Fillable DUE DATE: March 13, 2020 iscal Year: 2021 (Arizona)

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DUE DATE: March 13, 2020 iscal Year: 2021 (Arizona)

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Federal F
iscal Year: 2021
DUE DATE: March 13, 2020
Grant application decisions are reviewed and decided upon by GOHS and include consideration of the
following: analysis of crash data, need for the project, past performance with highway safety grants (if
applicable), and Federal funding availability. Please contact the Arizona Governor’s Office of Highway Safety
at (602) 255-3216 if you need assistance with this application.
SECTION A: Agency Application Information
Agency:
Agency Name:
Address:
City, State, Zip:
Fax:
Phone:
Title & Name:
Address:
City, State, Zi
p:
Phone:
Email:
Title & Name:
Address:
C
ity, State, Zip:
Phone:
Email:
Please attach a cover letter addressed to the Director of the Governor’s Office of Highway Safety
on agency letterhead. This cover letter must be signed by a representative of your agency
authorized to commit your agency to conduct the grant should it be approved for funding.
Project Director:
Project Admin:
Financial Contact:
Title & Name:
Address:
City, State, Zip:
Phone:
Email:
ARIZONA GOVERNOR'S OFFICE OF HIGHWAY SAFETY
Grant Application
Other - Non-Law Enforcement / Non-Profit
1 of 12
SECTIONB‐1:Agency/Organization Overview
Fillintheinformationinthissectionforyouragency/organization.
ProjectTitle:
ProjectDescription:(1or2paragraphs,briefoverview)
OrganizationSize:
TotalPopulationin yourcity/townorcountiesserved:
SelecttheCountyservedbyyouragency/organization:
StateWide MaricopaCounty
ApacheCounty MohaveCounty
CochiseCounty NavajoCounty
CoconinoCounty PimaCounty
GilaCounty PinalCounty
GrahamCounty SantaCruzCounty
GreenleeCounty YavapaiCounty
LaPazCounty YumaCounty
ARIZONA GOVERNOR'S OFFICE OF HIGHWAY SAFETY
Grant Application
Other - Non-Law Enforcement / Non-Profit
2 of 12
SECTION B-2: Problem Identification
Provide a narrative of the highway safety problem in your community/jurisdiction. Describe the nature
and magnitude of the problem using valid, up-to-date statistical data. Identify which program area(s)
have the greatest need, (i.e., impaired driving, occupant protection, speeding and aggressive driving,
pedestrian safety, etc.). Indicate what is happening, when it is happening, where it is happening, and
the contributing factors.
ARIZONA GOVERNOR'S OFFICE OF HIGHWAY SAFETY
Grant Application
Other - Non-Law Enforcement / Non-Profit
3 of 12
SECTIONC:GoalsandObjectives
In the spaces below, create 2 to 4 quantifiable goals that will relate to your agency/
organization's problem identification as stated in Section B-2. The 2020 Federal Fiscal Year begins
on October 1, 2020 and ends September 30, 2021.
OtherAgency/Non‐Profit:
ARIZONA GOVERNOR'S OFFICE OF HIGHWAY SAFETY
Grant Application
Other - Non-Law Enforcement / Non-Profit
4 of 12
SECTION D: Project Strategies and Activities (Method of Procedure)
In the spaces below, list or describe specific planned activities that your agency will perform in order to
achieve their project objectives on a quarterly basis. Activities should describe what will be done, who
will do it, and when it will take place. Objectives and subsequent activities in your project
should follow the SMART method:
S = Specific
M = Measurable
A = Action-Oriented
R = Realistic
T = Time-Framed
1st Quarter: 10/01/2020 - 12/31/2020
2nd Quarter: 01/01/2021 - 03/31/2021
Estimated 1st Quarter Expenditures:
Estimated 2nd Quarter Expenditures:
ARIZONA GOVERNOR'S OFFICE OF HIGHWAY SAFETY
Grant Application
Other - Non-Law Enforcement / Non-Profit
5 of 12
SECTION D: Project Strategies and Activities (Continued)
3rd Quarter: 04/01/2021 - 06/30/2021
4th Quarter: 07/01/2021 - 09/30/2021
Estimated 3rd Quarter Expenditures:
Estimated 4th Quarter Expenditures:
ARIZONA GOVERNOR'S OFFICE OF HIGHWAY SAFETY
Grant Application
Other - Non-Law Enforcement / Non-Profit
6 of 12
SECTION E: Detailed Project Budget
Please fill in the budget category that relates to your agency’s project proposal. Please note that GOHS
only grants overtime projects at a maximum employee related expense (ERE) rate of 40%.
Personnel Services
Description:
Personnel Services:
Employee Related
Expenses:
Description
Requested
Amount
Overtime
Amount
ERE
Amount
ERE %
Total:
ARIZONA GOVERNOR'S OFFICE OF HIGHWAY SAFETY
Grant Application
Other - Non-Law Enforcement / Non-Profit
7 of 12
0.00%
0.00%
0.00%
0.00%
0.00%
Description:
Professional & Outside Services:
Total:
Professional & Outside Services
Description
Requested
Amount
Total:
ARIZONA GOVERNOR'S OFFICE OF HIGHWAY SAFETY
Grant Application
Other - Non-Law Enforcement / Non-Profit
8 of 12
Description:
Travel:
Description Transport Lodging Per Diem Misc. Amount
Total:
Travel
In-state & Out-of-State
ARIZONA GOVERNOR'S OFFICE OF HIGHWAY SAFETY
Grant Application
Other - Non-Law Enforcement / Non-Profit
9 of 12
Description
Quantity
Price
Per Unit
Tax
Shipping
Amount
Total:
Materials & Supplies
Description:
Materials & Supplies: Designated for items with a per unit cost less than $5,000.00.
ARIZONA GOVERNOR'S OFFICE OF HIGHWAY SAFETY
Grant Application
Other - Non-Law Enforcement / Non-Profit
10 of 12
Description
Quantity
Price
Per U
nit
Tax
Shipping
Amount
Total:
Capital Outlay
Description:
Capital Outlay: Designated for any equipment with a per unit cost of $5,000.00 or more without accessories, tax, or
shipping. All other items should be placed in Materials & Supplies.
NOTE: It is the Agency's responsibility to confirm the equipment is Buy America compliant. A letter from the manufacturer
may be required.
ARIZONA GOVERNOR'S OFFICE OF HIGHWAY SAFETY
Grant Application
Other - Non-Law Enforcement / Non-Profit
11 of 12
Description
Requested
Amount
Personnel Services
ERE:
Employee Related Expenses
Professional & Outside Services
Travel
Materials & Supplies
Capital Outlay
Total:
SECTION F: Additional Proposal Information
If there is any additional information that your agency would like to attach to their proposal, please
include a PDF attachment with your proposal. Additional information may include: pictures, invoice
estimates, City/Town/County resolutions, additional enforcement information, etc.
Total Estimated Costs
ARIZONA GOVERNOR'S OFFICE OF HIGHWAY SAFETY
Grant Application
Other - Non-Law Enforcement / Non-Profit
12 of 12
$ 0
0.00%
$ 0
$ 0
$ 0
$ 0
$ 0
$ 0
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DUE DATE: March 13, 2020 iscal Year: 2021 (Arizona)

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Completed 27 January 2021

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