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HomeMy WebLinkAbout20081825.tiff RESOLUTION RE: APPROVE APPLICATION FOR JUVENILE ACCOUNTABILITY BLOCK GRANT AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with an Application for the Juvenile Accountability Block Grant for the Female Offender Program and the Collaborative Crisis Assessment and Triage Services Program, from the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Sheriff's Office and North Range Behavioral Health, to the Colorado Division of Criminal Justice, commencing October 1, 2008, and ending September 30, 2009, with further terms and conditions being as stated in said application, and WHEREAS, after review, the Board deems it advisable to approve said application, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Application for the Juvenile Accountability Block Grant for the Female Offender Program and the Collaborative Crisis Assessment and Triage Services Program, from the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Sheriff's Office and North Range Behavioral Health,to the Colorado Division of Criminal Justice be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said application. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 30th day of June, A.D., 2008. BOARD OF COUNTY COMMISSIONERS � WELD COUNTY, COLORADO `'J ATTEST: �` , 6it-( l= William H. Jerke, Chair Weld County Clerk to B dcn / 0 9 EXCUSED Robert D. Maslen Pro-Tem BY: / j Deputy Clerk o the Board L� Willie Garcia APPROVE S FORM: `40? ��` ', vid E. Long n ttor (a1 q o � Dougla(Rademacher ate of signature: /Ozze // 2008-1825 SO0029 2007 JABG Application Direct Awards J COLORADO DIVISION OF CRIMINAL JUSTICE JUVENILE ACCOUNTABILITY BLOCK GRANT APPLICATION FOR PROGRAM FUNDS SECTION I - APPLICANT INFORMATION STATE USE ONLY Ill I App #: I Grant#: I Award: APPLICANT AGENCY: I Weld County Address 1950 O Street City,ZIP Greeley,CO 80631 Project Director Ken Poncelow E-mail kponcelow@co.weld.co.us Telephone (970)356-4015 ext 2802 FAX (970)304-6467 Federal Employer ID Number 8 4 6 0 0 0 8 1 3 _ . , FEDERAL FUNDS REQUESTED: $15,248 CASH MATCH: $1,694.00 TOTAL: $16,942.00 TYPE OF AGENCY: (check one) OState ❑City/Town ®County ❑Indian Tribe ❑Private Non-profit ❑Faith-Based Non-Profit ❑ Other FUNCTION OF ® Law Enforcement El Probation ❑ Prosecution AGENCY: 9 Courts ❑ Social Services 9 Youth Services ❑ Public Defense ❑ Education El Treatment/Mental Health ❑ Treatment/Substance Abuse ❑ Other Describe: TYPE OF APPLICATION: X JABG Local Allocation 9 State Program Funds 00ther New: Continuation: 0 Start a new project ® Continue a project currently receiving JABG funds 0 Expand or enhance an existing project not D Expand/enhance an existing project receiving JABG funds previously JABG-funded For continuation applications,list up to three years of prior JABG funding in the table below. GRANT NUMBER FEDERAL FUNDS DURATION PROJECT TITLE:Weld County Juvenile Accountability PROJECT DURATION: From 10/01/2008 To 09/39/2009 PROJECT DESCRIPTION (Limit to space provided):These funds support services to juvenile offenders in Weld County through two agencies. North Range Behaviorial Health will deliver needed mental health services to detained youth from Weld county at Platte Valley Youth Services Center. Services to be provided will include risk and needs assessments of juvenile offenders,crisis intervention, and referral to ongoing mental health care as needed. The 19th Judicial Probation Department will provide gender specific probation services in an effort to provide greater access to services/accountability for 15-20 female juvenile offenders utilizing as Individual Probation Plan(IPP). In addition to the IPP the girls will participate in weekly groups and collaborative case management. PURPOSE AREA#1: 12 PURPOSE AREA#2 (if applicable): 15 PROJECT WILL BE USING EVIDENCE-BASED PROGRAMS OR ACTIVITIES: Yes ❑No SERVICE AREA: U. S. Congressional District(s): ❑1 ❑2 D3 Z4 ❑5 ❑6 ❑7 ❑Statewide Judicial District(s)(Identify by District Number): 19 Cities and Counties to be served: Weld County - 1 - 19TH JUDICIAL PROBATION FEMALE OFFENDER PROGRAM FUNDING REQUEST PROBLEM: In the last five years in Weld County there has been a significant increase of female offenders being served by Juvenile Probation Officers. In 2001 101 new juvenile female offenders served by probation, in 2007 there were 155, a Weld County increase of 53%. Probationers considered at maximum level or"highest risk" are referred to Probation Officer Donna DeLuca, who oversees and coordinates the Juvenile Female Offender Program (JFOP). The term"high risk" as it relates to JFOP is defined as: a female juvenile who is not profiting from standard probation interventions that have been implemented to date and who is continuing to put herself or others at risk through her current behavior. Between 70% and 80% of these young women present with multiple issues such as prior sexual assault, family violence and substance abuse that need to be address in concert with multiple agencies and programs. Without program intervention, maximum level/high risk female offenders are not successful at completing probation. Gender specific issues tied directly to their "high risk"behaviors must be addressed to increase the chance of successful completion of probation. B. Contributing Factors: A key factor is understanding the gender specific relationship between victimization,traumatic and abusive home life, and juvenile female crime. In order to appreciate the complexity of these gender specific issues, it is critical to consider the inter-relationship of all the accompanying behavior variables that play a major role in determining probation outcomes: 1. Youth and Family Issues: Parental disengagement, sexual assault, domestic violence, pregnancy, gang involvement, extensive substance abuse, multiple educational failures and unidentified educational needs and significant losses within the family. 2. Probationer Behaviors: Defiant, disgraceful, aggressive, resistive,belligerent, antagonistic, angry, uncooperative, truant, irresponsible, impulsive, thoughtless. 3. System Issues: Previously failed placements, failure to access or profit from needed services, inappropriate referrals, and program or agency resistance to provide services, lack of gender specific programs, incomplete assessment of needs, lack of access to specific programs or services that might address these needs. Unfortunately, the attention of the families and professionals is often focused on a single, isolated behavior variable. Their reaction to the isolated behavior determines how they relate to these young women, and triggers requests for punitive detention, suspension, expulsion, or even DYC commitment. Rather, their focus must be driven by the dynamic interplay of victimization, the trauma of abusive home life and dysfunctional parental interactions. PROJECT TITLE: Juvenile Female Offender Program (JFOP) PURPOSE AREA: Number 12. Establishing and maintaining programs to conduct risk and needs assessments of juvenile offenders that facilitate the effective early intervention and the provision of comprehensive services, including mental health screening and treatment and substance abuse testing and treatment to such offenders. SUMMARY OF FOCUS WITHIN THE PURPOSE AREA: To continue providing services to high- risk juvenile female offenders, by expediting access to appropriate services and greater accountability, and to increase the number of probationers that successfully complete probation. Through providing more intensive supervision, weekly gender specific groups and the development of the Individualized Probation Plan (IPP) a greater number of young women will be served. This grant will continue probation's current services with the professional skills of Hawk II Systems, whose personnel are trained in specialty areas such as family/group dynamics and substance abuse/mental health needs. This collaboration between Probation, Hawk II Systems and other service providers give broader service delivery and greater accountability to this unique population. GOAL 1: For each young woman referred, a collaborative, gender responsive, culturally sensitive process that facilitates timely access to specific community programs, actively involves parents and/or meaningful relations, and incorporates weekly groups, while simultaneously responding to the needs of the probationer and the orders of the court. This rapid and meaningful response, reflected in the creation of an Individualized Probation Plan (IPP), is a critical step in developing a comprehensive assessment, activating appropriate substance abuse services, developing pro-social skills, maintaining accountability, reducing revocations, and increasing the number of positive program completions. Objective 1: To provide greater access to services/accountability to a minimum of 18-22 juvenile female offenders utilizing the Individual Probation Plan (IPP). Responsible Time-Line Measurement Person Through the use of the multi-disciplinary staffing team, the # of female JFOP IPP will reflect the needs, services and collective inter-agency 10/01/08 to juveniles Probation goals the juvenile female offender will address both short and 9/30/09 assessed Officer long-term. Objective 2: Provide weekly groups and collaborative case management to a minimum of 18-22 juvenile, female offenders facilitated by the contracted services of Hawk II Systems. Responsible Time-Line Measurement Person Once accepted into the JFOP, the parent/youth group will be # of female JFOP required for a period of one month, and then peer education 10/01/08 to juveniles Probation groups will address multiple life-skill subjects. Additionally, 9/30/09 attending Officer random/collaborative in-home supervision will be provided. completing GOAL 1 INDICATORS 1. Output indicator: • Caseload of grant funded probation officer. Objective #1, the program will serve a minimum of 18-20 high-risk juvenile female probationers, assessed and recorded from 10/1/08 to 9/30/09. For each of the probationers, an IPP staffing will be initiated and documented by the grant funded probation officer; the IPP will be present in each probationer's file. Review staffing for each probationer will be formally conducted every 30 days for up to 6 months. 2 Objective #2, the actual number of juvenile female probationers who attended the weekly JFOP group will be counted, the assignment completed will be counted as well as the actual number completing / graduating from the groups. 