Okaloosa County BOCC — January 19, 2016 — SF424 Chairman signature needed — reading text

1-800-518-4726 WORKSPACE FORM SUPPORT@GRANTS.GOV This Workspace form is one of the forms you need to complete prior to submitting your Application Package. This form can be completed in its entirety offline using Adobe Reader. You can save your form by clicking the "Save" button and see any errors by clicking the “Check For Errors” button. In-progress and completed forms can be uploaded at any time to Grants.gov using the Workspace feature. When you open a form, required fields are highlighted in yellow with a red border. Optional fields and completed fields are displayed in white. If you enter invalid or incomplete information in a field, you will receive an error message. Additional instructions and FAQs about the Application Package can be found in the Grants.gov Applicants tab. OPPORTUNITY & PACKAGE DETAILS: Opportunity Number: OVW-2016-9003 Opportunity Title: OVW FY 2016 Justice for Families Program Opportunity Package ID: PKG00219779 CFDA Number: 16.021 CFDA Description: Justice Systems Response to Families Competition ID: OVW-2016-9003 Competition Title: OVW-2016-9003 Opening Date: 11/24/2015 Closing Date: 01/21/2016 Agency: Office on Violence Against Women Contact Information: Carrie Mitchell E-mail: OVW.JFF@usdoj.gov Phone: 202-307-6026 APPLICANT & WORKSPACE DETAILS: Workspace ID: WS00002018 Application Filing Name: Okaloosa County Board of County Commissioners DUNS: 6132776490000 Organization: OKALOOSA, COUNTY OF Form Name: Application for Federal Assistance (SF-424) Form Version: 2.1 Requirement: Mandatory Upload Count: 0 Download Date: 01/06/2016 Form State: Error(s) FORM ACTIONS:  OMB Number: 4040-0004 Expiration Date: 8/31/2016 Application for Federal Assistance SF-424 * 1. Type of Submission: * 2. Type of Application: * If Revision, select appropriate letter(s): Preapplication New Application Continuation * Other (Specify): Changed/Corrected Application Revision * 3. Date Received: 4. Applicant Identifier: Completed by Grants.gov upon submission. 5a. Federal Entity Identifier: 5b. Federal Award Identifier: State Use Only: 6. Date Received by State: 7. State Application Identifier: 8. APPLICANT INFORMATION: * a. Legal Name: Okaloosa County Board of County Commissioners * b. Employer/Taxpayer Identification Number (EIN/TIN): * c. Organizational DUNS: 59-6000765 6132776490000 d. Address: * Street1: c/o Contract and Grants Street2: 101 E James Lee Blvd, Room 104 * City: Crestview County/Parish: Okaloosa * State: FL: Florida Province: * Country: USA: UNITED STATES * Zip / Postal Code: 32536-3501 e. Organizational Unit: Department Name: Division Name: Growth Management f. Name and contact information of person to be contacted on matters involving this application: Prefix: Mrs. * First Name: Marcella Middle Name: B. * Last Name: Eubanks Suffix: Title: Contracts and Grants Manager Organizational Affiliation: Okaloosa County Clerk of Courts * Telephone Number: (850) 689-5000 x 4381 Fax Number: (850) 689-4272 * Email: meubanks@okaloosaclerk.com Application for Federal Assistance SF-424 * 9. Type of Applicant 1: Select Applicant Type: B: County Government Type of Applicant 2: Select Applicant Type: Type of Applicant 3: Select Applicant Type: * Other (specify): * 10. Name of Federal Agency: Office on Violence Against Women 11. Catalog of Federal Domestic Assistance Number: 16.021 CFDA Title: Justice Systems Response to Families * 12. Funding Opportunity Number: OVW-2016-9003 * Title: OVW FY 2016 Justice for Families Program 13. Competition Identification Number: OVW-2016-9003 Title: OVW-2016-9003 14. Areas Affected by Project (Cities, Counties, States, etc.): Add Attachment Delete Attachment View Attachment * 15. Descriptive Title of Applicant's Project: Justice for Okaloosa County Families Program Attach supporting documents as specified in agency instructions. Add Attachments Delete Attachments View Attachments Application for Federal Assistance SF-424 16. Congressional Districts Of: * a. Applicant FL-001 * b. Program/Project FL-001 Attach an additional list of Program/Project Congressional Districts if needed. Add Attachment Delete Attachment View Attachment 17. Proposed Project: * a. Start Date: 10/01/2016 * b. End Date: 09/30/2019 18. Estimated Funding ($): * a. Federal 557,329.00 * b. Applicant 0.00 * c. State 0.00 * d. Local 0.00 * e. Other 0.00 * f. Program Income 0.00 * g. TOTAL 557,329.00 * 19. Is Application Subject to Review By State Under Executive Order 12372 Process? a. This application was made available to the State under the Executive Order 12372 Process for review on . b. Program is subject to E.O. 12372 but has not been selected by the State for review. c. Program is not covered by E.O. 12372. * 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.) Yes No If "Yes", provide explanation and attach Add Attachment Delete Attachment View Attachment 21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001) ** I AGREE ** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions. Authorized Representative: Prefix: * First Name: Charles Middle Name: K. * Last Name: Windes Suffix: Jr. * Title: Okaloosa County Board of County Commissioners * Telephone Number: (850) 689-5000 x 4381 Fax Number: * Email: meubanks@okaloosaclerk.com * Signature of Authorized Representative: * Date Signed: