SAMPLE - FY27 Support Incentive Grant Application.pdf

FY 2026 Support and Incentive Grant

Type of PSAP: (please check one) Primary Regional Regional Secondary

Regional Emergency Communication Center

Name Municipality / PSAP / RECC Anytown Police Department

Address 25 Main Street City/Town/Zip Anytown, MA 01234 Telephone Number 617-555-1212 Fax Number 617-555-1213 Website www.anytownpolice.org

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

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

Total Grant Program funds requested: $ 79,152.00

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 above Authorization and Certification, the grant conditions and reporting requirements listed in the grant guidelines.

Signed under the penalties of perjury this 15 day of July , 20 24.

Chief Shawn Grant

ORIGINAL SIGNATURE OF AUTHORIZING SIGNATORY

BUDGET SUMMARY

*Grand Total = Total allocation amount and, if requesting, Mobile Behavioral Health Crisis Response Services

Primary PSAP, Regional PSAP, Regional Secondary PSAP, & RECCs

CATEGORY AMOUNT

A. Enhanced 911 Telecommunicator Personnel Costs $ 15,317.11

B. Heat, Ventilation, Air Conditioning, and Other Environmental Control Equipment

C. Computer-Aided Dispatch Systems $ 39,155.00

D. Radio Console $

E. Console Furniture and Dispatcher Chairs $ 1,540.00

F. Fire Alarm Receiving and Alerting Equipment Associated with Providing Enhanced 911 Service

G. Other Equipment $ 8,139.89

REGIONAL PSAPs and RECCs ONLY

H. Public Safety Radio Systems

I. Annual Maintenance $

REGIONAL SECONDARY PSAP ONLY

J. PSAP Customer Premises Equipment Maintenance

TOTAL ALLOCATION $ 64,152.00

REVIEW APPENDIX B FOR ELIGIBILITY AND AMOUNT

Mobile Behavioral Health Crisis Response Services $ 15,000.00

GRAND TOTAL* $ 79,152.00

Commented [9(3]: Applicant will ONLY be eligible if they currently DISPATCH Mobile Behavioral Health Crisis Responders aka Clinicians

PRIMARY PSAP, REGIONAL PSAP, REGIONAL SECONDARY PSAP, & RECC

DETAIL NA

RRATIVE

Please make sure that every item listed in the above Budget Worksheet is listed in below narrative with a detailed description including category of item, price per unit, quantity, brand, model and any other pertinent and available information. Please include any and all quotes to support the budget narrative. For personnel costs, complete Appendix A – Personnel Costs Form. Please use additional pages if needed.

A. Enhanced 911 Telecommunicator Personnel Costs – to defray the costs of salary for enhanced 911 telecommunicator personnel, including enhanced 911 telecommunicators who are emergency communications dispatchers or supervisors. In order to be eligible for such funding, a grantee shall show that the personnel costs to be reimbursed: (1) cover only personnel who are trained and certified as an enhanced 911 telecommunicator in accordance with the requirements of the State 911 Department, or are in the process of obtaining such certification, in accordance with the requirements of the State 911 Department; and (2) except as otherwise approved by the State 911 Department, are solely for hours in which such personnel are working in the capacity of an enhanced 911 telecommunicator as their primary job function; and (3) except as otherwise approved by the State 911 Department, are solely for hours in which such personnel are conducting quality control/quality assurance of 911 calls. Reimbursement may be allowed for straight time costs for on the job training for new telecommunicators who are in the process of obtaining certification as an enhanced 911 telecommunicator, in accordance with the requirements of the State 911 Department. Reimbursement for personnel costs related to training may be allowed only for training courses that have been approved by the State 911 Department under the Fiscal Year 2026 State 911 Department Training Grant, or with the prior written approval of the State 911 Department. Reimbursement for personnel costs for individuals who have other primary job duties not directly related to enhanced 911 service, such as firefighters or police officers who may occasionally be assigned PSAP enhanced 911 telecommunicator duty, may be allowed only for the documented hours in which the employee is acting primarily in the capacity of an enhanced 911 telecommunicator. For example, if a police officer or firefighter is assigned to work as an enhanced 911 telecommunicator 1 day a week, funding from these grants may only be used to cover the portion of such firefighter or police officer’s salary for the 1 day a week that he or she is assigned to enhanced 911 telecommunicator duty. Funding awarded through these grants shall be assigned to specific identified personnel, and the funding shall be applied to the personnel costs associated with such specific identified personnel.

All wage reimbursements authorized under this Program shall be allocated by the grantee in adherence with applicable collective bargaining agreements. However, the State 911 Department is not bound by or required to adhere to grantee collective bargaining agreements when determining allocations or reimbursements.

Attach Appendix A

Total Category A

B. Heat, Ventilation, Air Conditioning and Other Environmental Control Equipment – to defray costs associated with the acquisition and maintenance of heat, ventilation and air-conditioning equipment and other environmental control equipment. Such funds may only be used to purchase, install, replace, maintain, operate, and/or upgrade such equipment used in the physical space used for the provision of enhanced 911 service.

B. Heat, Ventilation, Air Conditioning and Other Environmental Control Equipment

Description:

Vendor:

Attach Quote and mark with letter B

Total Category B $

$ 15,317.11

Please make sure that every item listed in the above Budget Worksheet is listed in below narrative with a detailed description including category of item, price per unit, quantity, brand, model, and any other pertinent and available information. Please include any and all quotes to support the budget narrative. Please use additional pages if needed.

C. Computer-aided Dispatch Systems – to defray costs associated with the purchase, installation, replacement, maintenance and/or upgrade of CAD hardware and software used by emergency communication dispatchers, call takers, and 911 operators in primary PSAPs, regional PSAPs, regional secondary PSAPs, and RECCs to initiate public safety calls for service and dispatch, and to maintain the status of responding resources in the field. Funds may be used for mobile devices that are linked to a CAD system. Primary PSAPs may not use funding for records management systems, whether or not part of a CAD system. Regional PSAPs and RECCs may apply for funding for records management systems.

C. Computer-aided Dispatch Systems

Description: Purchase two (2) Panasonic CF-31 Toughbook (MDTs), installation, keyboards, mounts, antennas, docking stations, plus shipping. The Mobile Data Terminals are for three new Police Cruisers the City of Anytown has purchased. To be used for interactive dispatching between CAD 911 Dispatcher and the patrol vehicles. $6,999.00 per unit x 2 = $13,998.00

Delphi Technology Solutions, Inc. Annual Network Support and IT Services contract directly related to enhance and maintain the Computer-Aided Dispatch Systems. $25,157.00

Are the requested items linked to CAD? Yes

If requesting MDT’s, list the number of vehicles that are linked to CAD? 15

Where will the requested items be located? City of Anytown new Police Cruisers

What will run or be displayed on computers/monitors, if requesting? CAD

Vendor: Patrol PC, SHI

Attach Quotes and mark with letter C Total Category C $39,155.00

Commented [94]: Internal 2D Law Enforcement Imaging Scanners, Barcode Readers, Thermal Cameras and PocketJet Printers and Accessories for MDT’s are NOT eligible. Please review your vendor quote to ensure these item are NOT included.

Commented [95]: If the vendor bills you on a monthly basis for your annual contract, your request must be pro-rated for the number of months remaining in the grant cycle.

Example: If you submit your grant application in December you would pro-rate the cost of the contract for the number of months remaining during that grant cycle = six (6) months.

Commented [9(6]: PSAP must list the number of vehicles that are linked to CAD DO NOT TYPE “ALL”

911DeptGrants Highlight

D. Radio Consoles – to defray costs associated with the purchase, installation, replacement, maintenance, and/or upgrade of radio consoles to be used at primary PSAPs, regional PSAPs, regional secondary PSAPs, and RECCs. Such funds may only be used to purchase, install, replace, maintain, and/or upgrade such radio consoles used in the physical space used for the provision of enhanced 911 service. All radio consoles shall comply with SIEC special conditions, as may be amended from time to time. The SIEC special conditions are available at:

http://www.mass.gov/eopss/docs/ogr/homesec/sd-siecs-pecialconditionsradiofrequenciesdec09.pdf.

The State 911 Department will submit requests for such funding to the SIEC for review and confirmation that the requested item(s) comply with the SIEC special conditions. Questions relating to the SIEC special conditions should be directed to the SWIC who can be reached by email at MA.SWIC@mass.gov.

Applicants requesting funds for interoperable communications components, such as radio consoles, or other communication system components must include with their grant application the Interoperable Communications Investment Proposal (ICIP). The ICIP Template can be found here ICIP Template Download (mass.gov).

D. Radio Consoles

Description:

Vendor:

Attach Quote and mark with letter D

Total Category D $

Commented [9(7]: All applicants requesting new radio consoles MUST complete an ICIP form signed by the head of the department and attached vendor quote, as both must be reviewed and approved by the SWIC

Please make sure that every item listed in the above Budget Worksheet is listed in below narrative with a detailed description including category of item, price per unit, quantity, brand, model, and any other pertinent and available information. Please include any and all quotes to support the budget narrative. Please use additional pages if needed.

E. Console Furniture and Dispatcher Chairs – to defray costs associated with the purchase, installation, replacement, maintenance, and/or upgrade of console furniture and dispatcher chairs necessary for enhanced 911 telecommunicators working at primary PSAPs, regional PSAPs, regional secondary PSAPs, and RECCs to perform their jobs effectively and in an ergonomically appropriate manner. Such funds may only be used to purchase, install, replace, maintain, and/or upgrade such console furniture and dispatcher chairs, including shelving, storage cabinets, and rotary resource files, used in the physical space used for the provision of enhanced 911 service.

E. Console Furniture and Dispatcher Chairs

Description: Purchase one high-back leather chair, ergonomically designed for 24/7 use to replace dispatcher chair that is broken and no longer under warranty.

Have you previously applied for funding for dispatcher chairs? Yes

If so, what year? FY2018

Are they under warranty? No

Vendor: Console Furniture, Inc.

Attach Quote and mark with letter E

Total Category E

F. Fire Alarm Receiving and Alerting Equipment Associated with Providing Enhanced 911 Service – to defray costs associated with the purchase, installation, replacement, maintenance, and/or update of fire alarm receiving and alerting equipment used at primary PSAPs, regional PSAPs, regional secondary PSAPs, and RECCs. Funding may be used to purchase, install, replace, maintain, and/or update systems used by such PSAPs to alert remote station personnel of emergency responses, including hardware and components installed within remote station locations.

Funding for street or structure based cable or radio fire alarm boxes and related hardware is not permitted.

F. Fire Alarm Receiving and Alerting Equipment Associated with Providing Enhanced 911 Service

Description:

Vendor:

Attach Quote and mark with letter F

Total Category F

$ 1,540.00

Dispatcher Chairs should be high intensity-use, 24/7 chairs. Additionally, these chairs usually come with a 6/10 year warranty, making the PSAP ineligible for new chairs until after the manufacturers warranty is over.

Please make sure that every item listed in the above Budget Worksheet is listed in below narrative with a detailed description including category of item, price per unit, quantity, brand, model and any other pertinent and available information. Please include any and all quotes to support the budget narrative. Please use additional pages if needed.

G. Other Equipment and Related Maintenance Associated with Providing Enhanced 911 Service – to defray costs associated with the purchase, installation, replacement, and/or maintenance of other equipment used in the physical space used for the provision of enhanced 911 service, except as otherwise approved by the State 911 Department, based on supporting documentation that the physical space used for the provision of enhanced 911 service is inadequate to house the equipment, or except as otherwise approved by the State 911 Department based on supporting documentation. Funding may be used for, but is not limited to: support technology (such as printers, headsets, and call recorders); supplies (such as disc and printer cartridges); hardware and support costs (excluding monthly recurring telephone service costs) for telephones; acoustic wall coverings; ESD-resistant flooring; lighting; and security equipment used for securing access to the PSAP to prevent entry by the public or unauthorized personnel.

G. Other Equipment and Related Maintenance Associated with Providing Enhanced 911 Service

Description: Cannon RX301 Copier Lease for 11 months at $739.99 per month (August 1, 2024 – June 30, 2025)

Use and location for each of the requested item(s). Copier is located in the Dispatch Center and is used solely by the Center’s staff to print/copy documents, schedules, Q/A reports, etc.

What will run or be displayed on computers/monitors, if requesting? N/A

Vendor: Cannon, Inc.

Attach Quote and mark with letter G

Total Category G

REMINDER: Disposal of Equipment Purchased with Grant Funding: Grantees may replace and/or dispose of equipment purchased with funds under the State 911 Department grant programs only if such equipment has reached the end of its useful life, in accordance with the manufacturer’s warranty or industry expected useful life, whichever is longer. Disposal shall be in compliance with municipal guidelines, and equipment may be transferred to public entities for public municipal purposes only.

All goods and/or services shall be received on or before June 30, 2026 to be eligible for reimbursement under the Fiscal Year 2026 State 911 Department Public Safety Answering Point and Regional Emergency Communication Center Support and Incentive Grant

$ 8,139.89

Commented [98]: If you are billed on a monthly basis by the vendor, your request must be pro-rated by how many months after you receive a contract start date.

Example: If you submit your grant application in December you would pro-rate the cost of the lease for the number of months remaining during the grant cycle = six (6) months.

Appendix A - Personnel Costs

(List Certified Enhanced 911 Telecommunicators)

NAME OF PSAP: Anytown Police Department Last Name, First Name Hourly Pay

Rate Overtime Pay Rate

Drake Horton $38.00 $57.00 Dudley Jake $26.93 $40.40 Jones Derek $22.00 $22.00 Patch Sarah $22.58 $33.87 Sampson Kyle $42.86 $64.29

Please use additional pages if needed.

List each person in alphabetical order by LAST NAME, as this is how they are listed in our system.

Appendix B: Mobile Behavioral Health Crisis Response Services

In addition to the allocation amount noted in the Appendix A of the grant guidelines, PSAPs, Regional Secondary PSAPs, Regional PSAPs, and Regional Emergency Communications Centers that dispatch mobile behavioral health crisis response services shall receive additional support grant funding to be used for allowable expenses under this grant program as follows:

The calendar year 2024 call volume is available on our website at www.mass.gov/e911.

The following information is required:

1. Grantee's requesting this additional funding must included a copy of your PSAP's/RECC's policy/procedure detailing the dispatching of mobile behavioral health crisis response services that clearly explains how the certified telecommunicator dispatches the Behavioral Health Clinician.

{NOT THE POLICE DEPARTMENT’S MENTAL HEALTH POLICY}

2. Who are you partnered with for the provision of providing the mobile behavioral health crisis response services?

JDP Grant Clinician

3. In the section below, enter the amount(s) in the funding category(ies) [A – G] where the additional mobile behavioral health crisis response service funds are to be added. Please note this, and the Budget Summary page, is where you identify the additional funding, DO NOT add these funds to the funding category(ies) in the budget narrative.

If requesting funds in Category B – G, you must provide the vendor quote(s) AND the detailed description including price per unit, quantity, brand, model, and the use and location of the requested item(s) below.

Description:

2024 911 Call Volume Funding Amount 0 - 2,999 $15,000

3,000 – 3,999 $20,000 4,000 – 4,999 $25,000 5,000 – 9,999 $35,000

10,000 – 19,999 $45,000 20,000 – 39,999 $60,000 40,000 – 59,999 $80,000 60,000 – 99,999 $100,000 100,000 or more $125,000

Funding Category Amount A: Personnel Costs $15,000.00 B: Heat, Ventilation, Air Conditioning C: Computer-aided Dispatch Systems D: Radio Consoles E: Console Furniture & Dispatch Chairs F: Fire Alarm Receiving & Alerting G: Other Equipment

TOTAL $15,000.00

Commented [9(10]: ONLY PSAPs that DISPATCH this service are eligible.

Transferring a call is NOT a Mobile behavioral Health Crisis Response Service. If the Clinician is not dispatched or contacted by the 911 Call Center staff to respond to a 911 behavioral health call, you will not be eligible for these additional funds.

Commented [9(11]: For eligibility amount, PSAPs must use our calendar year 2024 call volume.

Commented [9(12]: This should be a part of the PSAP's Standard Operating Procedures (SOP) and is a requirement for receiving this additional funding.

Commented [9(13]: PLEASE NOTE: The additional funds are for the PSAP and are NOT for the support of the Behavioral Health Clinician

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

Contractor Legal Name d/b/a Legal Address As entered on Form W-9 or Form W-4 Contract Manager Name

Phone Email x

Vendor Code VC

Vendor Code Address ID e.g. “AD001”. Note: The Address ID must be set up for Electronic Funds Transfer (EFT) payments.

AD

COMMONWEALTH INFORMATION

COMMONWEALTH INFORMATION

Department MMARS Code Contract Manager Name Business Mailing Address

Billing Address If Different Phone Email Fax

MMARS Doc ID(s)

RFR/Procurement or Other ID Number

Procurement or Exception Type (Check one option only) Statewide Contract (OSD or an OSD-designated department.)

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

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.)

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.)

Contract Employee (Attach any updates to scope or 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):

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:

Statutory/legal Ready Payments (M.G.L. c. 29, § 23A) If PPD percentages are left blank, identify reason:

Agree to standard 45-day cycle Only initial payment

Payment issued within: 10 days % PPD. 15 days % PPD. 20 days % PPD. 30 days % PPD.

Does the Supplier Diversity Program apply? YES

NO

If YES, the Contractor’s annual SDP commitment for this Contract is If NO, and the department is an Executive Department, enter the appropriate exemption:

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 performance shall terminate as of , 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.

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.

Signature Date

Print Name Print Title

Signature Date

Print Name Print Title

Fa

TERMS AND CONDITIONS

COMPENSATION (Check ONE option.)

PROMPT PAYMENT DISCOUNTS (PPD)

Updated 11/22/2024

CONTRACT AMENDMENTNEW CONTRACT

BRIEF DESCRIPTION OF CONTRACT PERFORMANCE or REASON FOR AMENDMENT

SUPPLIER DIVERSITY PROGRAM (SDP) PLAN

ANTICIPATED START DATE (Complete ONE option only.)

CONTRACT END DATE

CERTIFICATIONS

AUTHORIZING SIGNATURE FOR THE CONTRACTOR

Signature and date must be captured at time of signature.

AUTHORIZING SIGNATURE FOR THE COMMONWEALTH

Signature and date must be captured at time of signature.

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. Contract is for the reimbursement of funds under the State 911 Department FY 2026 Public Safety Answering Point and Regional Emergency Communication Center Support and Incentive Grant as authorized and awarded in compliance with the grant guidelines and the grantee’s approved application.

CT EPS SUPG

Chief Shawn Grant 7/1/2025 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-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://www.powerdms.com/public/MAComptroller/documents/1779666 https://malegislature.gov/Laws/GeneralLaws/PartI/TitleIII/Chapter29/Section23A https://www.mass.gov/law-library/801-cmr 911DeptGrants Highlight

911DeptGrants Highlight

911DeptGrants Highlight

911DeptGrants Highlight

911DeptGrants Highlight

911DeptGrants Highlight

911DeptGrants Highlight

911DeptGrants Highlight

911DeptGrants Highlight

911DeptGrants Highlight

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, WE DO NOT ACCEPT ELECTRONIC

SIGNATURES ON GRANT APPLICATIONS.

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)

911DeptGrants Highlight

911DeptGrants Highlight