SAMPLE- FY27 EMD Grant Application.pdf

FY 2027 Emergency Medical Dispatch

Grant Application Checklist

Continuity of Operations Plan (COOP) e-mailed to shahri.moin@mass.gov {Annually}

Signed and Dated Emergency Medical Dispatch Grant Application Cover Page

Completed Emergency Medical Dispatch Grant Budget Worksheet, to include requested funding by category and detailed narrative

Included Vendor Quote(s), if applicable

CEMDR Agreement/Contract if requesting funds under this category

Medical Director Contract/Agreement if requesting funds under this category

Completed Contractor Authorized Signatory Listing Form signed by a City or Town Official AND each listed signatory must sign next to their name on the form

Completed Highlighted Sections, Signed and Dated Standard Contract Form

DO NOT SUBMIT DOUBLE-SIDED APPLICATIONS, QUOTES OR CONTRACTS

All applications with original signatures shall be submitted to:

State 911 Department 151 Campanelli Drive, Suite A Middleborough, MA 02346

FY 2027 Emergency Medical Dispatch Grant

Name of Eligible Entity / PSAP / RECC Anytown Police Department Address

15 Main Street City/Town/Zip Anytown, MA 01234 Telephone Number 617-555-1234 Fax Number 617-555-4321 Website www.anytown-ma.org

Name/Title of Authorized Signatory Shawn Grant, Chief Telephone Number 617-555-1212 Email Address chief@anytownpd-ma.org

Name/Title Program/Contract Manager Kyle Sampson, Lieutenant Telephone Number 617-555-1214 Email Address ksampson@anytownpd-ma.org

Total Grant Funds Requested: $ 6,021.49

Applicant meets the EMD requirements established by the State 911 Department by:

Provide EMD in-house utilizing certified emergency medical dispatchers using the following Emergency Medical Dispatch Protocol Reference System (EMDPRS):

APCO PowerPhone Priority Dispatch

OR

Utilizing the following Certified EMD Resource:

CEMDR’s Emergency Medical Dispatch Protocol Reference System (EMDPRS):

APCO PowerPhone Priority Dispatch

Authorization and Certification

Through its submission of this application to the State 911 Department, the applying governmental entity and the authorized signatory of the applying governmental entity affirms and declares that all information submitted to the State 911 Department regarding the application, reimbursements, budget modifications, reporting, and any and all other submissions required throughout the duration of the grant process, its award and execution shall be true and verifiable through source documentation. The above noted documents, excluding this application, will no longer require a signature at the time of submission. Submission of this application by the applying governmental entity and authorized signatory shall be applicable to any and all transactions submitted under a contract awarded as the result of this application.

Sign below to acknowledge having read and agreed to the grant conditions and reporting requirements listed in the grant guidelines.

Signed under the penalties of perjury this 5 day of July, 20 2 6

Chief Shawn Grant

ORIGINAL SIGNATURE OF AUTHORIZING SIGNATORY

Commented [91]: Name of your PSAP / Regional / RECC

Commented [92]: Name of the Authorized Signatory who signs the application.

Applicant must complete each section / line item.

Commented [93]: Name of the person the State 911 Department can contact and/or the person working on the grant.

Applicant must complete each section / line item.

NOTE: THIS PAGE IS CALLED THE APPLICATION COVER PAGE

FY 2027 Emergency Medical Dispatch Grant

Budget Worksheet

Funding Category Amount Requested Detailed Narrative

1. Certified EMD Resource $ Name of CEMDR:

(Attached copy of the current contract with CEMDR)

2. Emergency Medical Dispatch Protocol Reference System

$ 299.70

PowerPhone Annual Plan: Total Response Software Renewal for EMD

NOTE: Site Licensed Training is not eligible under the EMD Grant

EMD Software or EMD Guide/Cardsets, Annual License, Annual Maintenance, Q/A Annual Maintenance

(Attach quote for this category)

3. Other Emergency Medical Dispatch and Quality Assurance of Emergency Medical Dispatch Services

$ 5,721.69

Lt. Kyle Sampson conducting EMD Q/A review on 10% of 1,500 EMD calls (amount reported on annual Certification of Compliance form), 30 minutes per call = 75 hours x $68.47/hr. OT = $5,135.25

Officer James Powell is the CPR certified training instructor conducting (3) 4-hour CPR courses at $48.87/hr. OT = $586.44

NOTE: Eligible under the EMD Grant ONLY if CPR instructor is NOT a certified telecommunicator/does not answer 911 calls for your PSAP

For Q/A, PSAPs must provide name of the individual(s), pay rate and number of Q/A review hours you are requesting.

