HomeMy WebLinkAboutTitle V Prevention Application Face Sheet
Augusta Richmond GA
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TITLE V PREVENTION
APPLICATION FACE SHEET
Office of the Governor
Children and Youth Coordinating Council
10 Park Place South, Suite 410
Atlanta, Georgia 30303
(404) 656-1725
PART ONE
SECTION 1 - APPLICANT AGENCY
(Must Be Fiscal Agentfor Grant) b,.U!A: 6is?:........-~e.
Applicant Agency Name: Beare! of Ce Igne~
A. Executive Officer Name: Mr. Bob Young
Title: Cheirn,an of tlge 008r8 gf COr::r:lR:liE:E:iOners4~
Mailing Address*: 530 Greene Street
City: Augusta State: GA Zip: 30901
County: Richmond Congressional District: 10
Phone: (706) 821-1831 Fax: (706) 821-1835
Email: Ib6764@co.Richmond.GA.US
B. Fiscal Contact: David Persuad
Title: Finance Director
Mailing Address*: 530 Greene Street
City: Augusta State: GA Zip: 30901
County: Richmond Congressional District: 10
Phone: (706) 821-2429 Fax: (706) 821-2520
Email:
SECTION 2 - IMPLEMENTING AGENCY
(IfdifJerentfrom applicant agency)
Implementing Agency Name: ARCCPCF, Inc.
Executive Officer: Dr. Roberta McKenzie
Title: Executive Director
Mailing Address*: 353 Telfair Street
City: Augusta State: GA Zip: 30901
County: Richmond Congressional District: 10
Phone: (706) 721-1040 Fax: (706) 721-1048
Email: dgoodwin@arccp.org
SECTION 3 . PROJECT DIRECTOR
Name: Dr. Roberta McKenzie
Title: Executive Director
Agency Name: Aug. Rich. Co. Comm Partnership
Mailing Address*: 353 Telfair Street
City: Augusta State: GA Zip: 30901
County: Richmond Congressional District: 10
Phone: (706) 721-1040 Fax: (706) 721-1048
Email: dgoodwin@arccp.org
(*ORGANIZATION MAILING ADDRESS)
SECTION 4
TYPE OF ApPLICATION (Check One):
I:!!I InitiaUlst Year I!:I 2nd Year CJ 3rd Year D 4th Year
D Other
If continuation application, please list all previous grant #s:
Amount Requested: $ 68,992.00
Federal Employer ID#: ..2 ~ - .Q ...Q -9 _8 _8_1_
Is the applicant delinquent on any federal debt?
[] YES [] NO
If yes, attach a detailed explanation.
I, the undersigned authorized representative of the applicant, have read, understand and agree to all relative conditions specified In the Children and Youth
Coordinating Council's Request for Proposals and Application KIt, and having read all attachments thereto do submit this application on behalf of the applicant
If awarded a grant I leme the provision herein, I do certify that all applicable federal and state laws, rules and regulations applicable thereto will be
followed.
fc
Implementing Agency executive OffIcer (Signature & Date)
Executive Director
Tltlo
PART Two
APPLICATION FACE SHEET
SECTION 5 - PRO.JECT DATA
Anticipated Number of Youth to be Served: 38 Anticipated Number of Volunteers: 12
Congressional District(s) to be Served: 10th County(ies) to be Served: Augusta-Richmond
Gender Served: D Male Only DFemale Only rn Male and Female
Approximate Age Range of Participants: Age~to age~
SECTION 6 - PRO.JECT TYPE
(Mark all appropriate types)
JCI After-school Program ia Juvenile Diversionffreatment Program
I:il:Mental Health Program :Ja Abstinence Education Program
fI Summer Program
[;J Juvenile Court Improvement
SECTION 7 - PROJECT SUMMARY
Project Title: Ado!. Substance Abuse Intensive Outpatient Services
Summary: (Less than 50 words)
The proposed program will provide intensive substance abuse outpatient services for
probated juvenile offenders referred from Richmond County Juvenile Courts. The
program will be implemented by the Augusta-Richmond County Community Partnership
with mental health support services provided by the Community Mental Health Center of
East Central Georgia
SECTION 8 - PROJECT ACTIVITIES
(Mark aU activities provided through this grant. List additional activities notfound below under "other.'?
!Xl Family Therapy
'* Enrichment Activities (i.e., arts & crafts, dance, etc.)
'* Life Skills Training (i.e., coping skills instruction, drug & alcohol education, etc.)
