PLCB Grant Application

to Reduce

Underage and High-Risk Drinking

Date:

Applicant Information:

Organization’s Name:

Address:

Line 1

Address:

Line 2

Address:

Line 3

Address:

Line 4

Grant applications are due by 4:00 P.M.Thursday, March 27, 2008 to:

Email:

Subject line to read: 2008 Grant

NOTE: If you do not receive an electronic receipt regarding your grant within 72 hours of sending it electronically to us, contact our office at 717-772-1432.

1

PLCB Grant Application to Reduce Underage and High-Risk Drinking

Application Packet Checklist

The original (with electronic signatures)must be emailed (as an attachment) back to the PLCB. See below for email address, etc.

The application packet will not be considered unless all of the following are included:

Cover Page

Application Packet Checklist

Application for Funding/Invoice

Organization’s Administrative Support Pledge

Grantee Authorized Signature Form

Grant Applicant Information Page

Grant Narrative

Grant Timeline

Grant Budget

Grant Budget Narrative

Signed Grant Agreement

For more information or assistance with this application contact:

Grants Division

Alcohol Education Bureau

Pennsylvania Liquor Control Board

Room 602

NorthwestOfficeBuilding

Harrisburg, PA 17124-0001

Phone: 717-772-1432

Grant applications are due by 4:00 P.M.Thursday, March 27, 2008 to:

Email:

Subject line to read: 2008 Grant

NOTE: If you do not receive an electronic receipt regarding your grant within 72 hours of sending it electronically to us, contact our office at 717-772-1432.

Pennsylvania Liquor Control Board

Grant Application

APPLICATION FOR FUNDING/INVOICE

Applications must be typed and submitted in this format. The original (with electronic signatures)must be emailed (as an attachment) to the PLCB. No faxed submitted copies will be accepted. The Project Director will be notified of Grant acceptance via email upon successful review of the Grant.

Organizational Name:
Grant Project Director:
Address:
City: / State:
Zip: / County:
Phone: / FAX:
PA Vendor #: / Federal Tax ID #:
Grant Project Director’s Signature: / Date:
Project Director’s Email:
Organization’s Fiscal Office Contact:
Address:
Email: / Phone:
Fiscal Officer Signature: / Date:

Organization’s Administrative Support Pledge

I, ,
(Type name of example: President, Mayor, Borough Manager, Chief Executive Officer)
of ,
(Type name of example: college/university, city, borough, organization)

Hereby express my commitment to address the issues of dangerous and underage drinking.

I will encourage and support the collaboration of all key stakeholders in the local area who are concerned and involved regarding this issue.

(Signature of Official above – can be typed name)

(Date)

I, (Name of authorized official),of(Name of business/entity),
at (Street address),Municipality of (Name of municipality),
County of (Name of county),Commonwealth of Pennsylvania, certify that I am
the (Title)of (Name of business/entity),organized under the laws of
the Commonwealth ofPennsylvania, having its principal office at
(Street address),Municipality of (Name of municipality),
County of (Name of county),Commonwealth of Pennsylvania
and resolve that (Name of signatory),(Title),
of (Name of business/entity),Municipality of (Name of municipality),
County of (Name of county),Commonwealth of Pennsylvania is hereby authorized
to execute contracts and grants on behalf of (Name of business/entity)
thereby binding this organization.
IN WITNESS WHEREOF, I have hereunto set my hand this
day of(Month),(Year).

Grantee Authorized Signature Form

Signature of Authorized Official

Print Name

Title

Pennsylvania Liquor Control Board

Grant Applicant Information

Check all that apply to your organization:

Borough or its law enforcement department

City or its law enforcement department

Township or its law enforcement department

Other Municipality or its law enforcement department

College

University

School District

Other Organization

If Borough/City/Township/Other Municipality:

UrbanSuburbanRuralOther

Population of 2,000 or lessPopulation of 2,001 – 10,000

Population of 10,001 – 20,000Population over 20,000

If College/University:

Student PopulationType of Campus Location

Under 5,0002-YearRural

5,000 to 10,0004-YearSuburb

10,001 to 15,000PublicUrban

15,001 or morePrivate

If School District:

Student PopulationLocation

Under 1,000 Rural

1,001 to 4,000 Suburb

4,001 or more Urban

If Other Organization:

Non-Profit Organization

For-Profit Organization

Board of Directors or Trustees

Individually-Owned Entity

Grant Narrative

Describe your Grant initiative to reduce underage and/or high-risk drinking.

(Type as many pages as necessary but make sure grant timeline page begins on new, separate page.)

  • What types of programs and activities are planned?
  • What are the goals and objectives of the programs and activities?
  • What type of evaluation will be conducted to measure progress?
  • How will the evaluation be conducted and by whom? (Name your evaluator, if known, at this time.)
  • Will grant activities conform to the National Institute of Alcoholism and Alcohol Abuse and/or the Environmental Management Strategies? (See guidelines packet.)

Begin grant narrative here:

1

Pennsylvania Liquor Control Board
Grant Timeline Page

(Type as many pages as necessary but make sure the

Grant Budget page begins on new, separate page.)

1

Pennsylvania Liquor Control Board

GrantBudget

Purpose of Grant: To provide assistance to reduce underage and high-risk drinking.

Maximum Amount: Eleven thousand and five hundred dollars ($11,500.00).

This is a cost reimbursement grant. No funds will be advanced toGrantee.

PLCB-sponsored/approved training$300.00 (Suggested line item include on line B-08 below – See Guidelines regarding this item.)

Coalition Enhancement $600.00 (Suggested line item include on line C-08 below –

(For College/University applicants)See Guidelines regarding this item.)

Begin Budget Here – Add additional sheets, if necessary

Budget Item / Amount
A - 08Project Evaluation
(Maximum of $1,500.00 – required line item. If your organization will use other funds for evaluation, state this in budget narrative and place a $0 here.) / $
B - 08
(If planning on attending PLCB sponsored training, place amount here.) / $
C - 08
(If using grant funds for Coalition Enhancement, place amount here.) / $
D - 08 / $
E - 08 / $
F - 08 / $
G - 08 / $
H - 08 / $

(Place additional line items on following page.)

Additional Budget Items

I –08 / $
J –08 / $
K –08 / $
L –08 / $
M –08 / $
N –08 / $

Total(of all line items above) $

Comments, if needed.

1

Pennsylvania Liquor Control Board

Matching Funds Information

Grantee organization must supply a twenty-five (25) percent matching fund component

tothe amount of the Grant funds requested. Example: If you are requesting $11,500.00, your matching fund amount must be a minimum of $2,875.00 and be a cash match. See Guideline document for detailed information and sample application for example of line items below.

Begin Matching Fund Information

Matching Fund Item – Give detail and amountAmount

MF – 08 / $
MF – 08 / $
MF – 08 / $
MF – 08 / $
MF – 08 / $
MF – 08 / $

Matching Funds Total $

Comments, if needed.

Pennsylvania Liquor Control Board

GrantApplication

Budget Narrative - Briefly describe each line item of your budget and how it will assist in the overall goal of reducing underage and/or high-risk drinking. (Describe only PLCB funded budget.)

1

Pennsylvania Liquor Control Board
GRANT AGREEMENT

The Commonwealth of Pennsylvania, Pennsylvania Liquor Control Board (PLCB or Commonwealth) has the authority to award this Grant by authorization of section 207(k) of the Liquor Code [47 P.S. § 2-207(k)].

Theundersigned Grantee, / ,
FederalIdentification Number / (Grantee), makes

the following representations and agrees to the following conditions in accepting funds under this Grant from the PLCB through this Grant Project:

