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<br />Supporting Documents Form
<br />
<br />Legal Name of Organization:
<br />Title of Project:
<br />Grant Period:
<br />Current Grant Number (If Continuation):
<br />
<br />PART 1: COMPREHENSIVE CERTIFICATION AND ASSURANCES
<br />
<br />Applicants must complete and submit this form to CJD before they will receive state and/or federal funds.
<br />Recipients of state and/or federal funds must fully understand and comply with the requirements listed for the
<br />Comprehensive Certification and Assurances in the Application Instruction Kit for this project. Failure to comply
<br />may result in the withholding of funds, termination of the award, or other sanctions.
<br />
<br />1.1 Certifications and Assurances
<br />
<br />
<br />The applicant has read and will fully comply with the Comprehensive Certifications and
<br />Assurances in the Application Instruction Kit for this project:
<br />
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<br />
<br />1.2 Audit Certification - Federal Funds
<br />
<br />a) Select the appropriate choice:
<br />
<br />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 OMB
<br />Circular A-133.
<br />
<br />Option 2: The applicant certifies that the applicant agency currently expends combined federal
<br />funding of less than $500,000 and, therefore, is exempt from the Single Audit Act and cannot charge
<br />audit costs to a CJD grant. I understand, however, that CJD may require a limited scope audit as
<br />defined in OMB Circular A-133.
<br />
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<br />
<br />b) Enter agency fiscal year:
<br />
<br />
<br />
<br />(e.g., 09/0112004 - 08/31/2005)
<br />
<br />c) Enter date of the last audit:
<br />
<br />100/3012004
<br />
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<br />
<br />d) Provide information regarding the financial support received by the applicant agency during the most recently completed
<br />fiscal year noted in Section 1.3(b) above:
<br />Source of Financial Support Total Estimated Amount of
<br />Support
<br />
<br />$ 1.690.000.00
<br />
<br />Federal Funds (excluding this request):
<br />
<br />
<br />State Funds (excluding this request):
<br />
<br />Local Government Funds:
<br />
<br />Private Funds:
<br />
<br />Program Income:
<br />
<br />Other (SPECIFY):
<br />
<br />EXHIBIT A
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<br />Page 10(5
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<br />Supporting Documents Form
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