Okaloosa County BOCC — January 7, 2014 — LETF Application

OKALOOSA COUNTY LETF APPLICATION PROGRAM INFORMATION Program Title: Name/ Title of Contact: Address: Phone: City • Zip Code: Fax: Total Program Budget: E-mail: New Renewal Amount Program is: P Requested: If renewal, circle number of years this program has been funded thru LETF? 1 2 3 4 or more APPLICANT AGENCY INFORMATION Applicant Agency Legal Name: Program Name: Main Administrative Address: City & State: Zip Code: Telephone Number: Fax Number: Website: CEO/Executive Director: Office Phone Number: E-mail Address: Federal Identification Number: LETF CATEGORY (Place an “X” to the left of one program area for which you Intend to Apply): 1. Crime Prevention 2. Drug Abuse Prevention/Education 3. Safe Neighborhood 4. School Resource Officer 5. Other Law Enforcement Purpose (specify below) 1  PROPOSED PROGRAM INFORMATION 1. Program Summary (1-3 sentences): Provide an overview of program services. 2. Program Purpose (1-3 sentences): Please identify the services, target population and how many will be served while completing the following statement. The purpose of this program is… 3. Proposed use of LETF proceeds: Please identify the proposed use(s) of LETF proceeds and specify how it fulfills the statutorily authorized uses set forth in Section 932.7055, Florida Statutes. These proceeds shall not be utilized to meet normal operating needs of the applicant agency/organization. 4. Has your agency received funding from LETF within the last three (3) years? (If yes, identify the source of that funding, when it was received and the dollar amount that the agency has received). 5. Have you applied for funding for this program from any other entity or agency? (If yes, identify the source from which the funding was sought, the dollar amount requested from the source and provide the outcome of that application). 2  Upon completing this application in its entirety, please read the following statement and affix your signature accordingly. I have read, fully understand and agree to be bound by Okaloosa County’s Operating Procedures for Law Enforcement Trust Fund and applicable state statutes. I have completed this application fully and accurately and have not misrepresented any information contained herein. I certify that the requested funds will be used for the purposes set forth in this application and in conformity with Florida law. I agree to submit proper supporting documentation within sixty (60) days of expending the LETF proceeds, which establishes that such proceeds were expended for the purposes they were approved and in conformity with Florida law. I further agree that should I fail to provide such documentation within the specified time period, I will be responsible for reimbursing Okaloosa County for the amounts received. Signature of Applicant Date of Application Print Name of Applicant OFFICIAL USE ONLY I, Larry R. Ashley, do hereby certify that the aforementioned request for LETF proceeds is in compliance with Section 932.7055, Florida Statutes. ____________________________ Sheriff Larry R. Ashley Board of County Commissioners: Approved/Disapproved Date: _________ Amount approved: $________ 3