Attach contract for Medical Director or Third-party vendor conducting EMD case review for this category.

For CPR Instructor, list name of instructor, # of 4-hour courses being taught and OT pay rate.

Total Amount of Emergency Medical Dispatch Grant Funding Requested

$ 6,021.39

Statewide Contract (OSD or an OSD-designated department.)

Department Procurement - Includes all Grants 815 CMR 2.00.

(Attach Solicitation Notice or RFR, and Response or other procurement supporting documentation.)

Emergency Contract (Attach justification for emergency, scope, and budget.)

Contract Employee (Attach Employee Status Form, scope, and budget.)

Interim Contract with new Contractor (Attach justification for Interim Contract and updated scope/budget.)

Other Procurement Exception (Attach authorizing language, legislation with specific exemption or earmark, and exception justification, scope, and budget.)

Contract Employee (Attach any updates to scope or budget.)

COMMONWEALTH OF MASSACHUSETTS | STANDARD CONTRACT FORM

This form is jointly issued and published by the Office of the Comptroller, the Executive Office for Administration and Finance, and the Operational Services Division as the default contract for all Commonwealth Departments when another form is not prescribed by regulation or policy. The Commonwealth deems void any changes made on or by attachment (in the form of addendum, engagement letters, contract forms or invoice terms) to the terms in this published form or to the Standard Contract Form Instructions and Contractor Certifications, the Commonwealth Terms and Conditions, the Commonwealth Terms and Conditions for Human and Social Services, or the Commonwealth IT Terms and Conditions which are incorporated by reference herein. Additional non-conflicting terms may be added by Attachment.

Contractors are required to access forms at macomptroller.org/forms or mass.gov/lists/osd-forms.

CONTRACTOR INFORMATION COMMONWEALTH INFORMATION

Contractor Legal Name Department MMARS Code d/b/a Contract Manager Name

Legal Address As entered on Form W-9 or Form W-4

Business Mailing Address

Contract Manager Name Billing Address If Different

Phone Fax Phone Fax

Email Email

Vendor Code

VC

MMARS Doc ID(s)

Vendor Code Address ID e.g. “AD001”. AD

Note: The Address ID must be set up for Electronic Funds Transfer (EFT) payments.

RFR/Procurement or Other ID Number

NEW CONTRACT CONTRACT AMENDMENT

Procurement or Exception Type (Check one option only)

Collective Purchase (Attach OSD approval, scope, and budget.)

Current Contract End Date PRIOR to Amendment

Amendment Amount Or Enter “No Change”

Amendment Type Check one option only. Attach details of amendment changes.

Amendment to Date, Scope, or Budget (Attach updated scope and budget.)

Interim Contract with Current Contractor (Attach justification for Interim Contract and updated scope/budget.)

Other Procurement Exception (Attach authorizing language/justification and updated scope/budget.)

TERMS AND CONDITIONS

The Standard Contract Form Instructions and Contractor Certifications and the following document are incorporated by reference into this Contract and are legally binding.

Check ONE option:

Commonwealth Terms and Conditions Commonwealth Terms and Conditions for Human and Social Services Commonwealth IT Terms and Conditions

COMPENSATION

Check ONE option.

The Department certifies that payments for authorized performance accepted in accordance with the terms of this Contract will be supported in the state accounting system by sufficient appropriations or other non-appropriated funds, subject to intercept for Commonwealth owed debts under 815 CMR 9.00.

Rate Contract (No Maximum Obligation). (Attach details of all rates, units, calculations, conditions or terms and any changes if rates or terms are being amended.)

Maximum Obligation Contract. Total maximum obligation for total duration of this contract (or new total if contract is being amended):

Updated 07/01/2025 http://www.macomptroller.org/wp-content/uploads/instructions_standard-contract-form.pdf http://www.macomptroller.org/wp-content/uploads/instructions_standard-contract-form.pdf http://www.macomptroller.org/wp-content/uploads/form_commonwealth-terms-and-conditions.pdf http://www.macomptroller.org/wp-content/uploads/form_commonwealth-terms-and-conditions-for-human-and-social-services.pdf http://www.macomptroller.org/wp-content/uploads/form_commonwealth-terms-and-conditions-for-human-and-social-services.pdf http://www.macomptroller.org/wp-content/uploads/form_commonwealth-terms-and-conditions-for-information-technology.pdf https://www.mass.gov/lists/osd-forms https://www.mass.gov/law-library/815-cmr http://www.macomptroller.org/wp-content/uploads/form_commonwealth-terms-and-conditions.pdf http://www.macomptroller.org/wp-content/uploads/form_commonwealth-terms-and-conditions-for-human-and-social-services.pdf http://www.macomptroller.org/wp-content/uploads/form_commonwealth-terms-and-conditions-for-information-technology.pdf https://www.mass.gov/law-library/815-cmr https://mass.gov/lists/osd-forms https://macomptroller.org/forms

10 days 15 days 20 days 30 days

% PPD.

