SAMPLE - FY27 Training Grant Application.pdf

FY 2027 TRAINING GRANT

Name of Eligible Entity / PSAP / RECC Anytown Police Department Address 25 Police Street City/Town/Zip Anytown, MA 01234 Telephone Number 617-555-1212 Fax Number 617-555-1213 Website www.anytownpd.org

Name & Title of Authorized Signatory Shawn Grant, Chief of Police

Telephone Number 617-555-1212 Email Address chief@anytownpd-ma.org

Name & Title Grant Contract Manager Kyle Sampson, Lieutenant

Telephone Number 617-555-1214 Email Address ksampson@anytownpd-ma.org

Total Grant Program Funds Requested: $ 35,748.95

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

Providing EMD in-house utilizing certified emergency medical dispatchers and 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 Authorization and Certification above and the grant conditions and reporting requirements listed in the grant guidelines.

Signed under the penalties of perjury this 06 day of July , 2026

Chief Shawn Grant

ORIGINAL SIGNATURE OF AUTHORIZING SIGNATORY

Commented [9(1]: 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.

Commented [9(2]: Beginning with the FY2025 grant cycle, the State 911 Department will no longer require signatures on reimbursement and budget modifications for our grant programs.

FY 2027 TRAINING GRANT BUDGET

NARRATIVE

A. Fees – Fees associated with attendance at approved live or online 911 training courses, including certifications/ recertifications for certified Telecommunicators to include 16 hours of continued education or for those working toward certification. Add the Total Vendor Fees from the Personnel Costs Worksheet(s) and the total Membership & Conference Fees below to get the total for Category A.

For Membership fees, list the name and amount for each below.

Membership Fees: APCO $550, NENA $779, MCSA $175

For Conference fees, list the name of the conference, number attending and the amount for each conference below.

Conference Fees: APCO (3) $687, NENA (1) $745

Total Category A

B. Personnel Costs – Straight time or overtime expenses for participants or replacement/backfill (who are certified telecommunicators), to cover participant class hours but not both. Add the Total Salary column(s) from the {{REQUIRED}} Personnel Costs Worksheet(s) and enter below.

Total Category B

C. Training Materials and Other Products – Funding may be authorized for the purchase, installation, replacement, maintenance, and/or upgrade of software and other products related to the certification and training of enhanced 911 telecommunicators, including but not limited to, call handling guide cards, call handling software, skill and ability pre-employment testing software, and additional related training materials such as books and manuals. In addition, funding not to exceed $2,500 may be authorized for the purchase of skill and ability software/programs/subscriptions utilized by a PSAP to enhance the skill set of its certified telecommunicators.

Description: (5) CPR Cards @ $10 each $50 CritiCall Pre-Employment Testing Software $2,965

Attach quote for this category Total Category C

D. Enter the lodging expenses to include the number of people and number of nights for two (2) or more consecutive days of training (not to include the night prior to the training) and the distance of which is equal to or greater than ninety (90) miles away from where travel originates. NOTE: Lodging for conferences is not eligible.

Description:

Total Category D

E. Mileage – Funding may be authorized for the payment of mileage when an employee utilizes his/her personal vehicle for travel to attend eligible trainings. Mileage, where applicable, will be verified utilizing a recognized mileage guide such as Google Maps. Eligible mileage will be calculated by determining the round-trip mileage from the PSAP to the training location, rounded to the nearest mile. Other expenses associated with travel, such as tolls and parking, may also be eligible.

If requesting funding under this category, applicant must provide its employment agreement.

Description: Explain your calculation for the amount you are requesting on a separate sheet of paper.

Total Category E

$ 5,722.03 _ ____

$_26,544.48____

$_3,015.00 _____

$ 467.44 ____

911DeptGrants Comment on Text To arrive at this amount, add all fees from:

Certified Personnel Worksheet $1,714.48 New Personnel Worksheet $1,071.55 Total Membership Fees $1,504 Total Conference Fees $1,432

911DeptGrants Comment on Text Completed set by 911DeptGrants

911DeptGrants Comment on Text Accepted set by 911DeptGrants

911DeptGrants Comment on Text None set by 911DeptGrants

911DeptGrants Comment on Text Completed set by 911DeptGrants

Mileage Calculation

Mileage for round trip to training courses and back to PSAP for certified personnel and (4) new hires at $0.72/mile for a total of 149.25 miles = $107.44

Mileage for round trip to TERT trainings and back to PSAP for (2) TERT members at an estimated 50 miles per training at $0.72/mile for a total of 00 miles = $

Mileage Total = $

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 911DeptGrants Comment on Text New Contract form is now 2 pages

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

Signature and date must be captured at time of signature.

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, 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

911DeptGrants Highlight

LAST NAME FIRST NAME OT Rate Con Ed. Travel Total Hrs

Total Salary

Enter the Vendor Fees for 16 Hours of Training

Anderson Mark $ 35.00 16 16 560.00$ 214.31$ Beckman Christoper $ 42.00 16 16 672.00$ 214.31$ Donovan Michael $ 33.00 16 16 528.00$ 214.31$ Douglas Kristine $ 31.29 16 16 500.64$ 214.31$ Maxim Paul $ 56.00 16 16 896.00$ 214.31$ McLeon Sarah $ 28.00 16 16 448.00$ 214.31$ Perkins Kenneth $ 36.00 16 16 576.00$ 214.31$ Smith John $ 29.00 16 16 464.00$ 214.31$

CPR Instructor Paul Maxim (4) 4-hour classes $ 56.00 16 16 896.00$

EX: APCO EMD Recert fee 2 @ $35 70.00$

5,540.64$ 1,714.48$

DO NOT ADD LINES TO THIS WORKSHEET, AS THE FORMULAS MAY CHANGE,

CONTINUE ON THE NEXT WORKSHEET TAB BELOW

FY 2027 Training Grant Personnel Costs Worksheet

CERTIFIED PERSONNEL

PSAP: Anytown Communications SAMPLE - PowerPhone Site Licensed Training (SLT) {List Personnel in Alphabetical Order by Last Name}

EMD {ONLY} RECERTIFICATION FEES WITH NO TRAINING HOURS:

TOTALS

DO NOT WRITE IN THIS SPACE

PowerPhone/Total Response SLT Amount $2,786 / 13 = $214.308

911DeptGrants Highlight

911DeptGrants Highlight

LAST NAME

FIRST

NAME OT Rate

Training Academy

Next Gen New Hire PST

EMD (APCO

32) CPR Travel

Total Hours

Total Amount

16 40 24 / 32 4 200 0 0 24 / 32 4

TBD $ 31.44 16 40 24 4 84 2,640.96$

TBD $ 31.44 16 40 24 4 84 2,640.96$

TBD $ 31.44 16 40 24 4 84 2,640.96$

TBD $ 31.44 16 40 24 4 84 2,640.96$

TBD $ 20.00 200 24 4 228 4,560.00$

15,123.84$ Vendor Fees New Hires

Course Amount

# Taking Course Total

EMD New Certification 214.31$ 5 1,071.55$

CPR New Certification -$ 1,071.55$

PST(VENDOR ONLY) -$

Total Vendor Fees

PSAP: Anytown Communications SAMPLE WORKSHEET

Total Salary for New Hires

FY 2027 Training Grant Personnel Costs Worksheet

NEW PERSONNEL

In the Process of Obtaining Certificaiton

EXAMPLE OF TRAINING ACADEMY HOURS

New Hires, if applicable, need these course hours

Last Name First Name OT Pay Rate Hours Travel Time

Total Hours Salary

EX Smith Jane 47.00$ 40 20 60 2,820.00$

1 Maxim Paul 56.00$ 40 20 60 3,360.00$

2 Becker Christopher 42.00$ 40 20 60 2,520.00$

3 0

4 0

5 0

6 0

7 0

8 0

9 0

10 0

5,880.00$

FY 2027 TRAINING GRANT

Instructions: Enter your Credentialed TERT Team Member(s) last name, first name, OT rate and travel time; example highlighted in blue on the worksheet below.

*ADD THIS TOTAL TO THE CATEGORY B: PERSONNEL COSTS TOTAL ON THE

APPLICATION'S BUDGET NARRATIVE

At the time of the grant application, PSAPs that have Credentialed TERT Team Member(s) should fill out this worksheet in addition to the Personnel Costs Worksheets AND provide with the application, the TERT Team Member Credentialed Letter(s) from the SWIC.

Credentialed TERT Team Members are required to attend two (5) 8-hour TERT trainings per year plus travel time.

Credentialed TERT Team Member Training Expense Worksheet

PSAP NAME: Anytown Police Department

*TOTAL