STATE OF NEW JERSEY
VICTIMS OF CRIME ACT (VOCA)
Grant Program

PART I

APPLICATION DOCUMENTS
TO BE COMPLETED AND RETURNED

APPLICATION OVERVIEW

Name of Applicant:_____________________________________________________________________

Title of Project:__________________________________________________________________________

Amount Applied for:	$_________Federal		$_________Match		$_________Total

Type of Agency:	☐  State        ☐  County        ☐  Municipality        ☐  Nonprofit

What County is your agency located in:_________________________________

Counties Served if more than one: ____________________________________________________________

Type of Project:	☐  New		☐  Continuing	☐  Expansion

Have you been designated by the Department of Community Affairs, Division on Women as the lead sexual assault agency in your county?		☐  Yes		☐  No

Have you been designated by the Department of Children and Families, Division of Youth and Family Services as the lead domestic violence agency in your county?	☐  Yes	☐  No

Types of Victims Served for this Project:	☐  Sexual Assault	☐  Domestic Violence	☐  Stalking

☐  Child Abuse	☐  Homicide Survivors	☐  Elder Abuse	☐  DUI/DWI	

☐  Dating Violence	☐  Other  _____________________________________________________________

[FFY2013 VOCA APP 10/2013]

State of New Jersey
Victims of Crime Act (VOCA)
Grant Program

SUBGRANTEE CHECK LIST

SUBGRANTEE:  	___________________________________________________________________

	INSTRUCTIONS:	The Application Check List is a guide to file a complete application.  Return 1 
				original (with original signatures) and 2 copies of the completed application.

PART I:  Documents to be Completed and Returned
		□	Subgrantee Check List
		□	Application Overview
		□	Applicant Information Form
		□	Agency Information Form
		□	Project Narrative (Provided by Applicant)
		□	Project Management and Staff
□	Job Descriptions (for each position listed in budget)
□	Current Resumes (reflecting staff currently works at agency for each position listed in budget)
□	Project Work Plan
□	Budget Detail Form
□	Budget Narrative (Provided by Applicant)
□	Sources of Funds Form

Additional forms provided by nonprofit applicants:
□	Proof of Nonprofit status
□	New Jersey Charitable Registration
□	Applicable Licenses, Certifications and Permits
□	Single Audit, Form 990-Income Tax Return or audited financial statements
□	Applicable List of Officers/Directors/Trustees
	
PART II:  Documents to be Signed and Returned:
		□	Application Authorization
		□	Certification of Equal Employment Opportunity Plan (EEOP) Form
		□	General Conditions and Assurances
		□	Certifications Regarding Lobbying, Debarment, Suspension and Other Responsibility Matters and Drug-Free Workplace Requirements
		□	Resolution of Participation and Certification of Recording Officer
		□	Federal Financial Accountability and Transparency Act Information Form
		□	Audit Requirements Form
		□	Accounting System and Financial Capability Questionnaire

NOTE:   ONLY COMPLETE APPLICATIONS CAN BE PROCESSED.  ABOVE ITEMS MUST BE SUBMITTED WITH THE APPLICATION.   DO NOT STAPLE APPLICATIONS.

[FFY2013 VOCA APP 10/2013]

Applicant Information Form

Official Name of Applicant Agency:

Address:

City/State:	Zip Code + 4:	County:	

Implementing Agency (if different than applicant):	

Agency Website:	Fiscal Year Start Date:	Federal ID Number:	

Charitable Registration Number (If nonprofit & not exempt): 	Have there been any findings filed against the agency in regard to its charitable status?
□ Yes	□ No	If yes, please explain on a separate sheet.	

New Jersey Business Registration Certificate:	

Name and Title of Chief Executive/Agency Director:
	
Street Address, City, State, Zip Code +4 (if different from above)
	
Telephone:	Ext.	Email:	Fax:	

Name and Title of Project Director:
	
Street Address, City, State, Zip Code +4 (if different from above)
	
Telephone:	Ext.	Email:	Fax:	

Name and Title of Contact Person:
	
Street Address, City, State, Zip Code +4 (if different from above)
	
Telephone:	Ext.	Email:	Fax:	

Name and Title of Chief Financial Officer:
	
Street Address, City, State, Zip Code +4 (if different from above)
	
Telephone:	Ext.	Email:	Fax:	

Name and Title of Fiscal Contact Person:
	
Street Address, City, State, Zip Code +4 (if different from above)
	
Telephone:	Ext.	Email:	Fax:	
Agency Information Form

Name of Agency/Applicant: ______________________________________________________________

Project Title: ___________________________________________________________________________

Project Specific Information	
This Project Provides:
	□ Outreach Services	□ Legal Services	□ Training 	□ Direct Services	
	□ Other (Please Describe) _______________________________________________________	
Project Service Area:  Indicate the service area of this project by county or municipality name(s).
Write statewide if all counties in New Jersey will be served by this project.
_____________________________________________________________________________	
Project Population Served:  Is this project servicing a special population group or underserved population of victims? (for example, Spanish-speaking, Latino, African American, Disabled, Elderly, etc.).

