerque, New Mexico 87104

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Indian Highway Safety Law Enforcement
Grant Application Instructions

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APPLICATION CHECKLIST
Use the checklist to gather documents required for submission of the grant application. Initial the
Terms, Conditions, Responsibilities, sign and date page 13. Attach Tribal Resolution (Draft or
Final), and the Tribe’s most recent approved Indirect Cost Rate Letter. Check the box if the Tribes
A-133 Audit is current. Attach a Linear Trend Analysis for each target/performance measure with
the grant application. Sign the Application Check List and save all attachments as a PDF file.
GRANT TYPE:
Place a check next to the type of grant the Tribe is interested in applying for: Straight Time Hours
Grant, Overtime Hours Grant, or Highway Safety Specialist Grant.
Straight-time Hours:
Highway Safety Specialist Grant
Overtime Hours:
•
•
•
•
•
•
•
•

Traffic Officer Activity Hours
Overtime Hours
Fringe Benefits
GSA Lease/Mileage
Training
Travel
Indirect Cost Rate
Equipment

•

Media & Bill Board Rental

•
•
•
•
•
•
•
•

Overtime Hours
Fringe Benefits
Mileage
Training
Travel
Indirect Cost Rate
Equipment
Media & Bill Board Rental

•
•
•
•
•
•
•
•
•

Salary
Overtime Hours
Fringe Benefits
GSA Lease/Mileage
Training
Travel
Indirect Cost Rate
Equipment
Media & Bill Board Rental

FISCAL GRANT YEAR:
Indicate the grant year the application is being submitted for.
Example: Federal grant year cycle for FY26 begins on October 1, 2025 - September 30, 2026
SECTION A: General Information
Tribes Information:
Provide the Name of the Tribe, Tribal Leaders Name, Title, Phone and Fax Number, Mailing
Address, Tribes DUNS Number, Unique Entity Identifier (UEI) and SAM’s Cage Code for
the federally recognized tribe applying for grant funding.
Person completing the form:
Provide the Name, Title, Office/Department, Phone and Fax Number along with an E-Mail
Address of the person completing the application. If any questions arise on the application the
BIA IHSP will contact the person listed.
Tribal Grant Coordinator:
Provide the Name, Title, E-Mail Address, Office/Department, Address, Phone and Fax Number
of the person completing the application. The Tribal Grant Coordinator is the person
responsible for grant administration and the main point of contact for the grant.
Grant History:
Indicate if the Tribe has received federal funding from the BIA IHSP, other federal agencies,
and/or state(s) focused in traffic safety.
Reservation Information:
Complete all the fields with information regarding population, reservation acres, square miles,
and total road miles.
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Tribal Police Department Information:
Provide the Name of the Chief of Police, Phone and Fax Number, E-Mail Address, Address.
Enter the number of police officers in the department, and how many work traffic. Place a
check in the box if officers have the authority to conduct checkpoints. Place a check in the box
if officers have cross commissions with law enforcement agencies and list them.
SECTION B: Data.
Traffic Data Information:
Check the appropriate box indicating if the Tribe utilizes a software system to collect traffic
enforcement & crash statistics. If so, identify the type of software.
Place a check in the appropriate box in regards to reporting crashes or other traffic data to the
states. Provide the last fiscal year of traffic data available (Fiscal Year runs from October 1 to
September 30). Place a check in the appropriate box for calendar year or fiscal year.
Tribal Statutes and Enforcement Statistics:
Placing a check in the “no” box to questions in this category does not disqualify the Tribe from
receiving a grant.
Check yes or no if the Tribe:
•
•
•
•
•

has a traffic code.
has an impaired driving law. If yes identify the B.A.C. level (0.08 or 0.10).
has a seat belt law. If yes, check the box indicating if it is a primary or secondary law.
issues written warning for traffic violations. If yes, provide the total number issued the
previous year.
prosecutes Driving Under the Influence (DUI’s) arrests/cases. If yes, provide the
conviction rate.

Traffic Statistics:
ONLY Fiscal Year (October 1 – September 30) data will be accepted. Insufficient data will
significantly reduce chance of funding. Use most recent fiscal year data available for traffic
statistics in the table provided. Statistics must come from a confirm-able source. Tribal, State
and local sources can be utilized and should be subjective to the reservation not general
overall to the area if possible.
Example: If the tribe is applying for an FY2026 grant use data from FY2024 (October 1,
2023 - September 30, 2024.
List the type of roads, the day of the week, and time crashes occurred. This information
will assist in determining what day and time the most crashes occurred.
SECTION C: Targets, Performance Measures and Strategies
Problem Statement:
Providing a problem statement is essential in determining if a Tribe will receive an Indian
Highway Safety Grant. Confirmable data is required to support the statement. Identify the
specific traffic related problems the Tribe is experiencing on the reservation. Use three years
of traffic data along with data from page 4 to assist in identifying the traffic problem(s).
Three years of data can be used to strengthen the problem statement for a specific traffic
problem to show it exists.
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Example:
“The ___________ Tribe has identified speeding as a major traffic problem on the
reservation roadways. In FY22 there were 230 speeding citations issued and in FY23 there
were 200 citations issued and in FY24 199 citations were issued by the Tribal Police
Department.
By indicating the number of speeding citations, warnings, speed related motor vehicle crash
fatalities and crashes tribal police officers responded to in the previous fiscal years
strengthens the problem statement and shows a speeding problem exists.
Targets (Performance Measures):
Strategies:
Check appropriate strategy boxes which will assist in combating the traffic safety problem(s)
identified in the problem statement and targets. Select the appropriate strategies the Tribe will
use to achieve their targets. Provide the number of checkpoints and/or saturation patrols the tribe
will conduct during the grant year. Provide the total number of traffic enforcement hours tribal
officers will work during the 3 mandatory mobilizations scheduled during the grant year.
Survey (B-1):
If the Tribe has conducted an observed seat belt use for passenger vehicles, front seat outboard
occupants check “Yes”. If they would like to conduct one check “Yes”.
Strategies Statement:
Question to help develop the Strategies Statement:
Explain how does the Tribal Police Department plans to combat the traffic problem(s)
identified in the problem statement and accomplish target/performance measure goals. Use
the strategies boxes checked to accomplish this.
SECTION D: Budget
Training:
Training requested in this section must be traffic safety/enforcement related and needed to
properly execute the grant requested. All training requested must relate to a traffic problem
identified in the problem ID statement and assist in resolving a target/performance measure.
Provide the number of officers to be trained along with tuition fees and travel costs.
Example: In the previous Problem Statement (PG I-4)the tribe has identified speeding as
the traffic safety problem on the reservation. Speeding is also a mandatory target.
Training Course:

# To Be
Trained:
2

Radar/Lidar Certification

Total
Tuition:
$600.00

Estimated
Travel Cost:
$1,500.00

How will this training assist with the traffic problem identified in the problem ID?
Radar/Lidar Certification relates to the speeding problem identified in the problem ID. This training will
assist getting officer certified in monitoring speed.
3 How will this training assist in achieving this target?
Applies to target #
Training will assist in increasing the number of speed citations issued along with reducing speed related
crashes and fatalities

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Training will assist in increasing the number of speed citations issued along with reducing speed related
crashes and fatalities

Training requested in this section does not guarantee the budget requested. If the grant is
awarded all travel and training must be approved by the BIA IHSP prior to travel or training
attendance. Basic Police Academy Training and non-traffic related training IS NOT allowable
for reimbursement under this grant.
Equipment:
Federal guidelines require equipment requests to be necessary for the project and not for
general purpose use. Equipment must be essential for meeting and achieving the targets/
performance measures and outlined in the problem ID of the proposed project. In this section,
identify equipment, quantity, and costs along with a justification request.
Example: In the previous Problem Statement (PG I-4)the tribe has identified speeding as
the traffic safety problem on the reservation. Speeding is also a mandatory target.
Equipment:

Radar/Lidar

Cost Per Item

Quantity:

$1,184.00 Total:

$2,368.00

How will this equipment assist with the traffic problem identified in the problem ID?
The purchase of 2 Radar/Lidars will assist in monitoring the speed problem within the reservation
boundaries.
How will this equipment be used to assist in achieving a target?
Applies to target #: 4
Radar/Lidars will assist in issuing speed citations to exceed the FY26 targets.

Software:
Identify the software the tribe would like to request for the success of the program. State how
the software will assist in achieving the targets/performance measures identified in the problem
ID statement.
Personnel:
Tribal Finance Officer should assist in completing this page by providing their e-mail address,
and telephone number. IHSP grant funds are for performing highway traffic enforcement/
safety activities, not for hiring full-time tribal law enforcement. Therefore, grant application
must specify hours of eligible activity required to perform the project. The Law Enforcement
grants will reimburse hours of eligible activity which includes compensation for time spent on
the activity and a corresponding proportional share of fringe benefits (i.e. those fringe
benefits earned during the hours performing activity under a BIA IHSP funded grant).
Benefits Percentage, and Total Fringe Benefits. This guidance applies to straight time and
overtime hours grants.
GSA Vehicle Lease/Mileage and Overtime Mileage:
Tribes applying for a straight time hours grant who will have a GSA Lease in place will
complete the following fields: Vehicle Type, Monthly Lease Amount, Monthly Lease Fee, and
Estimated Monthly Mileage, Rate Per Mile, Monthly Total, Months (12) and yearly total. The
GSA Lease indicates the vehicle type and should list a mileage rate on the invoice or within
the contract. Straight time and overtime hour grant applicants who do not have a GSA Lease in
place but would like to be reimbursed for mileage will complete the following fields: Vehicle
Type, Estimated Monthly Mileage, Rate Per Mile, Monthly Total, Months (12), and yearly
total. Rate per mile is based off GSA Rates determined by make and model of the police unit.
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Office Supplies:
Identify the Office Supply, Item Cost, Quantity, and Total needed to carry out grant
activities.
Media:
Enter a budget for newspaper, and radio ads, along with bill board rentals costs to advertise the
national and Indian Country mobilizations if needed. Heatstroke messaging is mandatory.
Indirect Costs:
Tribes can be reimbursed Indirect Cost (IDC) Rate in accordance with their most current
approved IDC Letter if submitted with the application. Check the appropriate boxes IDC can
be applied to in accordance with the most recent signed approved IDC Letter.
Budget Line Item Tools:
Enter the grand totals from the previous for line item total budget.
SECTION E. ADDITIONAL INFORMATION:
Add any additional information which is not covered in the application’s previous pages.
Provide a description of how the tribe will use funds to counter measure the traffic problems
identified. (These can include working on updating or making stronger traffic laws, identifying
and increasing traffic enforcement in certain areas, increasing traffic fines, monitoring the
DWI offender, prevention or intervention, etc.)
SECTION F: Terms, Conditions and Responsibilities
Each Condition MUST be initialed. Applications received without initials, signature, and date
will not be considered for funding. Do not leave any field blank in the application.

Questions and grant applications along with attachments can be e-mailed to:
[email protected]

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Highway Safety
Overtime
Straight Time
Hours
Grant
Hours Grant
Specialist Grant
Each section of this grant application must be completed, do not leave any fields blank. Fiscal Year Applying For:

TYPE OF GRANT APPLYING FOR:

SECTION A: GENERAL INFORMATION
Tribe Name:
Tribal Leader Name:

Title:

Phone Number:

Fax Number:

Mailing Address:
City:

State:

Zip:

State:

Zip:

FedEx Address:
City:

SAMs UEI:

DUNS:

SAMs Cage Code:

PERSON COMPLETING THE APPLICATION:
Name:

Title:

Phone Number:

Fax Number:

E-Mail Address:
TRIBAL GRANT COORDINATOR INFORMATION:
If grant is awarded, please identify the Project Coordinator. (Person responsible for grant administration)
Name:

Title:

Phone Number:

Fax Number:

E-mail Address:
Office/ Department:
Address:
City:

State:

Zip:

GRANT HISTORY:
Has the Tribe ever received Indian Highway Safety grant funding from the BIA IHSP?