Ii Mentoring
'it Family Support/Parent Education
Ii IndividuaVGroup Counseling
Ii ThtoringIHomework Assistance
~ Character Education/Leadership Training
o Vocational Training
o Community Service
fid AftercarelTransitional Services
~ Intensive Supervision/Surveillance
Other
Revi.ed 12/00
ClllLDREN AND YOUTH COORDINATING COUNCIL
Suite 410,10 Park Place South, Atlanta, GA 30303
ACCOUNTING SYSTEM AND FINANCIAL CAP ABILITY INFORMATIONAL QUESTIONNAIRE
SECTION A: PURPOSE
The financial responsibility of subgrantees must be such that the subgrantee can properly discharge the public trust, which
accompanies the authority to expend public funds. Adequate accounting systems should meet the following criteria as outlined in the
CYCC Sub grantee Finance Manual.
1. Accounting records should provide information needed to adequately identify the receipt of funds under each grant awarded
and the expenditure of funds for each grant, for each action program covered by a State's grants and for each subgrant
awarded by the State.
2. Entries in accounting records should refer to subsidiary records and/or documentation which support the entry and which can
be readily located.
3. The accounting system should provide accurate and current financial reporting information.
4. The accounting system should be integrated with an adequate system of internal controls to safeguard the funds and assets
covered, check the accuracy and reliability of accounting data, promote operational efficiency, and encourage adherence to
prescribed management policies.
SECTION B: ACCOUNTING SYSTEM
I. Has any Government Agency rendered an official written opinion concerning the adequacy of the accounting system for the
collection, identification and allocation of costs under Federal contracts/grants? I:J Yes DNo
a. If yes, provide name and address of Agency performing review:
b. Attach a copy of the latest review and any subsequent
correspondence, clearance documents, etc.
(Note: If review occurred within the past three years, omit
questions 2-9 of this Section and Section C.
2. Which of the following best describes the accounting system? 0 Manual
3. Does the organization use a double-entry system in accounting for program funds?
4. Does the accounting system identify the receipt and expenditures of program funds
separately for each contract/grant?
5. Does the accounting system provide for the recording of expenditures for each grant/
contract by the component project and budget cost categories shown in the approved
budget?
6. Are time distribution records maintained for an employee when his/her effort can be
specifically identified to a particular cost objective?
7. Does the accounting/financial system include budgetary controls to preclude incurring obligations in excess of:
a. Total funds available for a grant? [] Yes [] No
b. Total funds available for a budget cost category (e.g. Personnel, Travel, etc.)? [j Yes IJ No
8. Is the firm generally familiar with the existing regulations and guidelines containing the [j] Yes 1:1 No
cost principles and procedures for the determination and allowance of costs in
connection with Federal contracts/grants?
IJI Automated IJ Combination
eYes C No [I Not Sure
eYes [:J No [J Not Sure
eYes
[:J No
IJ Not Sure
eYes
[ll No
[J Not Sure
1:1 Not Sure
[1 Not Sure
[J Not Sure
SECTION C: FUND CONTROL
I. Is a separate bank account maintained for grant/contract funds?
2. If Federal grant/contract funds are commingled with organization funds, can the Federal
grant funds and related costs and expenses be readily identified?
[ll Yes
[j Yes
ONo
CI No
IJI Not Sure
[) Not Sure
SECTION D: APPLICATION CERTIFICATION
I certify that the above information is complete and correct to the best of my knowledge.
I. Signature of Applicant Executive Officer
b. Firm Name, Address, and Telephone Number
a. Title:
1.
CERTIFICATION OF EQUAL EMPLOYMENT PROGRAM
\,
~~ ,%VtJ17
(agency executive officer)
~15~, Ce~~)iL
(applying ag cy)
has formulated an
, certify that the
Equal Employment Opportunity Program in accordance with 28 CFR 42.301,
et seQ., subpart E, that it has been signed into effect by the proper agency
authority and disseminated to all employees, and that it is on file in the office of:
(person's name)
(address)
(title)
for review or audit by officials of the Children and Youth Coordinating Council
or the Office for Civil Rights, U.S. Office of Justice Programs, as required by
~
J /107-
(Date)
OR
...............................**.............**.
..................****.......**.........*****....
2.
Certification (no EEOP required)
I,
, hereby certify that the
(agency executive officer)
, has less than 50 employees and
(applying agency)
is not required to maintain an EEOP, pursuant to 28 CFR 42.301, et seQ.
(Signature)
(Date)
SERVICE DELIVERY STRATEGY ACT COMPLIANCE
CERTIFICATION
I,
Bob Young
(county commission chair)
, certify that Richmond
(county name)
County is in
compliance with the Service Delivery Strategy Act (House Bill 489). I also understand that if my
county is not in compliance, the county and city governments contained therein are not eligible to
receive state-administered financial assistance, grants, loans, or permits.
