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## Office for Victims of Crime

**State Crime Victim/Survivor Scholarship Program** **Application**

Thank you for your interest in the OVC State Crime Victim/Survivor
Scholarship Program. Your application will allow us to learn more about
your organization and the conference that you are (co) sponsoring. This
scholarship is competitive, so please fill out the application
completely. [Incomplete applications will not be
considered.]{.underline} Applications received less than **60 days
prior** **to your event** will not be considered.

**Section A: Organization Information**

1\. Name of Organization:

2\. Street Address:

3\. City: State: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Zip:

4\. Telephone: Fax:

5\. Web site:

6\. Type of Organization:

1.  State Government

2.  VOCA Agency

3.  Private Nonprofit \[501(c)(3), for example\]

4.  Community-based or Faith-based Nonprofit Organization

5.  Statewide Coalition

7\. Has the organization previously received OVC funding under the
following programs and grants?

1.  OVC Project HOPE

2.  Discretionary grant

8\. If you have received funding from either source identified in
Question #7, were any of the funds designated for conference support?

>  Yes  No

9\. What is the mission of your organization?

10\. Whom does your organization serve?

11\. Please describe the experience your organization has had managing a
scholarship program: (Also complete subsequent questions a--d):

a.  Total budget of your scholarship program:

> b\. Size or range of scholarship(s) awarded:

c.  Number of scholarships awarded:

d\. Source of funding for the scholarship(s):

**Section B: Applicant Point of Contact Information**

1\. Name of Contact Person:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Title:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. Organization:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\. Street Address:

City: State: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Zip:

5\. Telephone: Fax:

6\. E-mail address:

**Section C: Conference Information**

1\. What is the title of the current conference?

2\. Date(s):

Location/City, State:

3\. What is the expected number of conference attendees?

4\. Who is the intended audience for your conference (for example,
SANE)? \_\_\_\_\_\_\_\_\_\_\_\_\_

5\. Please list any conference cosponsors:

6\. What are the goals of the conference? (If available, please attach a
brochure or other literature about the event.)

**Section D: Post-Conference Evaluation**

If the organization receives approval to award scholarships, the
organization's contact person will receive a feedback form with the
award letter. This form provides feedback on the event that your
organization is (co) sponsoring. It should be copied and distributed to
individual scholarship awardees attending the conference. The forms must
be completed, collected, and returned to the Office for Victims of Crime
Training and Technical Assistance Center (OVC TTAC) by the conference
organizers **within 30 days following the event** in order to receive
reimbursement for expenses.

**Section E: Scholarship Recipient Eligibility Criteria**

Please describe the selection process your organization will use to
award scholarships. Please be as detailed as possible. Your agency MUST
include the following as part of the criteria: (1) the crime victim
scholarship recipient must have at least one (1) year of
volunteer/advocacy service to other victims; (2) recipients must be able
to demonstrate financial need; and (3) scholarship recipients must
provide information about their victimization (nature of victimization,
city/state, and year).

*Please note:* If approved to award scholarships, your organization will
be asked to send OVC a list of scholarship recipients.

**Section F: Budget**

All individual expenses under the OVC State Crime Victim/Survivor
Scholarship Program will be reimbursed at the current government rates.
(*For current rates, please visit www.gsa.gov*.) If the government rate
is less than the rate charged, the conference attendee is responsible
for the difference. For example, if the government rate for Hotel A is
\$80/night and Hotel A charges \$90/night, the scholarship recipient
will be responsible for the \$10 difference. The request for
reimbursement, with required documentation, must be submitted by your
organization to OVC TTAC **within 30 days** **following the
conference.** **The request for reimbursement must include the required
documentation for [all]{.underline} individual scholarship awardees.**

Receipts for individual expenses greater than \$25 must be attached to
the reimbursement request. The following regulations are to be followed
for reimbursement of scholarship expenses:

1.  **Tuition/registration fees** will be reimbursed after the event.
    The organization is expected to encourage scholarship recipients to
    preregister for events to take advantage of the most favorable
    tuition/registration rates. Fees for late registration are not
    covered under the scholarship.

2.  **Transportation expenses** will be reimbursed after the event at
    the current government rate. Transportation expenses can include
    round-trip coach airfare, train fare, bus fare, or a personal
    vehicle mileage reimbursement. Personal vehicle mileage to and from
    the event site will be reimbursed at the current federal rate of
    \$0.445per mile. Rental cars are not covered. Scholarship recipients
    are encouraged to take advantage of excursion or other special
    airfares (such as 14-day advance purchase) when booking air travel.
    Train or air travel may be booked [only]{.underline} if it is the
    least expensive travel option.

3.  **Lodging expenses** will be reimbursed after the event at the
    current government rate.

4.  **Meals/incidental expenses** will be reimbursed after the event.
    These will be paid at the federal rate for the event location for as
    many days as required by the event. See www.gsa.gov, "key topics,"
    "per diem rates" for the per diem rates for the event location.