Yes

If yes, what years?
In the last 3 years, has the Tribe applied for and received other traffic safety related grants from other agencies?
Yes
If yes, list the agencies:

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Does the tribe have a traffic safety (focused) grant currently in place with another agency?
(i.e. CDC, Indian Health, State, FHWA, etc.):

Yes

If yes, list the agencies:
RESERVATION SIZE INFORMATION:
Square Miles:

Acres:

Population (Tribal Enrollment)
:
:
Total Number of Road Miles:

TRIBAL POLICE DEPARTMENT INFORMATION:
Chief of Police Name:
Fax Number:

Phone Number:
E-mail Address:
Address:
City:

State:

Total number of Police Officers:
Is Law Enforcement:

Tribal

Zip:
Total number of Officers who work traffic:

BIA

Both

Does Tribal Law Enforcement have the authority to conduct checkpoints?

Yes

Are cross commission agreements in place with any other law enforcement agencies?

No
Yes

If yes, identify the agencies:
SECTION B: DATA.
Provide a data breakdown utilizing the most recent fiscal year data available for the reservation.
TRAFFIC DATA INFORMATION:
Does the Police Department have a software system to collect traffic enforcement & crash statistics?

Yes

If yes, please identify the software:
Does the tribe report crashes or other data to the state?

Yes

What is the last fiscal year of traffic data available?

Is the Data by:

Calendar Year

Fiscal Year

TRIBAL STATUTES AND ENFORCEMENT STATISTICS:
Does the Tribe have a traffic code?

Yes

Does the Tribe have an Impaired Driving Law?

Yes

Does the Tribe have a Seat Belt Law?

If yes, is the law:

Yes

If yes, what is the B.A.C.?
Primary

Secondary

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Does the Tribe issue written warnings for traffic violations?

Yes

If yes, number of written warnings in the previous year: ____________
Does the Tribe prosecute DUI’s?

Yes

No If yes, what is the conviction rate in Tribal Court?

TRAFFIC STATISTICS: ONLY Fiscal Year (October 1, 20 ____ - September 30, 20____) data will be accepted
DUI ARRESTS & TRAFFIC CITATIONS
Total number of:
seat belt citations (A-1)

DUI/DWI/OWI arrests? (A-2)

child safety seat citations

speed citations (A-3)

traffic citations issued (excluding speed & DUI)
MOTOR VEHICLE FATALITIES AND CRASHES
Total number of:
motor vehicle crashes

traffic fatalities (C-1)
unrestrained passenger vehicle occupant
fatalities, all seat positions (C-4)

serious injuries in traffic crashes (C-2)
crashes involving alcohol?

motor vehicle fatalities involving a driver with
a BAC of .08 g/dl or higher (C-5)

crashes involving speed

speed related fatalities (C-6)

single vehicle crashes

motorcyclist fatalities (C-7)

property damage crashes

un-helmeted motorcyclist fatalities (C-8)

crashes involving two or more vehicles

drivers 20 or < involved in fatal crashes (C-9)
pedestrian fatalities (C-10)

crashes involving motorcyclists
crashes involving bicyclists

bicyclist fatalities (C-11)

crashes involving pedestrians

Of the total number of crashes (listed above), how many occurred on:
Rural Roads
State Highways
Other types of roads; describe:

Paved Streets
Interstates

Of the total number of crashes (listed above), how many occurred on:
Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Sundays

Unknown

Of the number of crashes (listed above), how many occurred between:
Midnight to 6:00 AM

6:01 AM to Noon

12:01 PM to 6:00 PM

6:01 PM to 11:59 PM

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SECTION C. PROBLEM STATEMENT, STRATEGIES, & TARGETS (PERFORMANCE MEASURES).
The Indian Highway Safety Grants are performance-based programs. In this section the Tribe will identify the traffic
problem, strategies, and targets.
PROBLEM STATEMENT:
Provide a written summary clearly outlining the specific traffic related problems the Tribe has identified, and will
address if grant funds are awarded.