~
Signature of Com
Bob Young;, Mayor
Typed Name and Title
May 21, 2002
Date
_......:~.'.
-f . I.
. \,
U.S. DEPARTMENT OF JUSTICE
OFFICE OF JUSTICE PROGRAMS
OFFICE OF THE COMPTROLLER
CERTIFICATIONS REGARDING LOBBYING; DEBARMENT; SUSPENSION AND
OTHER RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE REQUIREMENTS
Applicants should refer to the regulations cited below to determine the certification to which they are required to
attest. Applicants should also review the instructions for certification included in the regulations before completing this
form. Signature of this form provides for compliance with certification requirements under 28 CFR Part 69, "New
Restrictions on Lobbying" and 28 CFR Part 67, "Government-wide Debarment and Suspension (Non procurement) and
Government-wide Requirements for Drug-Free Workplace (Grants)." The certifications shall be treated as a material
representation of fact upon which reliance will be placed when the Department of Justice determines to award the
covered transaction, grant, or cooperative agreement.
1. Lobbying
As required by Section 1352, litle 31 of the U.S. Code, and
implemented at 28 CFR Part 69, for persons entering into a
grant or cooperative agreement over $100,000, as defined at
28 CFR Part 69, the applicant certifies that:
(a) No federal appropriated funds have been paid or will be
paid, by or on behalf of the undersigned, to any person for
influencing or attempting to influence an officer or employee of
any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in con-
nection with the making of any Federal grant, the entering into
of any cooperative agreement, and the extension, continuation,
renewal, amendment, or modification of any Federal grant or
cooperative agreement.
(b) If any funds other than Federal appropriated funds have
been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or
an employee of a Member of Congress in connection with this
Federal grant or cooperative agreement, the undersigned shall
complete and submit Standard Form - LLL, "Disclosure of
Lobbying activities," in accordance with its instructions;
(c) The undersigned shall require that the language of this cer-
tification be included In the award documents for all subawards
at all tiers (including subgrants, contracts under grants and
cooperative agreements, and subcontracts) and that all sub-
recepients shall certify and disclose accordingly.
1. Debarment, Suspension, and other
Responsibility Matters (Direct Recepient)
As required by Executive Order 12549. Debarment and
Suspension, and Implemented at 28 CFR Part 67, for prospec-
tive participants in primary covered transactions, as deflned at
28 CFR Part 67, Section 67.510-
A. The applicant certifies that it and its participants:
(a) Are not presently disbarred, suspended, proposed for
debarment, declared ineligible, sentenced to a denial of
Federal benefits by a State or Federal court, or voluntarily
excluded from covered transactions by any Federal depart-
ment or agency;
(b) Have not within a three-year period proceeding this applica-
tion been convicted of or had a civil judgment rendered against
them for commission of fraud or a criminal offense in connec-
tion with obtaining, attempting to obtain, or performing a public
(Federal, State, or local) transaction or contract under a public
transaction; violation of Federal or State antitrust statutes or
commission of embezzlement, theft, forgery, bribery, falsifica-
tion or destruction of records, making false statements, or
receiving stolen property;
(c) Are not presently Indicted for or otherwise criminally or
civilly charged by a govemmental entity (Federal, State, or
local) with commission of any of the offenses enumerated in
paragraph (1)(b) of this certification; and
(d) Have not within a three-year period preceding this applica-
tion had one or more public transactions (Federal, State, or
local) terminated for cause or default; and
B. Where the applicant is unable to certify to any of the
statements in this certlflcation, he or she shall attach an
explanatfon to this application.