2. Short-term indicator: • Average number of supervision meetings per month. Objective #1, each female offender accepted into the program will have a minimum of one supervision contact per week, and may have up to five meetings or contacts per week. These supervision events are based on the level of need, how recently the young woman was staffed into the program, the number of supportive services being provided, and her general day to day level of functioning. Objective #2, each group attended by parent and child, each weekly peer group session, each session on parenting held in the family's home, and each collaborative in-home or in-community contact will also be considered a significant part of the overall supervisory structure, and will vary depending on the level of need and/or functioning. • Number and percent of non-compliance events (missed court dates,positive UA's) Objective #1, the percentage of compliance or non-compliance events, based on a behavioral baseline established at the time of referral will be recorded at each of the monthly IPP staffings. Parents, private providers and other supportive agencies will have opportunities to review and report on the progress to date and help in the development of the next month's goals. Objective#2, the percentage of compliance or non-compliance will be recorded by the attendance and assignments completed at each of the groups provided. This information will then be reported at the monthly IPP staffing. 3. Intermediate Outcome Indicator: • Number and percent of youth to complete their justice requirements successfully. Results of Objective 1, measurements will be analyzed by comparing the total number of juvenile female probationers to those actually served. As part of the analysis, there is an expectation that 100 percent of the FOP girls will have an IPP staffing each month during the time in the program. These staffings will provide a formal method of data collection while giving on going feedback to the youth and her parents. Results of Objective 2 will be analyzed by reviewing the recidivism rate of the JFOP participants to those of the general female offender population. Of the original youth identified, 75% will successfully complete this six-month program. While being in the program for the entire six months is important, completing the IPP goals will be the benchmark for successful program graduation. GOAL 1 COST NEEDS: The cost needs will revolve around direct services and case management, with the goal of conducting immediate assessments on all clients so as to provide early and effective interventions. 3 NUMBER OF JUVENILES TARGETED: 18-22 juvenile (ages 10-18) female probationers will be targeted with an estimated ethnic composition of: 50% Caucasian, 40% Hispanic, and 10% Native American or other heritage. White Hispanic/Latin African Native Asian/Pacifi Multiracia Other Totals o American America c n Islander Multi Ethnic Males 0 0 0 0 0 0 0 0 Females 9-11 8-9 0 1-2 0 0 0 18-22 C. Evaluation and Long-Term Sustainability Plan Success will be achieved when 100% (a minimum of 18 annually) of all juvenile female probationers have received greater access to services through the use of the multi-disciplinary staffing and the IPP, and has been provided with weekly groups and collaborative case management. Goals for each individual will be reviewed, renewed and progress acknowledged monthly at the IPP staffing. Supporting measurements of success, weekly supervision meetings, in home collaborative visitations, group attendance, group assignment completion, school attendance, will also be collected on a regular monthly basis. We are confident that the above indicators of success will result in lowered recidivism / revocation rates as compared to the non-Juvenile Female Offender Program participants. The Juvenile Female Offender Program started approximately five years ago. We are dedicated now, more than ever, to the fact that gender specific services are essential in addressing the multifaceted needs of young women in our community. This year we are committed to training other community professionals using our multidisciplinary staffing forum and the Individualized Probation Plan format as a vehicle for learning and sharing. Despite the reduction in funding, we are committed to maintaining the integrity of this program and will provide service to as many young females as possible. This year, the JFOP Probation Officer will receive training from Hawk II Systems, who conducts our parent/youth groups, and the girl gender-specific groups. This training will ensure the future of our program continuity. Additionally, we will be meeting with other collateral agencies at least quarterly to discuss how we can better utilize the time, resources, and services that are currently available to the young women in our program. We have worked hard at identifying those skills,programs or services that seem to impact our clients in a healthy and positive manner. Continued effort will be made to refine our program, and evaluate "best practice"programs. 4 BUDGET/BUDGET NARRATIVE: CONTRACTED CONSULTANT/ PROFESSIONAL SERVICES Weld County Probation has contracted with Hawk II Systems L.L.C. continuously for the past several years to work with the Juvenile Female Offender Program @FOP). In order to continue the program and to maintain current services, the Probation Department is requesting $6,777.00 annually to be allocated towards Hawk II Systems. Hawk II Systems, as well as other providers or agencies working directly with JFOP, will attend monthly staffings where the Individualized Probation Plan (IPP) will be developed, and review and create new goals for the upcoming month outlined. Expenses will cover Hawk II Systems' provision of the required parent/daughter groups that will contain parenting and behavior management information. In addition, weekly, on-going cognitive girls groups will be provided by Hawk II Systems to address issues of personal safety, teen pregnancy, interpersonal relationships, personal decision making and career choices. In order for the girls and their families to receive support and program consistency, regular in-home and/or school visits will be conducted jointly by Hawk II Systems and the probation officer. These visits allow issues that arise to be addressed in a timely and supportive fashion. TOTAL Fed$ Match $ $ TOTAL SUPPLIES AND OPERATING $0 $0 Teo F" B ri'® h If !NI T � A of o t rp "; Weekly groups/Coordinate Monthly Staffing, Case management-Hawk II Systems, LLC $6,777.00 $6,777.00 TOTAL CONTRACTED COST $6,777.00 $6,777.00 TOTAL OF ALL PROJECT COSTS TOTAL Source 1,40 ' Fed $ % of Total Match % of Total "I" �.:�, � � $6,777.00 $6,777.00 5 JABG Grant Application 2008-2009 "Collaborative Crisis Assessment and Triage Services" Submitted by North Range Behavioral Health 1306 11th Avenue Greeley, CO 80631 (970) 347-2120 (970) 346-9800 (fax) Wayne Maxwell, PhD Executive Director June 30, 2008 10. BRIEF PROJECT SUMMARY North Range Behavioral Health (NRBH)will deliver needed mental health services to detained youths from Weld County, Colorado at the Platte Valley Youth Services Center. Services to be provided will include risk and needs assessments of juvenile offenders, crisis intervention, and referral to ongoing mental health care as needed. —1— 11. APPLICANT AGENCY CAPACITY, COMMUNITY COLLABORATION, & SUPPORT As its mission, "North Range Behavioral Health provides professional, culturally competent mental health services for Weld County." Known previously as the Weld Mental Health Center, Inc.,NRBH has served the mental health needs of the people in this area for more than four decades. From 1995 to 1997, it functioned as the Mental Health Assessment Service Agency (MHASA) for Weld County. In 1998, NRBH joined with the Larimer Center for Mental Health and Centennial Mental Health Center to form Northeast Behavioral Health, which is now the Behavioral Health Organization (BHO) for Weld County, Larimer County, and the 12 counties comprising the northeastern corner of Colorado. NRBH has developed numerous collaborative efforts over the years. Most notably, it currently works with Weld County School District Six (District Six) to provide day treatment, residential treatment, and education services through the Kathleen P. Littler Center in Greeley to children 12 years of age and under facing serious mental health problems. We have also worked with staff from District Six and other Weld County school districts to provide mental health services to students attending alternative educational programming at Weld Opportunity School, Trademark, and Colorado High. Staff members of NRBH also provide on-site services to the students of Centennial, Dos Rios, and Cameron Elementary Schools and Northridge, Greeley Central, and Greeley West High Schools. A positive working relationship between the Family Education Network of Weld county and NRBH enables selected Head Start students to receive mental health care in their schools. Staff of NRBH also worked collaboratively with staff of the Platte Valley Youth Services Center (PVYSC) and with the Juvenile Services Planning Committee (Senate Bill 94 or SB 94) to provide basic mental health services to detained youth. In addition, NRBH was again awarded a JABG grant for the current fiscal year that helped provide services to juveniles while they are detained. NRBH is a regular participant in meetings of the local Juvenile Services (SB94) Planning Committee, local JABG, the Greeley-Evans Prevention Council, and the Weld County Community Juvenile Review Board, and the Weld County Child Abuse Team. NRBH is a member of the Weld County Interagency Oversight Group and works with A Kid's Place in the reviewing and updating of the Weld County Child Abuse Protocol. An NRBH administrator is a member of the Board of Directors of A Kid's Place,which operates the local children's advocacy center and the Court Appointed Special Advocate (CASA)program. A related collaborative effort, Promises for Children, is now in place as well, necessitated by continuing needs in the community. An ongoing collaborative effort called the Multidisciplinary Youth Assessment Team (MYAT) is now in its fifth year. Comprised of the Weld County Department of Social Services (WCDSS,) the Weld County Division of Human Services through its Employment Services Program, the IGRTC, and NRBH, this team has planned for and developed a community-wide system to meet various needs of youth and families in conflict or in need of positive youth development. NRBH has also joined in a community collaborative resulting in the formation of the Juvenile Assessment Center(JAC,) a program designed to assess, provide crisis intervention and triage services to appropriate services for juveniles in the community. —2— 12. PROBLEM STATEMENT, LOGIC, AND TARGET POPULATION A. Problem: Through its work with JABG, its member agencies, and other areas of work in the communities of Weld County,North Range Behavioral Health (NRBH) is acutely aware of the variety of problems facing youths who come into contact with the juvenile justice system. Over the past few years, progress has been made in the identification of detained juvenile offenders who are in need of mental health services while they are detained and after they are released back into the community. Recidivism rates remain higher than acceptable and are still increasing for those juvenile offenders with identifiable mental health issues who have not received appropriate mental health care. This project, in the past, has helped to improve the communication between the numerous agencies, offices, institutions, and individuals involved with these juveniles but more work remains to be done in terms of holding the youths accountable for their actions, reducing recidivism, and ensuring greater integration of services in working with each juvenile. B. Contributing Factors: Despite ongoing efforts, not enough youths in Weld County are receiving the mental health and related services they need. This is, in part, due to their own reluctance and that of their families to follow through with recommended mental health care after leaving detention. There is an over-representation of Hispanic youth in the population served by PVYSC and the local juvenile justice system. There appears, despite the best efforts of the local juvenile justice system, to be a lack of immediate and meaningful consequences to the illegal behaviors of youth. There is a high level of gang influence in the community for the population targeted by this project. C. Describe the intended long-term change/outcome: Reduce the overall recidivism rate of youths entering the juvenile justice system and the negative impacts of their behavior on their families and the Weld County community. D. Proposed project: NRBH will be able to provide services to youths who typically would not have sought services on their own or had them sought for them by their families. Appropriate referrals for continuing mental health care and other types of services can then be made, enabling a way out of the problems they are facing. The youths and their families will be able to receive services directly connected to their needs, services that can be tailored to exactly what is needed to break maladaptive life patterns. Target Population: Number of Persons Proposed to be Served Ethnicity of Persons to be Served Adults Youth Male Female Male Female White 33 8 Black 4 2 Hispanic 33 8 Asian/Pacific Islander 1 1 Native American 3 2 —3— Other/Unknown 4 1 SUBTOTALS: 78 22 TOTAL Persons 100 Percent of Total to be Served with Limited English Proficiency: <5% PROJECT PLAN: GOALS, OBJECTIVES, AND OUTCOMES A. Description of proposed project: Through this proposal, NRBH seeks to be able to continue to quickly and appropriately identify, assess, evaluate, and treat those detained youth at the Platte Valley Youth Services Center(PVYSC) who are in need of mental health services; to communicate effectively with the juvenile court, probation officers, social services workers, detention facility staff, mental health therapists, school personnel, and pertinent others about each referred individual; and to provide timely mental health treatment to those identified in need of such. JABG funds have helped accomplish some of these tasks in past years. NRBH again requests continued and increased funding of its efforts. Because of proposed funding cuts this year, 6.2 hours (.1557FTE) of a mental health clinician's time will be made available weekly to serve these juveniles through this grant. This will allow up to 18 juveniles to be admitted annually to treatment services. In addition to this, up to three detainees may be seen each day the therapist is on site at their own requests through "Counselor Alerts" or via referrals made by the Court, the staffs of the PVYSC, the Weld County Department of Social Services (WCDSS,) and Weld County Probation Services for crisis intervention. Many juveniles in this latter group, expected to number at least 100, do not need ongoing mental health care but have an emergent or urgent need to speak to a counselor. NRBH proposes to continue to be funded to provide both direct and indirect mental health services to the referred juveniles and to improve its ability to communicate the results of assessments, evaluations, and other interventions to the juvenile court and probation officers so they may have more timely information concerning detained youths involved in this project. It is projected there will be more than 700 detention admissions of Weld County youth to PVYSC this fiscal year. This figure is not equal to the number of juveniles being admitted but to the total number of admissions which is a duplicated count. NRBH proposes to serve at least 100 of those juveniles through this project. Culturally competent services will be provided to all clients served by this project by staff from the Intensive Child and Family Services (ICFS) program with consultation when needed from the Multi-Cultural Services Program of NRBH, which is housed at the Monfort Children's Clinic. Following up on an initial round of training in cultural competency and sensitivity in May 2002 that has been and will be updated annually,NRBH provides culturally competent care to those seeking its services. Similarly, gender specific services will be available to meet the identified needs of the target population. Goal 1: To rapidly respond to the mental health needs of those detained youth referred to —4— the project Objective 1-1: Time-Line Measurement Responsible Person(s) To evaluate, refer, communicate 10/1/2008 - Track the number of Program about, and treat those youths referred. 9/30/2009. youths referred and Director and served, document clinical staff types of services provided. Objective 1-2: Time-Line Measurement Responsible Person(s) All referred youth opened as NRBH 10/1/2008 - Track the number of Program clients will have a service plan 9/30/2009. youths referred and Director and developed as part of the admission served, document clinical staff process. types of services provided and presence of plan. Objective 1-3: Time-Line Measurement Responsible Person(s) Seventy-five percent of the youth 10/1/2008 - Track the number of Program admitted to mental health treatment 9/30/2009. youths referred and Director and other than crisis services will served, document clinical staff complete their service plan. types of services provided. Goal 1 Outcome Measures: 1. What will be measured? The time and date of referral, time and date of evaluation will be tracked, as will be when the evaluation was delivered to the person or office needing it. What services were delivered to whom and the total amount of services delivered to each referral will be tracked as will be the impact of the services. 2. How will it be measured? Data will be entered on the form developed in previous years so that the activities can be measured. Provision of mental health services will be documented and measured by written progress and case management notes as well as by entries on a Staff Activity Log, a form already in existence and use at NRBH. Each youth's service plan will be analyzed for compliance and success data. —5— 3. How will the results be analyzed? Progress notes, case management notes, service plans, and Staff Activity Logs will be used to document the delivery of services reflecting quantity, quality, and appropriateness of the services rendered. 14. Evaluation Plan NRBH again seeks to continue its capacity to provide services to youths detained at the PVYSC. This project has served, and will continue to serve, as a pilot or model for how initial triage and evaluation, treatment, and case management services can be provided to this target population in a manner best suited to reducing recidivism and the severity of repeat offenses for those who do re-offend. Ideally, a full array of mental health services should be available to detained juveniles and their families. This project, as proposed, when linked with the other services to youths provided by the NRBH ICFS program will serve as a larger step toward achieving that ideal. The treatment and case management services to be delivered are part of a service plan developed with and for each youth admitted to NRBH services. Some of the youths to be served by this project will not complete their mental health services during the fiscal year, even some of those who are referred early on in the year. NRBH will continue to track them once they do finish and add their data to that of the others. Those who do finish will immediately help prove the value of services such as these and demonstrate the need for continuing this work. Over the time this project has been funded, the benefit of such services to the children and their families has been clearly shown, demonstrating that NRBH does provide cost savings to the community and the state as the mental health treatment costs are much less than those involved in detaining them and immensely less than serving them as committed youth. This project will continue to allow NRBH access to juveniles who otherwise would have nothing to do with mental health care either because they would have refused it or never would have been referred to it. Access is also gained to their siblings and other family members of the referred youths, again expanding NRBH's ability to help others make positive changes in their lives. Measurement of the achievement of the goals set forth herein will be ongoing with reports made at required or requested intervals. Both positive and negative results will be used to modify plans as the year progresses to realize maximum goal attainment and to ensure attainment of the desired impact on the needs the therapists are striving to meet. NRBH will continue to regularly evaluate how best to serve the target population over the course of the new grant period. The efficacy of various evaluation and treatment approaches will be studied to show what, if any, revamping of services is indicated. Strong efforts will be made to improve communications with all others involved in this project and the overall grant. 