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Certification Form •
<br /> Compliance with the Equal Employment Opportunity Plan(EEOP)Requirements
<br /> Please read carefully the Instructions(see below)and then complete Section A or Section B or Section C, not all three.If
<br /> recipient completes Section A or C and sub-grants a single award over$500,000, in addition,please complete Section D.
<br /> tk •• :,i ' ►:n-
<br /> Address:
<br /> Is agency a;o Direct or El Sub reci ient of OJP,OVW or COPS funding? Law Enforcement Agency? D Yes ❑ No
<br /> DUNS Number: Vendor Number(only if direct recipient)n/a
<br /> Name and Title of Contact Person:l I 1
<br /> Telephone Number: E-Mail Address: I
<br /> Section A—Declaration Claiming Complete Exemption from the EEOP Requirement
<br /> Please check all the following boxes that apply.
<br /> • Less than fifty employees. ❑Indian Vibe DMedical Institution.
<br /> '•Nonprofit Organization El Educational Institution ❑Receiving a single award(s)less than$25,000,
<br /> I, 1 • ! [responsible
<br /> official],certify that
<br /> [recipient]is not required to prepare an ESOP for the reason(s)checked above,pursuant to 28 C.F.R.§42.302.
<br /> I further certify that [recipient]
<br /> will comply with applicable federal civil rights laws that prohibit discrimination in employment and in the delivery of
<br /> services.
<br /> /
<br /> I ree tent sub-grants a single award over$500000In addition,g rig , , please complete Section D
<br /> i
<br /> i
<br /> 'rant or Type Name and Title Signature Date
<br /> Section B—Declaration Claiming Exemption from the EEOP Submission Requirement and Certifying
<br /> That an EEOP Is on File for Review
<br /> If a recipient agency has fifty or more employees and is receiving a single award or,subawarca of$25,000 or more,but less than$500,000,then i
<br /> the recipient agency does not have to submit an ESOP to the OCR for review as long as U certifies the following(42 C.FR§92,305);
<br /> I, [ 604.art .-o✓te-S [responsible
<br /> official],certify that ' ti , („I4f o -v-a{H I 1.JCcat1K74 1
<br /> [recipient],which has fifty or more mployees and is receiving a singe award or subaward for$25,000 or more,but less than
<br /> $500,000,has formulated an EEOP in'accordance with 28 CFR pt.42,subpt.E.I further certify that within the last twenty-
<br /> four months,the proper authority has formulated and signed into effect the ESOP and,as required by applicable federal law, 1
<br /> it is available for review by the public, employees,the appropriate state planning agency;and the Office for Civil Rights,rfi
<br /> ce of J stice Proggms.U.S.Department oflustice.The EEOP is on file at the following off'icel
<br /> ' 11,11A(4,11 iie-sou 's?
<br /> [organization],
<br /> [address]. Z9 30(,0e F71'(OK A.J. v
<br /> l '�V 't� , / I X18 SW f j
<br /> Print or Type Name and Title 4(2.jy i Cul ,iO4e r,f 12 (Cc/ Signature -oh.! • Date - # 1
<br /> Section C—Declaration Stating that an EEOP Short Forn( tas 'S .•witted to the Office for Civil .
<br /> Rights for Review i
<br /> Ifa recipient agency hasfifty or more employees and is receiving a single award,or subawar,of$500,000 or more,then the recipient agency i
<br /> must send an EEOP Short Form to the OCR for review. #
<br /> I, [responsible III r
<br /> of ci• ,ce ' that •
<br /> [recipient], which has fifty or more employees and is receiving a single award of$500,000 or more, has formulated an
<br /> ESOP in accordance with 28 CFR pt.42,subt.E,and sent it for review on 1.
<br /> [date]to the Office for Civil Rights, Office of Justice Programs,U.S.Department of Justice.
<br /> If recipient sub-grants a single award over$500,000, in addition,please complete Section D
<br /> Print or Type Name and Title Signature Date
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