If YES, the Contractor’s annual SDP commitment for this Contract is

NO If NO, and the department is an Executive Department, enter the appropriate exemption:

MMARS Doc ID(s)

PROMPT PAYMENT DISCOUNTS (PPD)

Commonwealth payments are issued through Electronic Funds Transfer (EFT) 45 days from invoice receipt. See Prompt Pay Discounts Policy.

Contractors requesting accelerated payments must identify a PPD as follows:

Payment issued within:

If PPD percentages are left blank, identify reason:

Statutory/legal Ready Payments (M.G.L. c. 29, § 23A) Agree to standard 45-day cycle Only initial payment

BRIEF DESCRIPTION OF CONTRACT PERFORMANCE or REASON FOR AMENDMENT Enter the Contract title, purpose, fiscal year(s) and a detailed description of the scope of performance or what is being amended for a Contract Amendment.

Attach all supporting documentation and justifications.

SUPPLIER DIVERSITY PROGRAM (SDP) PLAN

Does the Supplier Diversity Program apply?

YES

ANTICIPATED START DATE (Complete ONE option only.)

The Department and Contractor certify for this Contract, or Contract Amendment, that Contract obligations:

1. may be incurred as of the Effective Date (latest signature date below) and no obligations have been incurred prior to the Effective Date.

2. may be incurred as of , 20 , a date LATER than the Effective Date below and no obligations have been incurred prior to the Effective Date.

3. were incurred as of , 20 , a date PRIOR to the Effective Date below, and the parties agree that payments for any obligations incurred prior to the Effective Date are authorized to be made either as settlement payments or as authorized reimbursement payments, and that the details and circumstances of all obligations under this Contract are attached and incorporated into this Contract. Acceptance of payments forever releases the Commonwealth from further claims related to these obligations.

CONTRACT END DATE

Contract performance shall terminate as of , 20 , with no new obligations being incurred after this date unless the Contract is properly amended, provided that the terms of this Contract and performance expectations and obligations shall survive its termination for the purpose of resolving any claim or dispute, for completing any negotiated terms and warranties, to allow any close out or transition performance, reporting, invoicing or final payments, or during any lapse between amendments.

CERTIFICATIONS

Notwithstanding verbal or other representations by the parties, the “Effective Date” of this Contract or Amendment shall be the latest date that this Contract or Amendment has been executed by an authorized signatory of the Contractor, the Department, or a later Contract or Amendment Start Date specified above, subject to any required approvals. The Contractor certifies that they have accessed and reviewed all documents incorporated by reference as electronically published and the Contractor makes all certifications required under the Standard Contract Form Instructions and Contractor Certifications under the pains and penalties of perjury, and further agrees to provide any required documentation upon request to support compliance, and agrees that all terms governing performance of this Contract and doing business in Massachusetts are attached or incorporated by reference herein according to the following hierarchy of document precedence, the applicable Commonwealth Terms and Conditions, this Standard Contract Form, the Standard Contract Form Instructions and Contractor Certifications, the Request for Response (RFR) or other solicitation, the Contractor’s Response (excluding any language stricken by a Department as unacceptable), and additional negotiated terms, provided that additional negotiated terms will take precedence over the relevant terms in the RFR and the Contractor’s Response only if made using the process outlined in 801 CMR 21.07, incorporated herein, provided that any amended RFR or Response terms result in best value, lower costs, or a more cost effective Contract.

AUTHORIZING SIGNATURE FOR THE CONTRACTOR

Chief Shawn Grant

AUTHORIZING SIGNATURE FOR THE DEPARTMENT

Signature and date must be captured at time of signature.

Signature Date Signature Date

Print Name Print Title Print Name Print Title

Updated 07/01/2025 https://www.powerdms.com/public/MAComptroller/documents/1779666 https://malegislature.gov/Laws/GeneralLaws/PartI/TitleIII/Chapter29/Section23A https://www.mass.gov/law-library/801-cmr

Commonwealth of Massachusetts

CONTRACTOR AUTHORIZED SIGNATORY LISTING

This form is jointly issued and published by the Office of the Comptroller (CTR) and the Operational Services Division (OSD) as the default form for all Commonwealth Departments when another form is not prescribed by regulation or policy.

