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<br /> Certification Form
<br /> Compliance with the Equal Employment Opportunity Plan(EEOP)Requirements
<br /> Please read carefitAy the Instructions(see below)and then complete Section A or Section B or Section C,not all three (f
<br /> recipient completes Section A or C and sub grants a single award over$500,000 in addition please complete Section D.
<br /> Recinienf.s Nuns:.j
<br /> Address:
<br /> Is agency a',o Direct or®Sub recipient of OW,OVW or COPS funding? Law Enforcement Agency?0 Yes 0 No
<br /> DUNS Number! Vendor Number(only If direct recipient)n/a
<br /> Name and'rifle of Contact Person: _.m .]L__�,,,..� ,. . � ---,.. 1
<br /> Telephone Number: E A4ai1 Address: (�
<br /> Section A—Declaration Claiming Complete Exemption from the EEOP Requirement
<br /> Please check all the fa owing boxes that apply. •
<br /> C]less than fifty employees, El Tndlan Tribo OMeciloal Institution.
<br /> QNonproftOrganization 1Itduoationdinethudon QRecalving asingle award(e)teas tan V25,000,
<br /> [responsible •
<br /> •
<br /> official],certify that�..
<br /> [recipient]is not required to prepare an EEO?far the reason(s)checked above,pursuant to 28 C.F.R.§42.302,
<br /> I further certify that [(eci1ient]
<br /> will comply with applicable federal civil rights laws that prohibit discrimination in employment and In the delivery of
<br /> services, • .
<br /> (frecipient sub grants a single award over$500,00,to addition,please complete Section 1)
<br /> Print or 4pa Name and Title Stratum Date
<br /> Section B—Declaration Claiming Exemption from the EEOP Submission Req Certifying
<br /> and C ing
<br /> That an EEOP Is on File for Review
<br /> U•a recipient agency hasfilly or more employees and to receiving a single award or,subaward,of$25,000 or more,but lees than$500,000,then
<br /> the recipient agency does not have to submit an ESOP to the OCRfor review as long as U certifies tha,Jbllowlng(42 C,F.,R§41,305);
<br /> t.'41/1 . Vie- [responsible
<br /> official],certify that C i-}y of"Eve-uefi W � J ;
<br /> [recipient],which has fifty or mare bmployeea and is receiving a s' award or subaward for$25,000 or more,but less than
<br /> $500,000,has formulated an ESOP in•accordance with 28 CFR pt.42,subpt.E.I farther certify that within the last twenty-
<br /> four months,the proper authority bee formulated and signed into effect the EEOP and,as required by applicable federal law,
<br /> it is available for review by the public,employees,the appropriate state planning agency;and the Office for Civil Rights,
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<br /> [organiZation], •
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<br /> [addreisl. akr _
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<br /> Print or Type Name and.Title t§Y t q,e l f p F! • 'e4,/ Signature.,`..- `-_:e`A.e • .r Date 9',6.-/7
<br /> Section C4•-Declaration Stating thatanESOP Short Fo Has a witted to the Office for Civil
<br /> Rights for Review
<br /> .{fa recipient agency has fey or more employees and is receMnga single award or subawa ,eff500,000 or mare,then the recipient agency
<br /> must send an SHOP Short Form to the OCR for revnew.
<br /> • I, Ir rv� [responsible
<br /> 0J 1ad],certify that — .. l
<br /> [recipient], which has My or more employees and Is receiving a single award of$500,000 or more,has formulated an
<br /> MOP in accordance with 28 CFR.pt.42,sunt B,and sent It for review on
<br /> [date]to the Office for Civil Rights,Office of Justice Programs,U.S,Department of Justice
<br /> •lf recipient sub-grants a single award over$500,000,in addition,please complete Section D
<br /> Print or ry+pe Name and 7711e Signature Date
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