Mississippi Administrative Code › Title 1 - Secretary of State › Part 19 - Mississippi Voting Modernization Act Grant Program ("MVMGP") › Chapter 2 - Procedures › Appendix A - MVMGP Grant Application Form

Current through June 25, 2024
2022 Mississippi Voting Modernization Act Grant Program
				  ("MVMGP) Grant Application Form
County:
				  _______________________________________________________
Person Completing Application:
				  ________________________________________
Title/Position:
				  _____________________________________________
Phone Number:
				  ___________________________________________________
Fax Number:
				  ______________________________________________________
Email:__________________________________________________________
Additional Documents Checklist. Please check all that
				  apply:
Voting Systems:
_______ Copy of Contract/Invoice attached
_______ Verification from Vendor that Systems does not
				  utilize pre-scored punch card ballots, produces voter verifiable paper ballots;
				  and does not have capability for remote wireless connection. (For the purposes
				  of this grant, capability for remote wireless connection includes having
				  internal hardware that could allow for wireless communication such as wi-fi or
				  Bluetooth.)
Other Eligible Expenses:
_______ Copy of Contract/Invoice attached
_______ Verification that existing voting systems already in
				  compliance with MVMGP
_______ Affidavit of no existing debt
_______ If existing systems not already in compliance with
				  MVMGP, certification that grant money will only be applied to other eligible
				  expenses from funds remaining after applicant county is in compliance with
				  MVMGP
Outstanding Indebtedness:
_______ Certification from voting system vendor as to balance
				  owed.
_______ Copy contract and purchase order
_______ Verification from Vendor that Systems does not
				  utilize pre-scored punch card ballots, produces voter verifiable paper ballots;
				  and does not have capability for remote wireless connection. (For the purposes
				  of this grant, capability for remote wireless connection includes having
				  internal hardware that could allow for wireless communication such as wi-fi or
				  Bluetooth.)
Table A: Total Grant Request
Grant
								Area
Details and Proposed Date of
								Purchase
Proposed
								Cost
Voting Systems
Type of System:
__________________
Date of Purchase:
__________________
Vendor:
__________________
Manufacturer and Model No of System:
__________________
__________________
$
Other Eligible Expenses
Itemized other eligible expenses:
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
$
$
$
$
$
$
$
$
$
$
$
Outstanding Indebtedness owed for existing voting
								systems (attach required documentation)
Type of System: ________________
Date of Purchase:
____________
Vendor:
____________
Manufacturer and Model No of System:
__________________
__________________
$
Subtotal voting systems
$
Subtotal other eligible expenses
$
Outstanding Indebtedness
$
TOTAL
$