OVC requires a detailed account of how scholarship funds will support
your organization's conference. In the following table, please indicate,
in Part A, indicate the total assistance that your organization is
requesting through the scholarship program. Current budgetary
information should be recorded in Part B.

+---------------------------------------------------+--------+---------+
| > **A. Total Assistance Your Organization is      | **Rate | **      |
| > Requesting**\                                   | /Day** | Total** |
| > **(to be Completed by Organization's Contact    |        |         |
| > Person)**                                       |        |         |
+---------------------------------------------------+--------+---------+
| > Number of Event Days                            | N/A    |         |
+---------------------------------------------------+--------+---------+
| > Projected Number of Scholarship Recipients      | N/A    |         |
+---------------------------------------------------+--------+---------+
|                                                   |        |         |
+---------------------------------------------------+--------+---------+
| > Conference Registration Fee **x** \# of         |        |         |
| > recipients:                                     |        |         |
| > **\$**\_\_\_\_\_\_\_\_\_\_\_\_x\_\_\_\_\_\_     |        |         |
| >                                                 |        |         |
| > ***Example**: \$250 (conference fee) **x** 2    |        |         |
| > (total number of recipients) = **\$500***       |        |         |
+---------------------------------------------------+--------+---------+
| > Daily Allowance for Lodging **x** \# of         |        |         |
| > recipients:                                     |        |         |
| > **\$**\_\_\_\_\_\_\_\_\_\_\_\_x\_\_\_\_\_\_     |        |         |
| >                                                 |        |         |
| > ***Example**: \$85 per day including taxes      |        |         |
| > **x** 3 days **x** 2 (total number of           |        |         |
| > recipients) = **\$510***                        |        |         |
+---------------------------------------------------+--------+---------+
| > Daily Allowance M&IE **x** \# of recipients:    |        |         |
| > **\$**\_\_\_\_\_\_\_\_x\_\_\_\_\_\_             |        |         |
| >                                                 |        |         |
| > ***Example**: \$25 per day **x** 3 days **x** 2 |        |         |
| > (total number of recipients) = **\$150***       |        |         |
+---------------------------------------------------+--------+---------+
| > Ground Transportation **x** \# of recipients:   |        |         |
| > **\$**\_\_\_\_\_\_\_\_\_\_\_\_x\_\_\_\_\_\_     |        |         |
| >                                                 |        |         |
| > \- Personal Car Mileage (@ \$0.445per mile)\    |        |         |
| > Shuttle:                                        |        |         |
| >                                                 |        |         |
| > \- Taxi:                                        |        |         |
| >                                                 |        |         |
| > **Rental Car expenses are not covered.**        |        |         |
+---------------------------------------------------+--------+---------+
| > Travel (air/train/bus fare) **x** \# of         |        |         |
| > recipients:                                     |        |         |
| > **\$**\_\_\_\_\_\_\_\_\_\_\_\_x\_\_\_\_\_\_     |        |         |
+---------------------------------------------------+--------+---------+
| > **Total Request:**                              |        |         |
+---------------------------------------------------+--------+---------+

+-----------------------------------------------------+----------------+
| **B. Agency Budget Information**                    | **Total**      |
+-----------------------------------------------------+----------------+
| > What is the organization's current total          |                |
| > operating budget?                                 |                |
+-----------------------------------------------------+----------------+
| > What is the organization's conference budget?     |                |
+-----------------------------------------------------+----------------+
| > How many participants do you expect to attend the |                |
| > conference?                                       |                |
+-----------------------------------------------------+----------------+

**Section G: Additional Information**

Please provide any additional information in support of the
organization's request for scholarship funds.

(Not to exceed 1-page)

**Section H: Scholarship Concurrence**

I certify that:

1.  The information provided in this application is accurate;

2.  This conference is statewide in scope and audience;

3.  My organization is unable to completely underwrite scholarships for
    victims/survivors wishing to attend our conference;

4.  The victims/survivors who receive scholarships have [a minimum of
    ONE YEAR EXPERIENCE]{.underline} in the victim services field;

5.  My organization has the experience and capacity to administer a
    scholarship program, and

6.  Any support obtained via the OVC State Crime Victim/Survivor
    Scholarship Program will not be used to supplant state or local
    funding previously allocated to support scholarships for conference
    attendees.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature of Organization CEO/President/Executive Director Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name of Agency

[Please mail the original and ONE COPY of the application with a
conference agenda to:\
]{.underline}

**Office for Victims of Crime**

**Training and Technical Assistance Center**

OVC State Crime Victim/Survivor Scholarship Program

10530 Rosehaven Street, Suite 400

Fairfax, VA 22030

Phone: 1--866--OVC--TTAC (1--866--682--8822)

TTY: 1--866--682--8880

Fax: 703--279--4673

E-mail address: statescholarship@ovcttac.org

Web site: www.ovcttac.org