3. Drug-Free Workplace
(Grantees Other Than Individuals)
As required by the Drug-Free Workplace Act of 1988, and
implemented at 28 CFR Part 67, Subpart F, for grantees, as
deflned at 28 CFR Part 67 Sections 67.615 and 67.620-
A. The applicant certifles that it will or will continue to provide a
drug-free workplace by:
(a) Publishing a statement notifying employees that the
unlawful manufacture, distribution, dispensing, possession, or
use of a controlled substance is prohibited In the grantee's
workplace and specifying the actions that will be taken against
employees for violation of such prohibition;
(b) Establishing an on-golng drug-free awareness program to
inform employees about-
(1) The dangers of drug abuse in the workplace;
(2) The grantee's polley of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee
assistance programs; and
(4) The penalties that may be imposed upon employees for
drug abuse violations occuring in the workplace;
(c) Making It a requirement that each employee to be engaged
In the performance of the grant be given a copy of the state-
ment required by paragraph (a);
(d) Notifying the employee in the statement required by para-
graph (a) that, as a condition of employment under the grant,
the employee will-
OJP FORM 40616{3/91) REPLACES OJPFORMS 406112, 4061/3 AND 4061/4 WHICH ARE OBSOLETE
(1) Abide by the terms of the statement; and
(2) Notify the employer In writing of his or her conviction for a
violation of a criminal drug statute occurlng In the workplace no
later than five calendar days after such conviction;
(e) Notifying the agency, in writing, within 10 calendar days
after receiving notice under subparagraph (d)(2) from an
employee or otherwise receiving actual notice of such convic-
tion. Employers of convicted employees must provide notice,
including position titie, to: Department of Justice, Office of
Justice Programs. ATTN: Control Desk, 633 Indiana Avenue,
N.W., Washington, D.C. 20531. Notice shall include the Identifi-
cation number(s) of each affected grant;
(t) Taking one of the following actions, within 30 calendar days
of receiving notice under subparagraph (d)(2), with respect to
any employee who is so convicted-
(1) Taking appropriate personnel action against such an
employee, up to and including termination, consistent with the
requirements of the Rehabilitation Act of 1973, as amended; or
(2) Requiring such employee to particlpate satisfactorily in a
drug abuse assistance or rehabilitation program approved for
such purposes by a Federal, State, or local health, law
enforcement, or other appropriate agency;
(g) Making a good faith effort to continue to maintain a drug-
free workplace through implementation of paragraphs (a), (b),
(c), (d), (e), and (t).
B. The grantee may insert in the space provided below the
site(s) for the performance of work done in connection with the
specific grant:
Place of Performance (Street address, city, county, state, zip
code)
Check 0 if there are workplaces on file that are not identified
here.
Section 67, 630 of the regulations provides that a grantee that
Is a State may elect to make one certification in each Federal
fiscal year. A copy of which should be included with each appli-
cation for Department of Justice funding. States and State
agencies may elect to use OJP Form 4061/7.
Check 0 if the State has elected to complete OJPForm
406117.
Drug-Free Workplace
(Grantees Who Are Individuals)
As required by the Drug-Free Workplace Act of 1988, and
implemented at 28 CFR Part 67, Subpart F, for grantees, as
defined at 28 CFR Part 67; Sections 67.615 and 67.620-
A. As a condition of the grant, I certify that I will not engage in
the unlawful manufacture, distribution, dispensing, possession,
or use of a controlled substance in conducting any activity with
the grant; and
B. If convicted of a criminal drug offense resulting from a
violation occurring during the conduct of any grant activity, I
will report the conviction, In writing, within 10 calendar days of
the conviction, to: Department of Justice, Office of Justice
Programs, ATTN: Control Desk, 810 Seventh Street NW.,
Washington, DC 20531.
As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above
certifications.
1. Grantee Name and Address:
2. Application Number and/or Project Name
4. Typed Name and litle of Authorized Representative
Bob Young, Mayor
3. Grantee I RSNendor Number
6. Date
) J;r,f7--
'U.S. Govemmenl Printing Office: 1996 - 405-037/40014
NON-SUPPLANTING CERTIFICATION
(to be completed by all applicants)
Regulations adopted by the U.S. Office of Juvenile Justice and Delinquency Prevention
(OJJDP) require certification to the effect that federal funds have not been used to
increase state or local funds that would, in the absence of such federal aid, be made
available for juvenile justice and delinquency prevention.
This form should be used by applicants in making required certification. This certification
is required as part of the initial proposal for grant funds to the Children and Youth
Coordinating Council.
CERTIFICATION:
I certify that OJJDP funds will not be used to supplant state or local funds that would
otherwise be available for juvenile justice assistance. I further certify that the project
proposed in the grant application meets all the requirements of the Juvenile Justice and
Delinquency Prevention Act and its implementing guidelines; that all the information
presented is correct; that there has been appropriate coordination with affected
agencies; and that the applicant will comply with the provisions of the OJJDP Act, all
applicable federal and state laws, and the above-mentioned certification should a grant
be awarded.
~
cf Signature of Applica
Bob Young, Mayor
Typed Name and Title
~~(,~7.-
/ f
Date
" .
AUDIT INFORMATION
(to be completed by all applicants)
AGENCY'S FISCAL YEAR:
Enter Appropriate 12-Month Cycle
(e.g., Jan. 1-Dec. 31; July 1-June 30; Oct. 1-Sept. 30)
DATE OF LAST AUDIT:
DATE OF NEXT AUDIT:
Should a grant award be issued to your agency, note the approximate date the
audit/compilation will be submitted to CYCC:
(to be submitted verifying receipt &
expenditure of CYCC funding)
Applying Agency Name
Note: Most grants will cover two fiscal periods, and thus, two audits/compilations will need to be
submitted to CYCC.