1 CERTIFICATION FORM ompliance with the C R equirements Equal Employment Opportunity Plan ( EEOP ) Section C, not all three (see below Section B or or . If recipient the Instructions ) and then complete Section A Please read carefully or completes C and sub - grants a single award over $500,000, in addit ion, please complete Section D. Section A Recipient’s Name: Address: □ Direct or □ Sub recipient of OJP, OVW or COPS funding? Law Enforcement Agency? □ Yes □ No Is agency a; Vendor Number (only if DUNS Number: direct recipient ) Name and Title of Contact Person: - Mail Address: Telephone Number: E Claiming Complete Exemption from the EEOP Requirement Section A — Declaration boxes that apply. following Please check all the than f ifty e mployees . Less □ Indian T ribe □ Medical I nstitution. □ E ducational I nstitution Nonprofit O □ □ □ R eceiving a single award (s) less than $25,000 . rganization I, ____________________________________________________________ ____ ____________ _ [ responsible ], certify _________________________________________________________________ ____________ _ official that ] is not required to prepare an EEOP for the reas on(s) checked above, pursuant to 28 C.F.R § 42.302. [ recipient ___________________________________________________________ ___________ [ recipient ] I further certify that will comply with applicable federal civil rights laws that prohibit discrimination in employment a nd in the delivery of services. - grants a single award over $500,000, in addition, please complete Section D If recipient sub _____________________________________________________________________ _______________ __ _________ Print or T ype Name and Title Signature Date Section B — Declaration Claiming Exemption from the EEOP Submission Requirement and Certifying That an EEOP Is on File for Review f a recipient agency has fifty or more employees and is receiving a single award or , subaward , of $25,000 or more, but less than $500,000, then I : the recipient agency does not have to submit an EEOP to the OCR f or review as long as it certifies the following (42 C.F.R. § 42.305) ____________ I [ responsible _______________________________________________________________ , __ , certify that official ________________________________________________________ ____________ _____ _ _ ] ___ recipient ] , which has fifty or more employees and is receiving a single award or subaward for $25,000 or more, but less [ in accordance with 28 CFR pt. 42, subpt. E. I further certify that within th e last than $500,000, has formulated an EEOP - twenty four months, the proper authority has formulated and signed into effect the EEOP and, as required by applicable federal law, it is available for review by the public, employees, the appropriate state planning agency, and the Office for Civil The EEOP is on file at the following office: Rights, Office of Justice Programs, U.S. Department of Justice . ______________________ _________________________ ______________________ ________ _ __ __ _ __ organization [ , ] __ ____________ ________ _ _____________________ ___ _ ________________________________________ _ [ address ]. __________________________________________________________________________________ _________________ _________________ Print or T Signature Date ype Name and Title Section C Declaration Stating that an EEOP Short Form Has Been Submitted to the Office for Civil — Rights for Review d , or subaward , If a recipient agency has fifty or more employees and is receiving a single awar of $500,000 or more, then the recipient agency must send an EEOP Short Form to the OCR for review. I , _______________________________________________________________ ____________ __ [ responsible official ] , certify that ___ ___________________________________ _____________________ ____________ _____ __ [ recipient , which has fifty or more employees and is receiving a single award o f $500,000 or more , has formulated an ] in accordance with 28 CFR pt. 42, subpt. E , and sent it for review on ______________________ __________ EEOP [ date ] to the Office for Civil Rights, Office of Justice Programs, U.S. Department of Justice . If recipient sub grants a single award over $500,000, in addition, please complete Section D - ______________________________________________________________________________________ ______________________________ Print or T ype Name and Title Signature Date
2 Section D — wards a Single Award Over $500,000 Declaration Stating that Recipient Suba name, address , including , ; If a recipient agency subawards a single award of $500,000 or more then the granting agency should provide a list - recipient. and DUNS # of each such sub - Recipient Agency Name /Address Sub - Recipient DUNS Number Sub If additional space in necessary , please duplicate this page. OMB Control No. 1121 - 0340 Expiration Date: 12/31/2015
3 INSTRUCTIONS Co mpleting the Certification Form Compliance with the Equal Employment Oppor tunity Plan (EEOP) Requirements The federal regulations implementing the Omnibus Crime Control and Safe Streets Act (Safe Streets Act) of 1968, as amended, require some recipients of financial assistance from the U.S. Department of Justice subject to the statute’s administrative provisio ns to create, keep on file, submit to the Office for Civil Rights (OCR) at the Office of Justice See 28 C.F.R. pt. 42, subpt. Programs (OJP) for review, and implement an Equal Employment Opportunity Plan (EEOP). E. All awards from the Office of Community O riented Policing Services (COPS) are subject to the EEOP requirements; many awards from OJP, including awards from the Bureau of Justice Assistance (BJA), the Office of Juvenile Justice and e (OVC) are subject to the EEOP requirements; and Delinquency Prevention (OJJDP), and the Office for Victims of Crim many awards from the Office on Violence Against Women (OVW) are also subject to the EEOP requirements. If you have any questions as to whether your award from the U.S. Department of Justice is subject to th e Safe Streets Act’s EEOP requirements, please consult your grant award document, yo ur program manager, or the OCR. either Section A or Section B or Section C, not all three. Recipients should complete If recipient completes Section A C and sub - grants a single award over $500,000, in addition, please complete Section D. or Section A The regulations exempt some recipients from all of the EEOP requirements. Your organization may claim an exemption from all of the EEOP requirements if it m eets any of the following criteria: it is a nonprofit organization, an educational or it received an award under $25,000; or it has less than fifty institution, a medical institution, or an Indian tribe; EEOP re employees. To claim the complete exemption from the quirements, complete Section A. Section B Although the regulations require some recipients to create, maintain on file, and implement an EEOP, the regulations allow some recipients to forego submitting the EEOP to the OCR for review. Recipients th at (1) are a unit of state or local government, an agency of state or local government, or a private business; and (2) have fifty or more employees; and (3) have received a single grant award of $25,000 or more, but less than $500,000, may claim the limite d exemption from the submission requirement by completing Section B. In completing Section B, the recipient should note that the EEOP on file has been prepared within twenty four months of the date of the most recent grant award. - Section C t (1) are a unit of state or local government, an agency of state or local government, or a private business, Recipients tha and (2) have fifty or more employees, and (3) have received a single grant award of $500,000 or more, must prepare, submit to th e OCR for review , and implement an EEOP. Recipients that have submitted an EEOP maintain on file, Utilization Report (or in the process of submitting one) to the OCR, should complete Section C. Section D Recipients that (1) receive a single award over $500,000; and (2) subaward a single award of $500,000 or more must provide a list ; including , name, address and DUNS # of each such sub - recipient by completing Section D. Submission Pro cess , complete required sectio ns Recipients should download the online Certification Form have the appropriate official sign , it, electronically scan the signed document, and then send the signed document to the following e - mail address: [email protected] . The document must have the following title: EEOP Certification. If you have question s about completing or submitting the Certification Form, please contact the Office for Civil Rights, Office of Justice Programs, - 0690 and TTY: (202) 307 - 2027). 810 7th Street, NW, Washington, DC 20531 (Telephone: (202) 307 OMB Approval No. 1121 - 0340 Expi ration Date: 12/31/15
4 Public Reporting Burden Statement Paperwork Reduction Act Notice. Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a current valid OMB control number. We try to create forms and instructions that are accurate, can be easily understood, and which impose the least possible burden on you to provide us with information. The estimated minimum average time to complete and file this application is 20 minutes per form. If you have any comments regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the Office of Justice Programs, 810 7th Street, N.W., Washington, D.C. 20531.
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