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ATTACHMENT C
<br /> CERTIFICATION FORM
<br /> Compliance with the Equal Employment Opportunity.Plan(EEOP)Requirements
<br /> Please read carefullytlre Instructions(see below)and then complete Section A or Section B or Section C not all three,
<br /> Recipient's Name:Everett Police Department
<br /> Address:3002 Wetmore Avenue,Everett,WA 98201-4018
<br /> Is agency a ❑ Direct or E]Sub recipient of OJP,OVW or COPS funding? Law Enforcement Agency?Q Yes❑No
<br /> DUNS Number: 608909156 Vendor Number(only if direct recipient):N/A
<br /> Name and Title of Contact Person:Jerry Strieck,Lieutenant
<br /> Tele'hone Number: 425)257-8447 E-Mail Address: jstriec.'ci.everett.wa.us
<br /> Section A—Declaration Claiming Complete Exemption from the EEOP Requirement
<br /> Please check all the following boxes that apply:
<br /> n Less than fly employees. Indian tribe. Medical Institution.,
<br /> I Nonprofit Organization. Educational Institution. n Receiving an award less than S25,000
<br /> [responsible official],
<br /> certify that[recipient]is not required to prepare an EEOP for the:reason(s)checked above,pursuit to 28 C.F.R. §42.302.
<br /> I further certify that [recipient]
<br /> will comply with all applicable federal civil rights laws that prohibit discrimination in employment and in the delivery of
<br /> services.
<br /> Print or T-.e Name and Title Si: ature Date
<br /> Section B—Declaration Claiming Exemption from EEOP Submission Requirement and Certifying
<br /> That an EEOP Is on File for.Review
<br /> If a recipient has fifty or more employees and is receiving a single award or,szzbaward of$25,000 or more,but less than$500,000,then the recipient
<br /> agency does not have to submit an LEO?to the OCR for review as long as it certifies the following(42 GFR§42.305):
<br /> I. ?,,, Ck0 G l 61\.. [responsible official],
<br /> certify that ) (';:;,1t-\„\ 0 ll ,' , [recipient]
<br /> Which has fifty or more employees and is receiving a single award for $25,000 or more, but less than $500,000, has
<br /> formulated an EEOP in accordance with 28 CFR pt.42, subpt E. I further certify that within the last twenty-four months,
<br /> the proper authority has formulated and signed into effect the EEOP and, as required by applicable federal law, it is
<br /> available for review by the public, employees, the appropriate state planning agency, and the Office for Civil Rights,
<br /> Office of Justice Programs,U.S.Departmen of Justice.The EEOP is on file at the following office:
<br /> [organization], •
<br /> 4 o O, or PYetAi 1
<br /> [ ` rI( S - h llE - ,t r
<br /> Print or P e Nae andTitle •nature Date
<br /> Section c-Declaration Stating that an EEOP Short Form Has Been Submitted to the Office for Civil
<br /> Rights for Review
<br /> If a recipient agency has fifty or moreemployees and is receiving a single award or subaward of$500,000 or more,then the recipient agency must
<br /> send an EEO?Short Form to the OCR for review.
<br /> [responsible official], s:
<br /> certify that [recipient],
<br /> which has fifty or more employees and is receiving.a single award of$500,000 or more,has formulated an EEOP in
<br /> accordance with 28 CFR pt. 42,subpt.E,:anal sent it for review on [date]to the
<br /> Office for Civil Rights,Office of Justice Programs,U.S. Department of Justice.
<br /> Print ori Type Name and Title Signature Date
<br /> ATTEST.
<br /> City Clerk
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