15. Evaluation of Services and Goal Attainment to Date All goals and objectives for the current fiscal year will be met or exceeded, based on data —6— gathered through 4/18/08. Timely evaluation, case management, and treatment services have been provided to all referred juveniles. The racial balance of those referred was markedly different than predicted with Hispanic/Latino youths comprising about 69% of those referred, up from 64% the previous year. Of the Hispanic/Latino youths referred, approximately 25%were females, up from about 20% last year. This also reflects the disproportionately high percentage of detained youth who are Hispanic/Latino. Timely responses to both the referred youths and to the agencies/individuals who referred them occurred more than 95% of the time. The expected proportion of the youths seen under this grant needed only crisis intervention services while detained. Ongoing services were offered to the rest and included as part of their release plans. 16. Sustainability Plan: NRBH views this project as a necessary part of its services to the Weld County community and will seek funding to perpetuate and expand it. NRBH will continue to look to JABG, Senate Bill 94, federal, state, and other sources for continuing funding. 17. Budget and Budget Narrative Overall Budget The overall budget for this project will be $8,471 broken down as follows: A. Personnel: No personnel expense is planned. B. Supplies and Operating: No support is being requested for costs anticipated for supplies and operating expenses for this project. C. Travel: No funds to cover travel expenses are being sought. D. Equipment: No equipment expense is planned. E. Contracted Consultant/Professional Services: Contract personnel expenses of$8,471 include the salary and fringe benefits for the clinical staff who will be performing the services to be delivered. Fringe benefits account for 23% of gross salary and are prorated based on the full time equivalent. Additional personnel expenses such as the salaries of the Program Director and clinical supervisor are not included here nor is grant support sought for them. Data from Mountain States Employers Council,Inc. of Denver indicates the proposed salary is consistent with what is paid for equivalent positions and employee qualifications in this area. 7 k. PERSONNEL TOTAL No expenses in this category will be charged to the grant. [ff -0- TOTAL PERSONNEL COST to be charged to this grant -0 - • B. SUPPLIES AND OPERATING TOTAL No expenses in this category will be charged to the grant. $ -0- TOTAL SUPPLIES AND OPERATING COST to be charged to this grant $ -0- C. TRAVEL (Designate specifically in-state and out-of-state travel.) TOTAL No expenses in this category will be charged to the grant. $ -0- TOTAL TRAVEL COST to be charged to this grant $ -0- D. EQUIPMENT (Items costing $5,000 or more- see Instruction Manual) TOTAL No expenses in this category will be charged to the grant. $ -0- TOTAL EQUIPMENT COST to be charged to this grant $ -0- 8 E. CONTRACTED, (1) (2) (4) CONSULTANT Annual Annual (3) % to be paid by TOTAL AND Full-time Fringe Benefit Sub-total grant funds PROFESSIONAL Salary Cost SERVICES Therapist 44,355 + 10,221 I = 54,556 X 15.52% $ 8,471 TOTAL CONTRACTED CONSULTANT AND PROFESSIONAL SERVICES COST to be charged to this grant $ 8,471 F. TOTAL OF ALL PROJECT COSTS (A through E) $ 8,471 (This should equal the amount in Item 4 on page 1) 9 2007 JABG Application 3. TOTAL PROJECT FUNDING: From 10/01/2008 to 09/30/2009 Will this project BE FUNDED using ADDITIONAL FUNDS other than those provided from this grant? YES / X NO If yes, what % of the total project costs will be supported by these federal funds? List the type and amount of other funding that will be provided to this project. Fund Type/Describe Amount Federal State County Government Municipal Government Private Other- specify TOTAL - 16- 2007 JABG Application 4. FINANCIAL MANAGEMENT: Please complete the items below. A. Has a copy of your last independent audit or financial review been previously submitted to DCJ? YES/ NO. If YES, to which program? If audit last provided to DCJ is older than one year, include one copy of the most recent audit or financial review, including any management report or other auditor comments in the appendix. Also, if there were findings, please attach the audit resolutions and/or corrective action plan. B. Does your agency expend over$500,000 from combined federal sources in a year? YES / NO If YES, attach a copy of the A-133 audit, including audit resolutions and/or corrective action plan. C. Please respond to the following questions about whether your accounting system meets the criteria for managing federal grant funds. (These questions cover areas that will be monitored by DCJ staff during site visits or through other reporting mechanisms. They are not intended to be all inclusive and do not substitute for the agency's responsibility to meet all federal and state requirements for these grant funds.) ®YES ENO Does your accounting system separate ALL revenues and expenditures by funding source? EYES ONO Does your system track revenues and expenditures for each grant award separately through a sub-ledger system? ®YES ONO Does your system allow expenditures to be classified by the broad budget categories listed in the approved budget in your grant, i.e. Personnel, Supplies and Operating, Travel, Equipment and Professional Services? ®YES ONO Do you reconcile sub-ledgers to your general ledger at least monthly? ®YES ONO Do you mark your invoices with the grant number? EYES ONO Do you maintain time sheets, signed by the employee and supervisor for each employee paid by DCJ grant funds? ZYES ONO Do you have written financial policies and procedures in place? EYES ONO Do you have accounting internal controls in place, such as separation of duties, two signatures on certain checks, reconciliations or other reviews? For Continuation Applicants only ®YES ONO Do you use your accounting system data to prepare your quarterly financial reports for DCJ? ®YES ONO Do you reconcile your accounting system data with your quarterly financial reports for DCJ? If you answered "No" to any of the questions above, please provide an explanation on an inserted page referencing Section V Item#4. - 17- 2007 JABG Application SECTION VIII - CERTIFICATION OF MATCH This Certification of Appropriation of Match form should be completed by all agencies providing match. Certification of Appropriation of Match Date: June 30, 2008 Colorado Division of Criminal Justice Office of Adult and Juvenile Justice Assistance 700 Kipling Street Denver, Colorado 80215 To Whom It May Concern: Please be advised that Weld County Board of County Commissioners has committed support in the form of form of cash match in the amount of$1,694.00 to match the State of Colorado funds for the Juvenile Accountability Block Grant for the 19`h Judicial Probation Office and North Range Behavioral Health. Execution of this document represents a certification that said funds have been earmarked within the appropriation of budget process for use as matching funds for this grant application. Sincerely, . . . a . e 01 . 14 Iteit >Y raiefgetotagiq e ee . •ee .,,p. . + . JUN 3 0 2008 Signature/Date William H. Jerke, Chair, Board of Weld County Cnmmicoinners Typed Name and Title - 18- 7 2007 JABG Application SECTION VII—BUDGET Copy this Budget Table and complete the Table and Narrative for each purpose area as well as the applicant agency's administrative portion of the funds. For continuation applicants: Identify and justify all new budget items and increases in each budget category from previous year funding. Project Title:Juvenile Female Offender Program Purpose Area: 12 (1) (2) (3) (4) Source Annual Full- Annual Sub-Total %of time TOTAL Fed$ Cash Match time Salary Fringe for This 1.PERSONNEL Benefit Cost Project + = X % $0 0 0 + = X % $ + = X % $ + = X % $ _ TOTAL PERSONNEL COST $ TOTAL Source 2.SUPPLIES AND OPERATING Fed S Cash Match $0 0 0 - $ $ l TOTAL SUPPLIES AND OPERATING COSTS $ TOTAL Source 3.TRAVEL(Designate specifically in-state and out-of-state travel.) Fed$ Cash Match $0 0 0 $ TOTAL TRAVEL COST $ TOTAL Source 4. EQUIPMENT Fed$ Cash Match $0 0 0 $ TOTAL EQUIPMENT COST $ 5. CONTRACTED CONSULTANT AND PROFESSIONAL SERVICES TOTAL Source Attach a copy of each contract with a detailed budget. Fed$ Cash Match - $6,777.00 , $6,777.00 i $0 $ TOTAL CONTRACTED COST $6,777.00 $6,777.00 $0 6. TOTAL OF ALL PROJECT COSTS Source (1 through 5) TOTAL Fed$ I %of Total I Cash Match$ %of Total • TOTAL COST $6,777.00 0$6,777.00 J 100% $0 0% - 13- 2007 JABG Application SECTION VII— BUDGET Copy this Budget Table and complete the Table and Narrative for each purpose area as well as the applicant agency's administrative portion of the funds. For continuation applicants: Identify and justify all new budget items and increases in each budget category from previous year funding. Project Title: Collaborative Crisis Assessment and Triage Services Purpose Area: 15 (1) 2 O 3 O q O Source Annual Full- Annual Sub-Total %of time TOTAL Fed$ Cash Match time Salary Fringe for This 1.PERSONNEL Benefit Cost Project = X % 0 0 = X % $ + = X % $ + = X % $ TOTAL PERSONNEL COST $ TOTAL Source 2.SUPPLIES AND OPERATING Fed$ Cash Match $0 0 0 $ TOTAL SUPPLIES AND OPERATING COSTS $ TOTAL Source 3.TRAVEL(Designate specifically in-state and out-of-state travel.) Fed$ Cash Match $0 0 0 TOTAL TRAVEL COST $ TOTAL Source 4. EQUIPMENT Fed$ Cash Match $0 0 0 TOTAL EQUIPMENT COST $ 5. CONTRACTED CONSULTANT AND PROFESSIONAL SERVICES TOTAL Source Attach a copy of each contract with a detailed budget. Fed$ Cash Match $8,471.00 $6,777.00 $1,694.00 TOTAL CONTRACTED COST $6,777.00 $6,777.00 $1,694.00 6. TOTAL OF ALL PROJECT COSTS Source 1 through 5 TOTAL ( g ) Fed$ %of Total Cash Match$ %of Total TOTAL COST $6,777.00 $6,777.00 75% $1,694 25% - 13- COLORADO DIVISION OF CRIMINAL JUSTICE JUVENILE JUSTICE AND DELINQUENCY PREVENTION(JJDP)ACT APPLICATION FOR JUVENILE ACCOUNTABILITY BLOCK GRANT PROGRAM FUNDS SPECIAL PROVISIONS AND CERTIFIED ASSURANCES Special Provisions&Certified Assurances must remain attached to the application August 21,2007 SPCA Page 1 of 10 CHECK BELOW TO INDICATE WHICH CATEGORY BEST DESCRIBES YOUR AGENCY: Inter-Governmental Grant Grant to a Colorado State Agency(Section A does not apply) )C Grant to a Unit of Local Government,Tribal Government,or Special District. Grant to a Non-Profit,Private Organization(Non-Governmental) The applicant certifies by signing that the project described in this application meets all the requirements of the applicable governing legislation as indicated below; that all information contained in the application is correct; that there has been appropriate coordination with affected agencies; and,that the applicant will read,understand and comply with all provisions of the governing legislation and all other applicable federal and state laws, rules and regulations that have been or may hereafter be established. The applicant further understands and agrees that any subgrant award received as a result of this application shall be subject additionally to the grant conditions set forth in the Statement of Grant Award, and in the current applicable Administrative Guide of the Division of Criminal Justice. GOVERNING LEGISLATION FOR THIS GRANT PROGRAM: Juvenile Accountability Block Grant Program. From the United States Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention, under federal statutory authority, PL107-273, November 2002, Making Appropriations for the Departments of Commerce, Justice and State,the Judiciary, and related Agencies and for other Purposes (Appropriations Act) and under applicable program guidelines established by said federal program office. A. STANDARD STATE SPECIAL PROVISIONS Effective Date of Special Conditions: August7,2006 1. CONTROLLER'S APPROVAL.CRS 24-30-202 (1) This subgrant award shall not be deemed valid until it has been approved by the Colorado State Controller or designee. 