State Use Only Grant # ______________ NEBRASKA CRIME COMMISSION FY 2018 STOP Violence Against Women Act GRANT APPLICATION *Attach Proof of Non-profit Status 1. Applicant Name: (Agency/Organization) The applicant must be the agency that will receive and disburse the grant funds. Legal Name: Telephone ( ) Fax ( ) 2. Applicant Federal Employer ID #: (must be 9 digits) 3. Applicant DUNS #: 4. Applicant Address: (physical address) (Include zip code + 4 digits) 5. Project Title: 6. Project Point of Contact: PPOC (Main contact. Responsible for all correspondence regarding grant award and project.) Name: Title: Email: Telephone( ) Fax ( ) Address: (Include zip code + 4 digits) 7. Project Coordinator: (Individual who serves as the secondary contact for the project.) Name: Title: Telephone( ) Fax ( ) Address: (Include zip code + 4 digits) 8. Fiscal Point of Contact: FPOC (Responsible for fiscal oversight and fiscal reports. Cannot be same as the PPOC) Name: Title: Email: Telephone( ) Fax ( ) Address: (Include zip code + 4 digits) 9. Authorized Official: (NOTE: The authorized official is the Mayor, Chair of County Board or City Council or the Board Chair of a Private Non-profit Agency.) Name: Title: Email: Telephone( ) Fax ( ) Address: (Include zip code + 4 digits) 10. Previous 5-Years Commission Funding for This Project: Grant #: Amount: #: Amount:
From To $ $ $ From To $ $ $ c. Meals # of days X $ X # people $ $ $ # of days X $ X # people $ $ $ d. Lodging # of nights X $ X # people $ $ $ # of nights X $ X # people $ $ $ e. Other Costs (Must be Explained in Budget Narrative) $ $ $ $ $ $ $ $ $ $ $ $ TRAVEL TOTAL $ $ $ Travel Allocation Chart: Complete on fund requested. Do not include match. Of the total requested funds for each category how much will be dedicated to SA services and/or Prevention & Education Consultant/Contracts: Total Requested by Category Sexual Assault Service Prevention & Education LE $ $ $ Prosecution $ $ $ Victim Services $ $ $ Culturally Specific $ $ $ CRT Coordination (Discretionary) $ $ $ BIP (Discretionary) $ $ $ CATEGORY C - TRAVEL EXPENSES NARRATIVE: All sources of match must be identified. Address supplanting of CATEGORY D – SUPPLIES AND OPERATING EXPENSES 1. SUPPLIES: Item Quantity Unit Amount Requested Applicant TOTAL COSTS $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Supplies Subtotal $ $ $ OPERATING EXPENSES – (Note Special Instructions): Rate (per month) % Allocated Amount Requested Applicant Match TOTAL COSTS Rent – Equipment $ % $ $ $ Rent – Facilities $ % $ $ $
Other Costs: Total Requested by Category Sexual Assault Service Prevention & Education LE $ $ $ Prosecution $ $ $ Victim Services $ $ $ Culturally Specific $ $ $ CRT Coordination $ $ $ BIP $ $ $ CATEGORY F - OTHER COSTS NARRATIVE: All sources of match must be identified. Address supplanting of funds. For each line item, outline the calculation, allocation, and justification. CATEGORY G – INDIRECT COSTS Attach agreement. Federally Approved Indirect Cost Rate Rate % Total Amount Requested Applicant Match Total $ $ $ 10% De Minimis - Attach copy of the agency’s written allocation policy for these costs and certification letter. Direct Costs: Budget Category Amount Requested Comments/Narrative Personnel $ Consultants/Contracts $ Travel $ Supplies/Operating $ Equipment $
Solution 4 pages) Project Operations Outline pertinent day-to-day operations of the project related to the funding request. Identify strategies and methods the project will use to address the problem and accomplish the outcomes indicated in the application. Must identify evidence based or best practices utilized to increase safety and economic security for victims/survivors and or to increase offender accountable. Applicant must explain how the project (including subawards) coordinate with service area health care providers to ensure that victims of sexual assault are aware of the availability of a forensic medical exam at no cost (to the victim). Activity / Timeline (Limit 2 pages) ACTIVITY POSITION RESPONSIBLE 1ST Quarter 1st-3rd 2nd Quarter 4th-6th 3rd Quarter 7th-9th 4th Quarter *Add rows as needed Continuation Information 2 pages) Lists the specific results of the project’s measureable outcomes (if project operated on STOP funds last year report on the Outcomes and Performance Measures) achieved in the last 12 months. Explain problems, barriers, challenges, and how they were addressed, and any end results. Provide any other relevant information here.
Other CRT #4 CRT #5 CRT #6 Counties CRT POC Information Name: Phone: Email: Name: Phone: Email: Name: Phone: Email: # of mtgs. per yr. Date of last mtg. held CRT supported with STOP funds. (yes or no) CRT Members Active Participant MOU Attached Active Participant MOU Attached Active Participant MOU Attached Law Enforcement Courts Probation Prosecution Victim Services Culturally Specific Services Sexual Assault Response Teams: If a SART exist, is it a separate team from the CRT? ___Yes ____No SART #1 SART #2 SART #3 Counties SART POC Information Name: Email: Name: Phone: Email: Name: Phone: Email: Mtgs. Held per yr. Date of last mtg. held # of SANEs SART is supported with STOP funds (yes or no) See Instructions for sample Memorandum of Commitment for Coordinated Response Teams. Applicant Disclosures of Pending Applications: Applicants are to disclose whether they have pending applications for federally and or state funded grants that include requests for funding to support the same project being proposed under this solicitation and will cover the identical cost items outlined in the budget in the application under this solicitation. Mark none if you have no pending applications. Federal or State Funding Agency Solicitation Name / Project Name Name/Phone/E-mail for Point of Contact at Funding Agency