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<br />Supporting Documents Form <br /> <br />Le al Name of Organization: q!WJt!.f,g~!1fd,~gijrt$'$li,t!il~!711I1Jl_~ti!!~~tlti!!1'li~ <br />Tit of Project: '11i1'!iQt;r;i:;irrf~;~rt69ilii~~,r&i1iii~1i'Qf1KIll.1f'ft'fllIi!lilal.ill'ljll,'1!il!l#i!i~ <br />Gr nt Period: From:j'fllilllk.oQpfilJlj To: 'ililisl3i12@Wl <br />C rent Grant Number (If Continuation): 1;l1~Q:;pl,,; .' . <br /> <br />P RT 1: COMPREHENSIVE CERTIFICATION AND ASSURANCES <br /> <br />A plicants must complete and submit this form to CJD before they will receive state and/or federal funds. <br />R Iplenta of state and/or federal funds must fully understand and comply with the requirements listed for the <br />C mprehenslve Certification and Assurances in the Application Instruction Kit for this project. Failure to comply <br />m y result in the withholding of funds, termination of the award, or other sanctions. <br /> <br />1. Certifications and Assurances <br /> <br /> <br />Th applicant has read and will fully comply with the Comprehensive Certifications and <br />As urances in the Application Instruction Kit for this project: <br /> <br />r SELECT One: il <br />Ives'. <br /> <br />1. Audit Certification - Federal Funds <br /> <br />a) <br /> <br />elect the appropriate choice: <br /> <br />SELECT One: Option 1: The applicant certifies that the applicant agency currently expends combined federal <br />funding of $500,000 or more and, therefore, is required to submit an annual single audit by an <br />independent auditor made in accordance with the Single Audit Act Amendments of 1996 and OMS <br />Circular A-133. <br /> <br />Option 1 <br /> <br />Option 2: The applicant certifies that the applicant agency currently expends combined federal <br />funding of less than $500,000 and, therefore, is exempt from the Single Audit Act and cannot charge <br />audit costs to a CJD grant. I understand, however, that CJD may require a limited scope audit as <br />defined In OMS Circular A-133. <br /> <br />c) nter date of the last audit: <br /> <br />I 09130/2004 <br /> <br />~ <br />I <br /> <br />b) nter agency fiscal year: <br /> <br />l10101/2004 -09130/2005 <br />(e.g., 09/01/2004 - 08/31/2005) <br /> <br />d) Provide information regarding the financial support received by the applicant agency during the most recently completed <br />fis al year noted in Section 1.3(b) above: <br />Source of Financial Support <br /> <br />eral Funds (excluding this request): <br /> <br />Total Estimated Amount of <br />Support <br />$ 1,690,000.00 <br /> <br />- I <br />I <br />, J <br />I <br />lU <br />~ <br /> <br /> <br /> <br />P gram Income: <br /> <br /> <br />~ 12,500.00 <br />$ 117,000.00 <br />$ <br />$ 453,000.00 <br />$ <br /> <br />I Government Funds: <br /> <br />P vate Funds: <br /> <br />o er (SPECIFV): <br /> <br />EXHIBIT 1l <br /> <br />Page 0/5 <br /> <br />Supporling Documents Fonn <br />