2. FUND AVAILABILITY.CRS 24-30-202 (5.5) Financial obligations of the State payable after the current fiscal year are contingent upon funds for that purpose being appropriated,budgeted,and otherwise made available. 3. INDEMNIFICATION. a. The Subgrantee Agency shall indemnify, save, and hold harmless the State, its employees and agents, against any and all claims, damages, liability and court awards including costs, expenses, and attorney fees and related costs, incurred as a result of any act or omission by the Subgrantee Agency, or its employees, agents, subcontractors, or assignees pursuant to the terms of this subgrant award. FOR INTERGOVERNMENTAL GRANTS ONLY: b. No term or condition of this subgrant shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights,benefits,protection,or other provisions, of the Colorado Governmental Immunity Act,C.R.S. Section 24-10-101, et seq., or the Federal Tort Claims Act, 28 U.S.C. 2671, et seq., as applicable, as now or hereafter amended. The Subgrantee Agency,by execution of this grant containing this indemnification clause, does not waive the operation of any law concerning the parties'ability to indemnify. COLORADO DIVISION OF CRIMINAL JUSTICE JUVENILE JUSTICE AND DELINQUENCY PREVENTION (JJDP) ACT APPLICATION FOR JUVENILE ACCOUNTABILITY BLOCK GRANT PROGRAM FUNDS SPECIAL PROVISIONS AND CERTIFIED ASSURANCES Special Provisions& Certified Assurances must remain attached to the application August 21,2007 SPCA Page 2 of 10 4. INDEPENDENT CONTRACTOR. 4 CCR 801-2: (THIS PROVISION IS NOT APPLICABLE TO GRANTS TO COLORADO STATE AGENCIES): THE SUBGRANTEE AGENCY SHALL PERFORM THE DUTIES FUNDED UNDER THIS GRANT AS AN INDEPENDENT CONTRACTOR AND NOT AS AN EMPLOYEE OF THE STATE. NEITHER THE SUBGRANTEE AGENCY NOR ANY AGENT, SUB-CONTRACTOR, OR EMPLOYEE OF THE SUBGRANTEE AGENCY SHALL BE OR SHALL BE DEEMED TO BE AN AGENT OR EMPLOYEE OF THE STATE BY VIRTUE OF THIS SUBGRANT. SUBGRANTEE AGENCY SHALL PAY WHEN DUE ALL REQUIRED EMPLOYMENT TAXES AND INCOME TAX AND LOCAL HEAD TAX ON ANY MONIES PAID PURSUANT TO THIS GRANT. SUBGRANTEE AGENCY ACKNOWLEDGES THAT THE SUBGRANTEE AGENCY AND ITS EMPLOYEES ARE NOT ENTITLED TO UNEMPLOYMENT INSURANCE BENEFITS UNLESS THE SUBGRANTEE AGENCY OR THIRD PARTY PROVIDES SUCH COVERAGE AND THAT THE STATE DOES NOT PAY FOR OR OTHERWISE PROVIDE SUCH COVERAGE. SUBGRANTEE AGENCY SHALL NOT HAVE AUTHORIZATION, EXPRESS OR IMPLIED,TO BIND THE STATE TO ANY AGREEMENTS,LIABILITY,OR UNDERSTANDING EXCEPT AS EXPRESSLY SET FORTH HEREIN. IF THIS GRANT PROVIDES FUNDS FOR ANY PERSONAL SERVICES, SUBGRANTEE AGENCY SHALL PROVIDE AND KEEP IN FORCE WORKERS COMPENSATION (AND SHOW PROOF OF SUCH INSURANCE) AND UNEMPLOYMENT COMPENSATION INSURANCE IN THE AMOUNTS REQUIRED BY LAW AND SHALL BE SOLELY RESPONSIBLE FOR ITS ACTS OF ITS EMPLOYEES,INDEPENDENT SUB-CONTRACTORS AND AGENTS. 5. NON-DISCRIMINATION. The Subgrantee Agency agrees to comply with the letter and the spirit of all applicable State and federal laws respecting discrimination and unfair employment practices. 6. CHOICE OF LAW. The laws of the State of Colorado, and rules and regulations issued pursuant thereto, shall be applied in the interpretation, execution, and enforcement of this subgrant.Any provision of this subgrant,whether or not incorporated herein by reference, which provides for arbitration by any extra-judicial body or person or which is otherwise in conflict with said laws,rules,and regulations shall be considered null and void. Nothing contained in any provision incorporated herein by reference which purports to negate this or any other special provision in whole or in part shall be valid or enforceable or available in any action at law whether by way of complaint, defense, or otherwise. Any provision rendered null and void by the operation of this provision will not invalidate the remainder of this subgrant,to the extent that the subgrant is capable of execution. At all times during the performance of this subgrant,the Subgrantee Agency shall strictly adhere to all applicable federal and State laws,rules,and regulations that have been or may hereafter be established. 7. VENDOR OFFSET.CRS 24-30-202(1) &CRS 24-30-202.4 (THIS PROVISION APPLIES TO NON-INTERGOVERNMENTAL GRANTS ONLY:) The State Controller may withhold payment of certain debts owed to State agencies under the vendor offset intercept system for (a) unpaid child support debt or child support arrearages; (b) unpaid balance of tax, accrued interest, or other charges specified in Article 21, Title 39, CRS; (c) unpaid loans due to the Student Loan Division of the Department of Higher Education; (d) amounts required to be paid to the Unemployment Compensation Fund; and(e) other unpaid debts owing to the State or its agencies as a result of final agency determination or reduced to judgment,as certified by the State Controller. 8. EMPLOYEE FINANCIAL INTEREST.CRS 24-18-201 &CRS 24-50-507 The signatories aver that to theft knowledge,no employee of the State has any personal or beneficial interest whatsoever in the service or property described in this subgrant award. 9. SOFTWARE PIRACY PROHIBITION.(Governor's Executive Order D 002 00) No State or other public funds payable under this subgrant shall be used for the acquisition,operation,or maintenance of computer software in violation of federal copyright laws or applicable licensing restrictions. The Subgrantee Agency hereby certifies that, for the term of this subgrant and any extensions,the Subgrantee Agency has in place appropriate systems and controls to prevent such improper use of public funds. If the State determines that the Subgrantee Agency is in violation of this paragraph,the State may exercise any remedy available at law or equity or under this subgrant,including,without limitation,immediate termination of the Subgrant and any remedy consistent with federal copyright laws or applicable licensing restrictions. 10. FEDERAL FUNDING. This subgrant is subject to and contingent upon the continuing availability of Federal funds for the purposes hereof. COLORADO DIVISION OF CRIMINAL JUSTICE JUVENILE JUSTICE AND DELINQUENCY PREVENTION(JJDP)ACT APPLICATION FOR JUVENILE ACCOUNTABILITY BLOCK GRANT PROGRAM FUNDS SPECIAL PROVISIONS AND CERTIFIED ASSURANCES Special Provisions&Certified Assurances must remain attached to the application August 21,2007 SPCA Page 3 of 10 11. (NOT APPLICABLE TO INTERGOVERNMENTAL GRANTS ILLEGAL ALIENS-PUBLIC CONTRACTS FOR SERVICES AND RESTRICTIONS ON PUBLIC BENEFITS. CRS 8-17.5-101 and 24-76.5-101 The Subgrantee Agency certifies that it shall comply with the provisions of CRS 8-17.5-101 et seq. The Subgrantee Agency shall not knowingly employ or contract with an illegal alien to perform work under this subgrant or enter into a contract with a subcontractor that fails to certify to the Subgrantee Agency that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this subgrant. The Subgrantee Agency represents, warrants,and agrees that it(i) has verified that it does not employ any illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security, and(ii) otherwise shall comply with the requirements of CRS 8-17.5-102(2)(b). The Subgrantee Agency shall comply with all reasonable requests made in the course of an investigation under CRS 8-17.5-102 by the Colorado Department of Labor and Employment. Failure to comply with any requirement of this provision or CRS 8-17.5-101 et seq.,shall be cause for termination for breach and the Subgrantee Agency shall be liable for actual and consequential damages. Subgrantee Agency,if a natural person eighteen(18)years of age or older,hereby swears or affirms under penalty of perjury that the Subgrantee Agency(i)is a citizen of the United States or otherwise lawfully present in the United States pursuant to federal law,(ii)shall comply with the provisions of CRS 24-76.5-101 et seq,and(iii)shall produce one of the forms of identification required by CRS 24-76.5-103 prior to the effective date of this subgrant. B. GRANT REQUIREMENTS 1. FINANCIAL&ADMINISTRATIVE MANAGEMENT a. The Subgrantee Agency assures that fund accounting, auditing, monitoring, evaluation procedures and such records as necessary will be maintained to assure adequate internal fiscal controls, proper financial management, efficient disbursement of funds received, and maintenance of required source documentation for all costs incurred. These principles must be applied for all costs incurred whether charged on a direct or indirect basis. b. All expenditures must be supported by appropriate source documentation. Only actual, approved, allowable expenditures will be permitted. c. The Subgrantee Agency assures that it will comply with the provisions of the current applicable Administrative Guide of the Division of Criminal Justice which is hereby incorporated by reference. However,such a guide cannot cover every foreseeable contingency, and the Subgrantee Agency is ultimately responsible for compliance with applicable state and federal laws,rules and regulations. 