ATTACH AN ADDITIONAL PAGE IF NECESSARY

TARGETS (PERFORMANCE MEASURES):
Targets should fall in line with the traffic problem identified in the problem statement. 4-5 years of traffic data will be
needed to assist in determining the target to be reached at the end of the grant year. Use the Linear Trend Analysis to
complete this section. Targets 1-5 are mandatory for all Law Enforcement Grant Programs
Please use the trend analysis tool to determine the FY

targets/ performance measure:

1. To reduce the number of motor vehicle crash (MVC) fatalities by _____% from the FY_____ number of _______
to _______ by the end of FY_____. (mandatory)
2. To reduce motor vehicle crashes (MVCs) by _____% from the FY_____ number of _______ to _______ by the
end of FY _____.
3. To increase the number of DUI/OWI arrests by _____% from the FY_____ number of _______ to _______ by the
end of FY_____.
4. To increase the number of speed citations issued arrests by _____% from the FY_____ number of _______ to
_______ by the end of FY_____.
5. To increase the number of traffic citations (excluding speed & DUI) issued by _____% from the FY_____ number
of _______ to _______ by the end of FY_____.
6. To increase the number of seat belt citations issued by _____% from the FY_____ number of _______ to _______
by the end of FY_____.

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STRATEGIES:
Select from the following list of strategies the Police Department will conduct during the grant year.
Place an “X” in the box of the strategies your program will utilize to achieve the Targets:
Increase enforcement (traffic and DUI)
Provide appropriate training (traffic safety related).
Print and distribute public service announcements and/or press releases.
Provide traffic safety related presentations to school children and community members.
Distribute traffic safety related educational materials.
Specify other plans besides the strategies listed above: (Example, Patrolling differently by conducting high visible
traffic enforcement in identified problem areas, etc.).
Conduct not less than

checkpoints in FY

Conduct not less than

saturation patrols in FY

Provide not less than

hours of traffic enforcement during each mobilization period.

(Dates will be provided by BIA IHSP)

SURVEY (B-1): Has the Tribe or is the Tribe willing to conduct an observed seat belt use for passenger vehicles, front
seat outboard occupants:
Yes
No
STRATEGIES STATEMENT:
How does the tribe plan to combat the traffic problem(s) identified in the problem statement? What will the tribe do to
reach the performance targets?

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SECTION D. BUDGET
This section must be completed for all grant applications. Budgets must support the grant proposed. Be as accurate and
reasonable as possible when filling out the budget section. Federal guidelines require costs to be reasonable and
necessary to carry out and/or operate the grant.
TRAINING/TRAVEL
Use the drop-down menu to select traffic related training the Police Department is interested in and complete all fields
that apply to the course. All training must be traffic related, assist in achieving one of the targets and coincide with a
traffic problem identified in the problem ID.
# To Be
Estimated
Training Course:
Total
Trained:
Tuition:
Travel Cost:

Select One

How will this training assist with the traffic problem identified in the problem ID?

Applies to target #:_____

How will this this training assist in achieving this target?

# To Be
Trained:

Training Course:

Select One

Total
Tuition:

Estimated
Travel Cost:

How will this training assist with the traffic problem identified in the problem ID?

Applies to target #:_____

How will this this training assist in achieving this target?

Training Course:

# To Be
Trained:

Select One

Total
Tuition:

How will this training assist with the traffic problem identified in the problem ID?

Applies to target #:_____

How will this this training assist in achieving this target?

Grand Total Training & Travel Request:
ADD ADDITIONAL PAGE IF NECESSARY

Estimated
Travel Cost:

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EQUIPMENT
Enter the equipment needed carry out/accomplish the targets, and strategies of the grant. Complete the fields below and
answer each question. Equipment requested must be traffic related.
Equipment: _______________________________ Cost Per Item:_________ Quantity: ____ Total:____________
How will this equipment assist with the traffic problem identified in the problem ID?