	□ Yes		□ No	
If yes - indicate the population(s):_______________________________________________________

Agency Specific Information

Indicate if your agency provides the following services/programs to crime victims:

Core Services

□	Emergency/crisis response		□	Long term counseling
□	Criminal Justice advocacy		□	Short term counseling
□	Legal advocacy				□	Support groups
□	Courtroom advocacy			□	Victim outreach
□	Housing advocacy			             □	Community Education
□	Financial advocacy			□	Hotline
□	Legal services
□	Emergency financial assistance
□	In-person information/referral
□	Telephone information/referral
□	Economic development/networking services for victims
□	Services for the children of victims ( e.g., babysitting, recreation, etc.)
□	Shelter		If checked - indicate the number of beds available ____________
□	Transitional Housing	If checked - indicate the number of family housing units _______

Indicate if your agency has programs for the following types of crime victims:

□	DWI				□	Homicide
□	Neglected or abused children	□	Sexual Assault
□	Domestic violence		                              □	Human Trafficking	

[FFY2013 VOCA APP 10/2013]

Project Work Plan	Victims of Crime Act (VOCA) Grant Program

Project Name:____________________________________________________________________________________________________

Objective	Activity	Projected Start-up & Completion Dates
(Do not use on-going)	Person Responsible	

				

				

				

[FFY2013 VOCA APP 10/2013]

Applicants must submit a Budget Detail Form detailing how both the requested grant funds and the match, if applicable, will be used to implement the project. All costs must be itemized and the calculations used to determine the total project amounts must be shown. 
Applicants must submit a separate Budget Narrative explaining costs listed on the Budget Detail Form. The narrative must include a justification and the computation for each cost element listed that will be charged to the project.

Refer to applicable Program Administration and Funding Guidelines for information on the Budget Detail Form and Budget Narrative.

Applicant:  ________________________________                                                                                                     Grant No:  ___________

Budget Detail Form
	
COST ELEMENT	
A.  Personnel
1.   Salaries and Wages 
 List each name and position	Show % of time or number of hours spent on project to be funded with grant and  match funds	Annual Salary
or
Hourly Rate	Grant Funds	Match	Project Total

	

						

						

SUB-TOTAL SALARIES AND WAGES				

[VAWA 11/2013]

Applicant:	Grant #:_____________
Budget Detail Form	

COST ELEMENT	Grant Funds	Match	Project Total	
B.  Purchase of Services				
Name of Provider	                 Contracted Services Provided/
                                                        Seminar Registration/
                                                        Costs of professional services	Unit Cost/ Hourly Rate	Units/ Project Hours				
(e.g., cell phone service)				

				
TOTAL PURCHASE OF SERVICES				

C.  Travel, Transportation, Subsistence (show food costs related to travel only)
	Grant Funds	Match	Project Total	

Purpose / Location	Item
(e.g., # of Miles)	Computation
(e.g., $.31 per Mile)				

				
				
TOTAL TRAVEL, TRANSPORTATION, SUBSISTENCE				

[FFY2013 VOCA APP 10/2013]

Applicant:	Grant #:___________
Budget Detail Form	

COST ELEMENT	Grant Funds	Match	Project Total	
D.  Consumable Supplies, Postage, Printing 
       (list each item & show unit cost & calculations)				

				

TOTAL CONSUMABLE SUPPLIES				

E.  Facilities, Office Space, Utilities (calculate monthly project cost & show cost allocation method) 	Grant Funds	Match	Project Total	
Rent (in budget narrative, indicate square footage and cost per square foot)				
Utilities (in budget narrative, specify utility)				
Telephone (landline)				
Other (specify)				
Other (specify)				
Other (specify)				
TOTAL FACILITIES				

[FFY2013 VOCA APP 10/2013]

Applicant:	Grant #:_________
Budget Detail Form	

COST ELEMENT	Grant Funds	Match	Project Total	
F.  Equipment (List and explain in attached budget narrative; calculate per unit cost)

				

				
				
TOTAL EQUIPMENT				

G.	Victim Aid for VOCA, VAG, VAWA Grants Only
        (list each item & show unit cost & calculations)	Grant Funds	Match	Project Total	

				

TOTAL VICTIM AID				
TOTAL PROJECT COST				

[FFY2013 VOCA  APP 10/2013]

SOURCES OF FUNDS

List all sources of funds received by the agency during the past State fiscal year (July 1 thru June 30).  On the bottom of the form, list all funds received from the Division of Criminal Justice in the past three years.

Federal Sources

Name(s) of Federal Source	Date of Award	Amount	

			

State Sources

Name(s) of State Source	Date of Award	Amount	

			

County Sources	$	
Local and Other Sources	$	
Total of All Sources of Funds	$	
Indicate the percentage of funds used to support this project:	%	

Division of Criminal Justice Funding

	List funding awarded for the past three years:

Date of Award	Grant Number	Project Title	Amount	

				

				

[FFY2013 VOCA APP 10/2013]