2. PAYMENT&REPORTING a. The Division of Criminal Justice will pay the Subgrantee Agency the reasonable and allowable costs of performance, in accordance with current Colorado State Fiscal Rules, not to exceed the amount specified herein as the Total Award Amount,as identified in the Statement of Grant Award. b. The Division's requirements for invoice, advance payments, and cost reporting submissions are contained in the DCJ Form 3 - Cash Request Procedures, and DCJ Form 1-A - Subgrant Financial Report, which are hereby incorporated by reference. c. Advance payments cannot exceed 30-day operating expenses. d. The Subgrantee Agency assures that it shall maintain data and information to provide accurate quarterly program narrative and financial reports to the Division. Said reports shall be provided in such form and contain such data and information as the Division of Criminal Justice reasonably requires to administer the program. e. The Subgrantee Agency assures that quarterly financial and narrative reports shall be submitted within 30 days of the end of each calendar quarter and shall be current and actual. f The Subgrantee Agency further assures that final financial and narrative reports shall be submitted on the forms provided by the Division of Criminal Justice within 45 days of the end date of the subgrant. g. The Division reserves the right to make and authorize modifications, adjustments, and/or revisions to the Grant Award for the purpose of making changes in budget categories, extensions of grant award dates, changes in goals and objectives, and other modifications which do not change the total amount of the Grant Award. The Division's requirements for such grant adjustments are contained in the procedures for DCJ Forms 4A, 4B, 4C, and 4D, which are hereby incorporated by reference. h. The Division may withhold payment in the event the Subgrantee Agency fails to comply with conditions,including all financial reporting requirements and certifications contained in this grant award. COLORADO DIVISION OF CRIMINAL JUSTICE JUVENILE JUSTICE AND DELINQUENCY PREVENTION(JJDP)ACT APPLICATION FOR JUVENILE ACCOUNTABILITY BLOCK GRANT PROGRAM FUNDS SPECIAL PROVISIONS AND CERTIFIED ASSURANCES Special Provisions&Certified Assurances must remain attached to the application August 21,2007 SPCA Page 4 of 10 3. PROCUREMENT AND CONTRACTS a. The Subgrantee Agency assures that open, competitive procurement procedures will be followed for all purchases under the grant. All contracts for professional services, of any amount, and equipment purchases over five thousand dollars (per item, with a useful life of at least one year) must receive prior approval by the Division of Criminal Justice. b. The Subgrantee Agency assures that no contract or agreement will be made for execution of project activities or provisions of services (other than purchase of supplies or standard commercial or maintenance services) that is not incorporated in the approved application or approved in advance by the Division of Criminal Justice. c. The Subgrantee Agency assures that contractors/vendors who assist the Subgrantee Agency to develop specifications, requirements, statements of work and/or Request For Proposal for a proposed procurement shall be excluded from bidding or submitting a proposal to compete for the award of such procurement. d. The Subgrantee Agency assures that where activities supported by this subgrant produce any discovery or invention, original computer programs, writing, sound recordings, pictorial reproductions, drawing or other graphical representation and works of any similar nature,the following requirements apply: i. The Division of Criminal Justice reserves a royalty-free, non-exclusive, and irrevocable license to reproduce, publish, or otherwise use, and authorize others to use, for Federal government purposes: The copyright in any work developed under an award or subaward; and 2) Any rights of copyright to which a recipient or subrecipient purchases ownership with support. ii. If any program produces patentable items, patent rights, processes or inventions, in the course of work sponsored by the Federal award or subaward funds,such facts must be promptly and fully reported to the awarding agency, Division of Criminal Justice. The awarding agency shall determine whether protection on the invention or discovery shall be sought. The awarding agency will also determine how rights in the invention or discovery(including rights under any patents issued thereon) shall be allocated and administered in order to protect the public interest pursuant to published Presidential and government memorandums and guidelines, and the regulations promulgated by the Department of Commerce in 37 CFR Part 401. When issuing statements, press releases, requests for proposals, bid solicitations, and other published documents describing projects or programs funded in whole or in part with these grant funds, all Subgrantee Agencies must clearly: a) State the percentage of the total cost of the program or project, which will be financed with this grant money; b) State the dollar amount of state or federal funds for the project or program; c) Use the phrase-"This project was supported by grant# , issued by the Colorado Division of Criminal Justice." e. The Subgrantee Agency may not assign its rights or duties under this grant without the prior written consent of the Division of Criminal Justice. 4. AUDIT,RECORD-KEEPING,AND MONITORING/INSPECTION a. The Subgrantee Agency assures that it will procure an audit or financial review, incorporating this subgrant,by an independent Certified Public Accountant(CPA), licensed to practice in Colorado. If the agency expends more than $500,000 per year in combined federal funds, a Single Audit must be conducted in accordance with OMB Circular A-133 (Audits of States, Local Governments, and non-profit organizations). If the agency expends less than $500,000 per year in combined federal funds, the following policy applies: Agencies with total annual revenue from all sources of$200,000 or more shall procure a financial audit; a financial review shall not be sufficient to meet this requirement. Agencies with total annual revenue of less than $200,000 shall procure either a financial review or financial audit. i. At such time as the audit or financial review is completed, ONE COPY OF THE REPORT, INCLUDING THE CORRESPONDING MANAGEMENT LETTER, MUST BE FORWARDED TO THE DIVISION OF CRIMINAL JUSTICE for clearance. The audit or financial review incorporating this subgrant must be completed and received within 12 months of the end of the fiscal years that includes the end date of the grant. ii. The Subgrantee Agency accepts responsibility for the costs of a financial program audit to be performed by the Department of Public Safety in the event that the audit report or financial review: a) does not meet the applicable A-133 or DCJ standards; b) is not submitted in a timely manner; or, c) does not provide an audit response plan with corresponding corrections made sufficient to satisfy any audit findings. COLORADO DIVISION OF CRIMINAL JUSTICE JUVENILE JUSTICE AND DELINQUENCY PREVENTION (JJDP)ACT APPLICATION FOR JUVENILE ACCOUNTABILITY BLOCK GRANT PROGRAM FUNDS SPECIAL PROVISIONS AND CERTIFIED ASSURANCES Special Provisions&Certified Assurances must remain attached to the application SPCA Page 5 of 10 August 21,2007 b. The Subgrantee Agency assures that: i. It will retain all project records, as will facilitate an effective audit,for seven years after the end of the state fiscal year that includes the end date of the grant. (For example if the grant ended 9/30/2001,the state FY would be July 1,2001-June 30,2002. The files could be destroyed after 6/30/2009);except, ii. If an audit is in progress and/or the findings of a completed audit have not been resolved satisfactorily,then records must be retained beyond the seven-year period until such issues are resolved. c. The Subgrantee Agency assures that it will keep copies of all documents, correspondence, and required receipts related to this subgrant in a separate file bearing the project title and grant number. d. The Division may periodically request submission of supporting financial and programmatic documentation, subcontracts, general and sub-ledgers for the purpose of monitoring compliance with the grant award via desk review, or in preparation for an on-site monitoring visit. Routine or special on-site visits may be conducted at the subgrant agency, and at the location of any collaborating entities, for the same purpose. Subgrantee Agencies will be notified in advance of any on-site monitoring visit. e. The Subgrantee Agency assures that the Division of Criminal Justice, Colorado Department of Public Safety, shall have access for purposes of monitoring, audit and examinations to any bonds, documents,papers and records of the Subgrantee Agency and to relevant books and records of subcontractors of the Subgrantee Agency. It is the responsibility of the Subgrantee Agency to notify any of its project collaborators and subcontractors of these provisions. f. The Subgrantee Agency assures that signatories of the application and subgrant award and personnel employed through this subgrant will appear when requested at any administrative hearing, monitoring site visit, conference or meeting conducted by the Division of Criminal Justice. 5. COLORADO VICTIM RIGHTS ACT The Subgrantee Agency assures that the application signatories, all staff and all volunteers assigned to the funded project have read and understand the rights afforded to crime victims pursuant to § 24-4.1-302.5 C.R.S.,and the services delineated pursuant to§§ 24-4.1-303 and 24-4.1-304 C.R.S.,commonly known as the Victim Rights Act,and enabling legislation. 6. TERMINATION or REDUCTION IN GRANT AWARD The Division will monitor the performance of the Subgrantee Agency against goals and performance standards as found in the application, Section VI required herein. The Division will provide reasonable assistance to the Subgrantee Agency concerning project goals, performance standards and subgrant requirements. Any determination of substandard performance on the part of the Subgrantee Agency shall be within the discretion of the Division,based upon the Division's review of the terms and conditions of the Grant Award, the application and project summary, the grant terms and assurances, and the requirements of applicable law. Substandard performance, as determined by the Division, shall constitute non-compliance, which may result in termination for cause, or reduction of the Grant Award for cause,as follows: a. Reduction In Grant Award Amount for Cause i. The Division may reduce the total Statement of Grant Award amount for cause,without compensation for reduction costs. ii. If the state reduces the grant amount for cause, it will first give ten (10) days written notice to the Subgrantee Agency, stating the reasons for reduction, steps taken to correct the problems, and the date the subgrant award amount will be reduced in the event problems have not been corrected to the satisfaction of the Division. iii. In the event this grant is reduced for cause, the Division will only reimburse the Subgrantee Agency for acceptable work or deliverables received up to the date of reduction. iv. In the event this grant is reduced for cause, final payment to the Subgrantee Agency may be withheld at the discretion of the Division until completion of final Division review. b. Termination for Convenience: i. Either party may terminate the grant with thirty days written notice of intent to cancel or terminate. ii. If the grant is terminated for convenience by either the Subgrantee Agency or the state, the Subgrantee Agency shall be paid the necessary and allowable costs incurred through the date of termination, but not exceeding a prorated amount based on the number of days of project operation prior to the date of termination. c. Termination for Cause: i. The Division may terminate the grant for cause without compensation for termination costs. ii. If the state terminates the grant for cause, it will first give ten(10) days written notice to the Subgrantee Agency, stating the reasons for termination, steps taken to correct the problems, and the date the subgrant will be terminated in the event problems have not been corrected to the satisfaction of the Division. COLORADO DIVISION OF CRIMINAL JUSTICE JUVENILE JUSTICE AND DELINQUENCY PREVENTION(JJDP)ACT APPLICATION FOR JUVENILE ACCOUNTABILITY BLOCK GRANT PROGRAM FUNDS SPECIAL PROVISIONS AND CERTIFIED ASSURANCES Special Provisions& Certified Assurances must remain attached to the application SPCA Page 6 of 10 August21,2007 iii. In the event this grant is terminated for cause,the Division will only reimburse the Subgrantee Agency for acceptable work or deliverables received up to the date of termination. iv. In the event this grant is terminated for cause, final payment to the Subgrantee Agency may be withheld at the discretion of the Division until completion of final Division review. d. Any equipment purchased under this grant would revert, at the option of the Division, to the Division of Criminal Justice upon termination of the grant for any of the above reasons. 7. ORDER OF PRECEDENCE Any inconsistency or conflict in this grant shall be resolved by giving precedence in the following order: (a) Special Provisions and Certified Assurances,(b) Statement of Grant Award;and, (c)the final approved Subgrant Application. 8. DISPUTE RESOLUTION(THIS PROVISION APPLIES ONLY TO INTERAGENCY AGREEMENTS): Any failure of either party to perform in accordance with the terms of this agreement shall constitute a breach of the agreement. Any dispute concerning the performance of this agreement which cannot be resolved at the divisional level shall be referred to superior departmental management staff designated by each department. Failing resolution at that level, disputes shall be presented to the executive directors of each department for resolution. Failing resolution by the executive directors, the dispute shall be submitted in writing by both parties to the State Controller, whose decision on the dispute will be final. C. FEDERAL CERTIFIED ASSURANCES 1. FEDERAL PUBLIC POLICY ASSURANCES a. The Subgrantee Agency hereby agrees that it will comply, and all of its contractors will comply with the applicable provisions of: i. Title I of the Omnibus Crime Control and Safe Streets Act of 1968, as amended; ii. The Juvenile Justice and Delinquency Prevention Act and/or the Victims of Crime Act,as appropriate; iii. All other applicable Federal laws,orders, circulars,regulations or guidelines. b. The Subgrantee Agency hereby agrees that it will comply, and all of its contractors will comply with the provisions of 28 CFR applicable to grants and cooperative agreements including: i. Part 18,Administrative Review Procedure; ii. Part 22,Confidentiality of Identifiable Research and Statistical Information; iii. Part 23,Criminal Intelligence Systems Operating Policies; iv. Part 30 Intergovernmental Review of Department of Justice Programs and Activities; v. Part 35,Nondiscrimination on the Basis of Disability in State and Local Government Services; vi. Part 38,Equal Treatment for Faith Based Organizations; vii. Part 42 Nondiscrimination/Equal Employment Opportunity Policies and Procedure; viii. Part 61 Procedures of Implementing the National Environmental Policy Act; ix. Part 63 Floodplain Management and Wetland Protection Procedures; and, x. Federal Laws or regulations applicable to Federal Assistance Programs. 2. FINANCIAL&ADMINISTRATIVE MANAGEMENT a. Subgrantee Agency assures that it will comply with appropriate federal cost principles and administrative requirements applicable to grants as follows: i. For state, local or Indian tribal government entities; a) OMB Circular A-87, Cost Principles for State, Local&Indian Tribal Governments b) OMB Circular A-102, Common Rule-Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments c) 28 CFR 66, Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments ii. For non-profit organizations; a) OMB Circular A-122, Cost Principles for Non-Profit Organizations b) OMB Circular A-110, Uniform Administrative Requirements for Grants and Agreements with Institutions of Higher Education,Hospitals and Other Nonprofit Organizations c) 28 CFR 70, Uniform Administrative Requirements for Grants and Cooperative Agreements with Institutions of Higher Education,Hospitals, and other Non-Profit Organizations COLORADO DIVISION OF CRIMINAL JUSTICE JUVENILE JUSTICE AND DELINQUENCY PREVENTION(JJDP)ACT APPLICATION FOR JUVENILE ACCOUNTABILITY BLOCK GRANT PROGRAM FUNDS SPECIAL PROVISIONS AND CERTIFIED ASSURANCES Special Provisions&Certified Assurances must remain attached to the application SPCA Page 7 of 10 August 21,2007 iii. For colleges and universities; a) OMB Circular A-21, Cost Principles for Educational Institutions b) OMB Circular A-110, Uniform Administrative Requirements for Grants and Agreements with Institutions of Higher Education, Hospitals and Other Nonprofit Organizations c) 28 CFR 70, Uniform Administrative Requirements for Grants and Cooperative Agreements with Institutions of Higher Education, Hospitals, and other Non-Profit Organizations iv. For each agency spending more than$500,000 per year in federal funds from all sources; a) OMB Circular A-133,Audits of States, Local Governments and Nonprofit Organizations b. The Subgrantee Agency assures that it will comply with the provisions of the Office of the Comptroller, Office of Justice Programs OC Financial Guide for Grants, current edition. (For practical purposes,the requirements pertinent to the management of these funds have been extracted from the above documents and are contained in the current applicable Administrative Guide of the Division of Criminal Justice, which is hereby incorporated by reference. However, such a guide cannot cover every foreseeable contingency, and the Subgrantee Agency is ultimately responsible for compliance with applicable state and federal laws,rules and regulations.) 3. NON-SUPPLANTING OF FUNDS (Governmental Agencies Only) a. The Subgrantee Agency certifies that any required matching funds used to pay the non-federal portion of the cost of this subgrant are in addition to funds that would have otherwise been made available for the purposes of this project. b. The Subgrantee Agency certifies that federal funds made available under this grant: i. Will not be used to supplant state or local funds; ii. That the Subgrantee Agency's expenditures for the purpose described in this application for the annual period are as great as for the preceding year plus the average annual increment in such expenditures for the past two,three,four or five years;OR iii. Where the certification above(3bii)cannot be made,and there is a reduced or unchanged local investment, then the Subgrantee Agency shall give a written explanation demonstrating that the Subgrantee Agency's reduced or unchanged commitment would have been necessitated even if federal financial support under this federal grant program had not been made available. 4. PROHIBITIONS ON LOBBYING WITH FEDERAL FUNDS(Subgrantee Agencies receiving$100,000 or more in total federal funds per year. See 28 CFR Part 69.) The prospective Subgrantee Agency certifies,by submission of this proposal,that: a. No federal funds received through this subgrant will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with the making of any federal grant, the entering into of any cooperative agreement,and the extension,continuation,renewal,amendment,or modification of any federal grant or cooperative agreement; and, b. If any funds other than funds through this subgrant will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this subgrant, the prospective Subgrantee Agency shall complete and submit Standard Form-LLL,"Disclosure of Lobbying Activities." 5. CERTIFICATION REGARDING DEBARMENT,SUSPENSION,INELIGIBILITY AND VOLUNTARY EXCLUSION (Subgrantee Agencies receiving$100,000 or more in total federal funds per year. See, 28 CFR Part 67.) The prospective Subgrantee Agency certifies,by submission of this proposal,that neither it nor its principals,subcontractors or suppliers: a. Are presently debarred,suspended,proposed for debarment,declared ineligible, sentenced to a denial of Federal benefits by a State or Federal court,or voluntarily excluded from participation in this transaction by any Federal department or agency; b. Have not within a three-year period preceding this application been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public(Federal,State,or local)transaction or contract under a public transaction;violation of Federal or State antitrust statutes or commission of embezzlement,theft,forgery,bribery, falsification or destruction of records,making false statements,or receiving stolen property; c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity(Federal,State,or local)with commission of any of the offenses enumerated in paragraph(5)(b)of this certification;and d. Have not within a three-year period preceding this application had one or more public transactions(Federal, State,or local)terminated for cause or default; and COLORADO DIVISION OF CRIMINAL JUSTICE JUVENILE JUSTICE AND DELINQUENCY PREVENTION(JJDP)ACT APPLICATION FOR JUVENILE ACCOUNTABILITY BLOCK GRANT PROGRAM FUNDS SPECIAL PROVISIONS AND CERTIFIED ASSURANCES Special Provisions&Certified Assurances must remain attached to the application SPCA Page 8 of 10 August 21,2007 e. Where the prospective Subgrantee Agency is unable to certify to any of the statements in this certification,he or she shall attach an explanation to this application. 6. CERTIFICATION REGARDING DRUG FREE WORKPLACE (See, 28 CFR Part 67, Subpart F.) The prospective Subgrantee Agency certifies, by submission of this proposal, that it will comply with the Drug Free Workplace Act of 1988, as implemented at 28 CFR Part 67,Subpart F. 7. CIVIL RIGHTS COMPLIANCE (See, 28 CFR Part 42.) a. Upon award, each Subgrantee Agency will be provided DCJ's Form 30, entitled"Certification of Compliance with Regulations Regarding Federal Civil Rights Requirements and Equal Employment Opportunity Plans (EEOP), and will be required to do the following: i. The Project Director must submit the form to the Subgrantee Agency's Authorized Official for this grant; ii. The Authorized Official must review the form in conjunction with subgrant agency personnel responsible for reporting civil rights findings of discrimination; iii. The Authorized Official must accurately complete the required information and provide all information requested; iv. The Authorized Official must provide an original signature on the form as indicated;and, v. The DCJ 30 Form with original signature must be returned to the Division with the Statement of Grant Award(SOGA). b. Any subgrant agency findings of discrimination must be reported to the Division of Criminal Justice within 45 days of receipt of this grant award, and to the Office for Civil Rights, Office of Justice Programs, U.S. Department of Justice. 8. NON-DISCRIMINATION The following federal non-discrimination cites apply in particular: the nondiscrimination requirements of the Omnibus Crime Control and Safe Streets Act of 1968, as amended; Title VI of the Civil Rights Act of 1964; Section 504 of the Rehabilitation Act of 1973, as amended; Subtitle A,Title II of the Americans with Disabilities Act of 1990,42 U.S.C. 12101, et. seq. and Department of Justice Regulations on Disability Discrimination, 28 CFR Part 35 and Part 39;Title IX of the Education Amendments of 1972; the Age Discrimination Act of 1975; the Department of Justice Nondiscrimination Regulations 28 CFR Part 42, Subparts C, D, E, and G; and Executive Order 11246, as amended by Executive Order 11375, and their implementing regulations,41 CFR Part 60.1 et. seq., as applicable to construction contracts. 9. NATIONAL ENVIRONMENTAL POLICY ACT(NEPA)AND NATIONAL HISTORIC PRESERVATION ACT (NHPA)COMPLIANCE (42 USC§§4321-4370 and 16 USC§470) a. The Subgrantee Agency agrees to assist the Division of Criminal Justice and the Office of Justice Programs, U.S. Department of Justice,in complying with the National Environmental Policy Act,the National Historic Preservation Act (NHPA) and other related federal environmental impact analyses requirements in the use of these grant funds either directly by the Subgrantee Agency or by a subcontractor. As long as the activity needs to be undertaken in order to use these grant funds,this NEPA requirement first must be met whether or not the activities listed below are being specifically funded with these grant funds.The activities covered by this special condition are: b. New construction; c. Minor renovation or remodeling of a property either listed on or eligible for listing on the National Register of Historic Places,or located within a 100-year flood plain; d. Renovation, lease or any other proposed use of a building or facility that will either result in a change in its basic prior use,or significantly change its size. e. Implementation of a new program involving the use of chemicals other than chemicals that are either purchased as an incidental component of a funded activity and traditionally used, for example,in office,household,recreational or educational environments. 10. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (This provision applies only to entities that provide medical care and treatment) The Subgrantee Agency acknowledges that it is a covered health care provider under the Health Insurance Portability and Accountability Act,42 U.S.C. 1320d-1320d-8,and its implementing regulations and agrees to comply with the requirements of HIPAA concerning any uses and disclosures of protected health information. COLORADO DIVISION OF CRIMINAL JUSTICE JUVENILE JUSTICE AND DELINQUENCY PREVENTION(JJDP)ACT APPLICATION FOR JUVENILE ACCOUNTABILITY BLOCK GRANT PROGRAM FUNDS SPECIAL PROVISIONS AND CERTIFIED ASSURANCES Special Provisions&Certified Assurances must remain attached to the application SPCA Page 9 of 10 August 2l,2007 11. Uniform Relocation Assistance and Real Property Acquisitions Act of 1970(Government Entities Only) The prospective Subgrantee Agency certifies,by submission of this proposal, that it will comply with the requirements of the Uniform Relocation Assistance and Real Property Acquisitions Act of 1970,which govern the treatment of persons displaced as a result of federal and federally-assisted programs. 12. Political Activity of Certain State and Local Employees (5 U.S.C. §§ 1501-08 and §§ 7324-28 — applies to Government Entities Only) The prospective Subgrantee Agency certifies, by submission of this proposal, that it will comply with requirements of 5 U.S.C. §§ 1501-08 and §§ 7324-28, which limit certain political activities of State and local government employees whose principal employment is in connection with an activity financed in whole or part by federal assistance. D. PROGRAM SPECIFIC REQUIREMENTS The following program specific requirements are imposed by the Federal or State sponsoring agency conceming special requirements of law,program requirements, and other administrative requirements which must be passed on to subgrant award recipients. 1. Right if Privacy for Recipients of Service and Sharing of information. The prospective Subgrantee Agency certifies,by submission of this proposal,that: a. Pursuant to Section 223(a)(18)of the Juvenile Justice and Delinquency Prevention Act,procedures have been established to ensure that this program will not disclose program records containing the identity of individual juveniles. Exceptions to this requirement are authorization by law;consent of either the juvenile or his/her legal authorized representative;or justification that otherwise the functions of this title cannot be performed. Under no circumstances may public project reports or findings contain names of actual juvenile service recipients. b. Necessary information will be shared appropriately among schools,law enforcement,courts and juvenile- serving agencies pursuant to the Family Educational Rights and Privacy Act(FERPA)(20 U.S.C. §1232g),as amended by Improving America's School Act of 1994(IASA). FERPA allows schools to play a vital role in a community's effort to identify children who are at risk of delinquency and provide services prior to a child's becoming involved in the juvenile justice system. c. Necessary information will be shared in accordance with the"Children's Code Records and Information Act," 19-1-301 et seq.,Colorado Revised Statutes,to balance the best interests of children and the privacy interests of children and their families with the need to share information among service agencies and the need to protect the public safety. 2. In addition to the"Termination for Cause"item,F.3 under Grant Requirements above,the subgrant may be suspended or terminated by the Division of Criminal Justice if the Subgrantee Agency fails to comply with the core requirements of the Juvenile Justice and Delinquency Prevention Act, 1974, as amended: Deinstitutionalization of Stats Offenders,Section 223 (a)(12)(A); Separation of Juveniles from Incarcerated Adults, Section 223(a)(13); Removal of Juveniles from Adult Jails and Lockups, Section 223 (a)(14);Disproportionate Minority Confinement, Section(a)(23). COLORADO DIVISION OF CRIMINAL JUSTICE JUVENILE JUSTICE AND DELINQUENCY PREVENTION(JJDP)ACT APPLICATION FOR JUVENILE ACCOUNTABILITY BLOCK GRANT PROGRAM FUNDS SPECIAL PROVISIONS AND CERTIFIED ASSURANCES Special Provisions&Certified Assurances must remain attached to the application SPCA Page 10 of 10 August 21,2007 SIGNATURE PAGE ->->->TO BE COMPLETED BY ALL APPLICANTS (ORIGINAL SIGNATURES REQUIRED-Please sign in BLUE ink. See instructions for description of proper signatories.) The Subgrantee Agency and responsible signatories certify by signing that they have read the Application including the Special Provisions and Certified Assurances,and are fully cognizant of their duties and responsibilities for this project.The Subgrantee Agency understands and agrees that any subgrant award received as a result of this application shall incorporate by reference the information contained herein. Responsibility for narrative and fiscal reporting requirements are delegated to the designated Project Director, who will sign all such reports. This delegation is for purposes of reporting to the Division and for operational ease, and in no way limits the authority and responsibility of the Authorized Official. In accordance with the Colorado Revised Statutes 24-72-202.6,information supplied in this application is considered a public record. AUTHORIZED OFFICIAL Name William H. Jerke Position Chair Agency Board of Weld County Commissioners Mailing Address P.O. Box 758 915 10th Street City, State,Zip Greeley, Colorado 80632 Telephone# 970-356-4000 X4200 Fax# 970-352-0242 E-mail Address wjerke@co.weld.co.us Signature Date JUN 3 0 2008 FINANCIAL OFFICER Name Monica Daniels-Mika Position Director of Administrative Services Agency Weld County Colorado Mailing Address P.O. Box 758 915 10th Street City, State,Zip Greeley, Colorado 80632 Telephone# 970-356-4000 X4210 Fax# 970-352-0242 E-mail Address mmika@co.weld.co.us t�, Signaturecjfv D4UN 3 0 2008` + 1 PROJECT DIRECTOR Name !�/= r/ ✓ E %/7' - ✓"o„�CE COJ Position C O O &/� Agency C a ' ry r Y S Ora el /--i 1 O r=F c C Mailing Address —o p .S"r/1 ('ire' City,State,Zip Y- C :3 'v Le 3 / Telephone# '? ?a ) 33 G - SioiS - .27o -2 Fax# (' 7 ?" ) 30Y - VC7 E-mail Address /ye 4 G H /CI 4) et(' c.JE)/'--t" • e o , v S Signature Date O?OD8-/O,75 Hello