Applies to target #: _____ How will this equipment be used to assist in achieving a target?

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Equipment: _______________________________ Cost Per Item: _________ Quantity:_____Total:____________
How will this equipment assist with the traffic problem identified in the problem ID?

Applies to target #: _____ How will this equipment be used to assist in achieving a target?

Grand Total Equipment:
SOFTWARE: Identify the specialty software needed to carry out the grant with its purpose and anticipated use.
$ 0.00
Software:__________________________________ Cost per item:_________ Quantity: _____ Total:___________
How does this software request assist in meeting the needs of the grant?

$ 0.00
Software:__________________________________ Cost per item:_________ Quantity: _____ Total:___________
How does this software request assist in meeting the needs of the grant?

Grand Total Software:
ADD ADDITIONAL PAGE IF NECESSARY

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PERSONNEL: Complete ONLY those sections pertinent to the grant requested.
Federal guidelines require costs to be reasonable and necessary in order to carry out and operate the grant. Budgets
must support the grant proposed; be as reasonable as possible. Must be completed by Tribes Finance Officer.
Phone Number:
Grant Type: Select One

Finance Officer Name:
E-mail Address:

(Use drop down menus to select grant and personnel type)

Personnel: Choose an Item

Percent of Time:

Straight Time Hourly Rate:

Overtime Hourly Rate:

Number of Activity Hours:

Number of Activity Hours:
Number of Overtime ActivityHours:

Number of Overtime ActivityHours:
Total Salary:

$ 0.00

Total Salary:

$ 0.00

Total Overtime Salary:

$ 0.00

Total Overtime Salary:

$ 0.00

Fringe Benefit %:

Total Fringe Benefit:

Personnel: Choose an Item

Percent of Time:

Straight Time Hourly Rate:

Overtime Hourly Rate:

Number of Activity Hours:

Number of Overtime ActivityHours:

Total Salary:

$ 0.00

Total Salary:

$ 0.00

Total Overtime Salary:

$ 0.00

Total Overtime Salary:

$ 0.00

Fringe Benefit %:

Total Fringe Benefit:

Personnel: Choose an Item

Percent of Time:

Straight Time Hourly Rate:

Overtime Hourly Rate:

Number of Activity Hours:

Number of Overtime ActivityHours:

Total Salary:

$ 0.00

Total Salary:

$ 0.00

Total Overtime Salary:

$ 0.00

Total Overtime Salary:

$ 0.00

Fringe Benefit %:

Total Fringe Benefit:

Grand Total: Salary:

Overtime Salary:

Fringe Benefits:

FY ______

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Bureau of Indian Affairs - Office of Justice Services
Indian Highway Safety Program
Demonstrated Needs & Quarterly Goals for Highway Safety Specialist Position
1. Provide a brief description of the demonstrated need of a Highway Safety Specialist (HSS).

2. What are the quarterly goals for the HSS each fiscal year?
Quarter 1 -

Quarter 2 -

Quarter 3 -

Quarter 4 -

3. What is the overall achievement for the HSS at the end of the year?

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GSA VEHICLE LEASE: GSA Lease is allowable, if needed, for officers designated to work under straight time
hours grant for traffic enforcement/safety. Vehicle types will be determine at the GSA rate allowed. PLEASE NOTE:
Costs associated with vehicle maintenance tires will not be covered. These must be in-kind contributions by the tribe or
other agencies.
Vehicle Type:

Vehicle Type:
Monthly Costs

Monthly Costs

Lease Amount:

Lease Fee:

Lease: Fee:

Estimated Mileage:

Rate Per Mile:

Monthly Total:

Number of Months:

Yearly Total:

Vehicle Type:

Vehicle Type:
Monthly Costs

Monthly Costs

Lease Amount:

Lease Fee:

Estimated Mileage:

Rate Per Mile:

Monthly Total:

Number of Months:

Yearly Total:

Yearly Total:
Grand Total GSA Lease/Mileage:

GENERAL OFFICE SUPPLIES: List all supplies needed in order to successfully carry out the grant:
Office Supply:
Item Cost:
QTY:
Total:
Office Supply:
Item Cost:
QTY:
Total:

$ 0.00

Office Supply:
Item Cost:
QTY:
Total:

$ 0.00

Office Supply:
Item Cost:
QTY:
Total:

$ 0.00

Grand Total for Supplies:

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MEDIA COSTS: These costs are allowable as long as they are directly related to the project and/or support the
national mobilizations and Indian Holiday mobilization , along with mandatory Heatstroke messaging.
Media Type: News Paper
Media Type: Radio
Media Type: Bill Board Rental

Total:
Total:
Total:

INDIRECT COST RATE (IDC): Attach a copy of the tribe’s most recent Indirect Cost Rate letter and necessary
paper work to support reimbursement for the line items below:
Indirect Cost Rate:

Year IDC was for approved:

Check the boxes the indirect cost rate percentage applies to:
Salary
Overtime Salary
Fringe Benefits
Training & Travel Expenses
GSA Lease/ Mileage
Supplies

BUDGET LINE ITEM GRAND TOTALS:
Training/ Travel:
Equipment:
Software:
Straight Time Hours Salary:
Overtime Hours Salary:
Fringe Benefits:
GSA Lease/Mileage:
Overtime Mileage:
Supplies:
Media Costs:
Indirect Cost:
TOTAL BUDGET:

OMB Control. No. 1076-0190
Expiration Date XX/XX/XX

SECTION E. ADDITIONAL INFORMATION:
Add any additional information which is not covered in the application’s previous pages. Provide a description of how
the tribe will use funds to counter measure the traffic problems identified.

ATTACH AN ADDITIONAL PAGE IF NECESSARY

SECTION F. 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.
Tribe understands the Indian Highway Safety Grants are REIMBURSABLE grants. Copy of
the Tribe's most recent (IDC) Letter is attached.
A current draft/approved Tribal Resolution is attached. .
Tribe understands IDC is not reimbursable for equipment purchases.
The Tribes' accounting system is the same as previous years?

Yes

Tribes Single Audit is current and compliant with the Single Audit Act of 1984?
Tribe has received a Single Audit in accordance with 23 CFR 200 Subpart (F)?

No
No

Yes
Yes

Tribe must participate in the national enforcement mobilizations and the "Indian State" mobilization.
Tribe will participate in heatstroke awareness messaging.
In order to comply with the provisions of Bipartisan Infrastructure Law (BIL), and the required State
Certifications and Assurances, the BIA IHSP may allocate funds on behalf of the tribe to meet certain
conditions and comply with all applicable rules and regulations for administering a traffic national safety
program.
If requesting activity hours, non-traffic related activities WILL NOT be reimbursed: Dispatch for domestic
violence calls, gun calls, funeral escort, security escort, house parties, civil issue process service, welfare
checks, noise complaints, fights, suicides, drug interdiction, and other non-traffic safety related calls.

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: I have obtained all necessary approvals, and
have discussed this application with the necessary and appropriate people.
Signature:

Date:

Name (Print):

Title:

OMB Control. No. 1076-0190
Expiration Date XX/XX/XX

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) for the BIA
Indian Highway Safety Program (IHSP) to fulfill the data obligations of 23 CFR 1300.11. Your response is voluntary and we will not share the results
publicly. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB
Control Number. OMB has reviewed and approved this survey and assigned OMB Control Number 1076-0190, which expires XX/XX/XX.
Estimated Burden Statement: We estimate the application will take you 240 minutes to complete, including time to read instructions, gather
information, and complete and submit the application. You may submit comments on any aspect of this information collection to the Information
Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action—Indian Affairs (RACA), U.S. Department of the Interior, Indian
Affairs 1001 Indian School Road NW, Suite 229, Albuquerque, New Mexico 87104.

File Type	application/pdf
Author	Belone, Kimberly J
File Modified	2024-10-28
File Created	2024-10-10