Signature for Corporation (C or S), Partnership, Trust/Estate, Limited Liability Company (must match Form W-9 tax classification)

Contractor Legal Name City of Anytown

Contractor Vendor/Customer Code (if available, not the Taxpayer Identification Number or Social Security Number)

VC 6000000000

INSTRUCTIONS: Any Contractor (other than a sole-proprietor or an individual contractor) must provide a listing of individuals who are authorized as legal representatives of the Contractor who can sign contracts and other legally binding documents related to the contract on the Contractor’s behalf. In addition to this listing, any state department may require additional proof of authority to sign contracts on behalf of the Contractor, or proof of authenticity of signature (a notarized signature that the Department can use to verify that the signature and date that appear on the Contract or other legal document was actually made by the Contractor’s authorized signatory, and not by a representative, designee or other individual.)

For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank account numbers, social security numbers, driver’s licenses, home addresses, social security cards or any other personally identifiable information that you do not want released as part of a public record. The Commonwealth reserves the right to publish the names and titles of authorized signatories of contractors.

There are three types of electronic signatures that will be accepted on this form: 1) Traditional “wet signature” (ink on paper); 2) Electronic signature that is either: a. hand drawn using a mouse or finger if working from a touch screen device; or b. An upload picture of the signatory’s hand drawn signature; 3) Electronic signature affixed using a digital tool such as Adobe Sign or DocuSign.

Typed text of a name not generated by a digital tool, computer generated cursive, or an electronic symbol are not acceptable forms of electronic signature.

Authorized Signatory Name Signature (Signature as it will appear on contract or other documents)

Title Phone Number Email Address

Shawn Grant Shawn Grant Chief of Police 617-555-1212 chief@anytownpd-ma.org

Kyle Sampson Kyle Sampson Lieutenant 617-555-1212 ksampson@anytownpd-ma.org

Acceptance of any payment under a Contract or Grant shall operate as a waiver of any defense by the Contractor challenging the existence of a valid Contract due to an alleged lack of actual authority to execute the document by the signatory.

I certify that I am a responsible authorized officer of the Contractor and as an authorized officer of the Contractor I certify that the names of the individuals identified on this listing are current as of the date of execution and that these individuals are authorized to sign contracts and other legally binding documents related to contracts with the Commonwealth of Massachusetts on behalf of the Contractor. I understand and agree that the Contractor has a duty to ensure that this listing is immediately updated and communicated to any state department with which the Contractor does business whenever the authorized signatories above retire, are otherwise terminated from the Contractor’s employ, have their responsibilities changed resulting in their no longer being authorized to sign contracts with the Commonwealth or whenever new signatories are designated.

Please note you cannot self-certify your own signature as a single signer listed above.

Signature

Gerald M Lee

Date 7-2-2024

Print Name Gerald M. Lee

Phone Number 617-555-0000

Title Mayor of Anytown

Email Address mayorlee@anytown-ma.org

A copy of this listing must be attached to the “record copy” of a contract filed with the department.

Commented [9(6]: As of May 1, 2023, this is the NEW Contractor Authorized Signatory Listing form for governmental agencies/ municipalities to complete for grant applications.

Commented [9(7]: The State 911 Department REQUIRES all grant applications to have an original “wet” signature

Commented [9(8]: Signatories listed on this form MUST sign their name and must include two (2) signatoriese

This section must be signed by a City or Town Official, i.e. Mayor, Town Manager/Administrator/Select Board Chair (NOT the Chief of Police)

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Products & Services SKU

Billing Frequency Quantity Unit price Price

Items due now

Annual Plan:

Total Response Software July 2026-June 2027 for EMD

TRASWP 1 $299.70 $299.70

Annual Plan: Site Licensed Training from July 2026 - June 2027

TRATL 1 $4,179.00

Annual Service Plan

Annual Plan:

Total Response Software Renewal

Payment starts: July 1, TRASWPR Annually 1 $299.70 / year

$299.70 / year

Annual Plan:

Site Licensed Training Renewal

Payment starts: July 1, 2026

TRATLR Annually 1 $4,179.00 / year

$4,179.00 / year

Subtotal $4,478.70

Due now $4,478.70

$4,179.00

NOT ELIGIBLE

UNDER EMD GRANT

/ year / year

/ year / year

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