Certification Form printable pdf download

CERTIFICATION FORM

Compliance with the Equal Employment Opportunity Plan (EEOP) Requirements

Please read carefully the Instructions (see below) and then complete Section A or Section B or Section C, not all three. If recipient

completes Section A or C and sub-grants a single award over $500,000, in addition, please complete Section D.

Recipient’s Name:

Address:

Is agency a; □ Direct or □ Sub recipient of OJP, OVW or COPS funding?

Law Enforcement Agency? □ Yes □ No

DUNS Number:

Vendor Number (only if direct recipient)

Name and Title of Contact Person:

Telephone Number:

E-Mail Address:

Section A—Declaration Claiming Complete Exemption from the EEOP Requirement

Please check all the following boxes that apply.

□ Less than fifty employees.

□ Indian Tribe

□ Medical Institution.

□ Nonprofit Organization

□ Educational Institution

□ Receiving a single award(s) less than $25,000.

_____________________________________________________________________________

[responsible

official], certify that ______________________________________________________________________________

[recipient] is not required to prepare an EEOP for the reason(s) checked above, pursuant to 28 C.F.R § 42.302.

I further certify that ______________________________________________________________________ [recipient]

will comply with applicable federal civil rights laws that prohibit discrimination in employment and in the delivery of

services.

If recipient sub-grants a single award over $500,000, in addition, please complete Section D

_______________________________________________________________________________________________

Print or Type 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

If 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

the recipient agency does not have to submit an EEOP to the OCR for review as long as it certifies the following (42 C.F.R. § 42.305)

_____________________________________________________________________________

[responsible

official], certify that ______________________________________________________________________________

[recipient], which has fifty or more employees and is receiving a single award or subaward for $25,000 or more, but less

than $500,000, has formulated an EEOP in accordance with 28 CFR pt. 42, subpt. E. I further certify that within the last

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 Rights, Office of Justice Programs, U.S. Department of Justice. The EEOP is on file at the following office:

_____________________________________________________________________________________

[organization],

_________________________________________________________________________________________

[address].

____________________________________________________________________________________________________________________

Print or Type Name and Title

Signature

Date

Section C—Declaration Stating that an EEOP Short Form Has Been Submitted to the Office for Civil

Rights for Review

If a recipient agency has fifty or more employees and is receiving a single award, or subaward, of $500,000 or more, then the recipient agency

must send an EEOP Short Form to the OCR for review.

_____________________________________________________________________________

[responsible

official], certify that ______________________________________________________________________________

[recipient], which has fifty or more employees and is receiving a single award of $500,000 or more, has formulated an

EEOP in accordance with 28 CFR pt. 42, subpt. E, and sent it for review on ________________________________

[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 Type Name and Title

Signature

Date

Certification Form

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