Office of Criminal Justice Services

Franklin County Subgrant Number Receipt Date Office of Homeland Security & Justice Programs (OHS&JP use only) Subgrant Application Title Page

Form available for download at www.ohsjp.franklincountyohio.gov

S.T.O.P. Violence Against Women Act (VAWA) Application A. Program Area B. Title of Project C. Project Period January 1 to December 31 D. Type of Application New Project Existing Project E. Focus of Application City County Township Village F. Budget Summary VAWA Funds Cash Match Inkind Match Total Budget G. Project Director Prefix First Name MI Last Name Suffix The project director listed must be the main contact for Title Agency this project and the person with whom the OHS&JP can Address City Zip regularly communicate. Phone Fax

Email County

H. Implementing Prefix First Name MI Last Name Suffix Agency Please list the agency that Title Agency will implement the project. Address City Zip The representative listed must be the chief executive Phone Fax officer for the agency. Email County

I. Subgrantee Prefix First Name MI Last Name Suffix Please list the agency that will serve as the fiduciary Title Agency agent for the subgrant. Address City Zip The representative listed must be the chief executive Phone Fax officer for the agency. Email DUNS # Subgrantee Tax I.D. See Directives for Eligibility J. Application Prepared by: Name: K. Budget Pages Prepared by: Name: L. Quarterly Financial Reports will be Prepared by: Name: M. Quarterly Performance Reports will be Prepared by: Name: