FY 2022 Connect and Protect: Law Enforcement Behavioral Health Response Program

Subaward Applications and Required Forms

CFDA 16.745

All Assurances and Certifications (listed on the Subaward Application Checklist) that require signatures are attached at the end of the Subaward Application forms.

FY 2022 Connect and Protect: Law Enforcement Behavioral Health Response Program

Subaward Program Application Overview

Name of Applicant Agency: ____________________________________________

Title of Proposal: _____________________________________________

Proposal Abstract (limit 100 words or less):

Applicant Information

Official Name of Applicant Agency: ______________________________________________

Type of Agency: _____State _____County _____Municipality _____Nonprofit

Address: ________________________________________________________

City/State: ______________________ Zip Code: ___________ County: ______________

Implementing Agency (if different than applicant) ______________________________

Federal ID Number: ____________________________

Agency DUNS Number : __________________________________________

Is Applicant Agency registered with the System for Award Management? ____ Yes ____ No

If no, please explain _____________________________________

Name of Project: ____________________________________________________

Type of Application: _____ New _____ Continuation CFDA# _______________

Name of Project Contact: _________________________________

Address (if different from above): ________________________________________________

________________________________________________

Telephone Number: ___________________________________

Fax Number: ____________________ Email Address:______________________________

Congressional District: ______________________________

Areas affected by the Project (Statewide, county, city): ______________________________

Proposed Project start and end dates: ________________________________________

Name of Chief Financial Officer: _________________________ Telephone: _______________

Name/Title of Authorized Representative: _______________________________________

Signature of Authorized Representative: ___________________________________________________

Project Narrative

The program narrative must specifically describe the manner in which Connect and Protect grant funds will be used to carry out the State plan to support law enforcement and behavioral health cross-system collaboration and to improve public health and safety responses and outcomes for individuals with MHDs or co-occurring MHSUDs who come into contact with the criminal justice system.

Include: Problem Statement/Needs Assessment; Goals, Objectives, and Action Strategy; Planning, Management Structure, and Background; Performance Measures/Evaluation; and Program Budget.

Project Work Plan

Project Name: ____________________________________________________

Objective	Activity	Person Responsible	Project Start and Completion Dates

Subaward Application Checklist

Connect and Protect: Law Enforcement Behavioral Health Response Program

What an Application Should Include:

☐	Application Authorization
☐	Subaward Program Application Overview
☐	Applicant Information
☐	Project Narrative
☐	Project Work Plan
☐	Budget Detail Worksheet
☐	Budget Narrative (Budget should be annotated to delineate opioid-related and non-opioid items)
☐	Federally Approved Indirect Cost Rate Agreement (if applicable)
☐	Certification Regarding Lobbying; Debarment, Suspensions and Other Responsibility Matters; and Drug-Free Workplace Requirements
☐	Federal Single Audit Requirements & Certification with proof of compliance if applicant is subject to audit requirements
☐	New Jersey Single Audit Requirements & Certification
☐	Department of Law and Public Safety Debarment and Suspension Certification with proof of eligibility for federal funds
☐	Certified Standard Assurances
☐	Certification by a Credentialing Body