  1. To use the Grant monies exclusively for the purposes specified in the Grantee’s Grant Application, a copy of which is attached hereto and made a part hereof as Application for Funding/Invoice. The Grantee will directly administer the project or program being supported by the Grant, and agrees that no Grant funds shall be disbursed to any organization or entity, whether or not formed by the Grantee, other than as specifically set forth in its Grant Application. This Grant may be terminated by the PLCB for lack of appropriation of funds to support this Grant, or at the convenience of the PLCB. Any use by the Grantee of the Grant proceeds for any purpose other than those specified in the Grantee’s Grant Application is cause for the PLCB to terminate the Grant. Further, the PLCB, at its sole option, may terminate the Grant at any time if, in the PLCB’s judgment, the Grantee becomes unable to carry out the purposes of the Grant, or ceases to be an appropriate means of accomplishing the purpose of the Grant or fails to comply with any of the conditions hereof. The termination rights in this section are not exclusive and are in addition to any other termination rights provided herein or by law.
  1. To agree that the total payment to the Grantee under this Grant shall be the final approved budget amount but not to exceed the approved dollar amount reflected on the budget page attached to this Grant application. No payment will be made until the full execution by all required parties of the Grant Agreement and the Grantee is informed of the Effective Date, as defined herein. The Grant is a cost reimbursable grant. No funds will be advanced to the Grantee.
  1. To not use Grant monies to fund a Grant to another organization without prior written approval of the PLCB.
  1. To return/repay to the PLCB any Grant funds if:
  2. unexpended as of the termination date of the Grant;
  3. unexpended as of the expiration of the Grant period; and/or
  4. not used exclusively for Grant purposes as specified herein.
  1. To adhere to the specific line items in the Grantee’s approvedGrantbudget, a copy of which is attached hereto and made a part hereof as Grant Budget. The Grantee organization must identify a twenty-five percent (25%) matching fund cash component to the amount of the Grant funds requested.
  1. To indicate the Grant separately on its books of account and keep accounting records of the receipt and disbursement of funds and expenditures incurred under the terms of the Grant, including, but not limited to, bills, invoices, cancelled checks and receipts for a period of at least three (3) years following the termination or expiration of this Grant. The Grantee agrees to make its books and records available to the PLCB at reasonable times for review, inspection and/or audit by the PLCB. The PLCB, at its expense, may audit or have audited the books and records of the Grantee insofar as they relate to the disposition of the funds granted by the PLCB, and the Grantee shall provide all necessary assistance in connection therewith.
  1. To agree to submit required reports to the PLCB no later than November 15 of the PLCB fiscal year the Grant begins and two (2) additional reports are due the following: February 15 of the fiscal year the Grant begins, and within fifteen (15) days of the ending date of the Grant (forms to be mailed to approved Grant recipient). Included in these reports will be Grantee’s request for reimbursement forms as indicated in the Grant application packet. In addition, an evaluation report is due within forty-five (45) days after the Grant ending date. The PLCB may, at its expense, monitor and conduct an evaluation of operations under the Grant, which may include visits by representatives of the PLCB to observe the Grantee’s program. The PLCB reserves the right to hold any future grant funds until these reports are received.
  1. To grant to the PLCB a nonexclusive, irrevocable, perpetual, royalty-free license to reproduce, publish, copy, alter or otherwise use and to license others to use any and all materials created by the Grantee, including any and all data collected, in connection with the Grant in any and all forms in which said data are fixed.
  1. To obtain approval of the PLCB prior to issuing any news or press release regarding this Grant. In all public statements, press releases, annual reports or other announcements regarding the programs related to this Grant, the Grantee shall refer to the PLCB by its full name: The Pennsylvania Liquor Control Board.
  1. To comply with all applicable federal, state, and local laws.
  1. To possess the legal authority for the Grantee to apply for the Grant.
  1. To designate a project director to act in connection with the Grant application and this Grant, and to provide such additional information as may be required.
  1. To agree that neither the PLCB nor the Grantee assume any liabilities to each other, except as are specifically stated in this Grant. As to liability for damage or injuries or death to persons, or damage to property, the Grantee and the PLCB do not waive any defense as a result of entering into this Grant, unless such waiver is expressly and clearly written into part of this Grant.
  1. To comply with the following offset provision: The Grantee agrees that the Commonwealth may set off the amount of any state tax liability or other debt or obligation of the Grantee or its subsidiaries that is owed to the Commonwealth and is not beingcontested on appeal against any payments due the Grantee under this Grant or any other contract with the Commonwealth.
  1. To comply with the following contractor responsibility provision. For the purpose of this Grant, the term “Contractor” is defined as any person, including, but not limited to, a bidder, offeror, loan recipient, grantee or sub-grantee, who has furnished or seeks to furnish goods, supplies, services, or leased space, or who has performed or seeks to perform construction activity under the contract, subcontract, grant or sub-grant with the Commonwealth, or with a person under contract, sub-contract, grant or sub-grant with the Commonwealth or its state-affiliated entities, and state-related institutions. The term “Contractor” may include a permittee, licensee, or any agency, political subdivision, instrumentality, public authority, or other entity of the Commonwealth.
  1. The Contractor must certify, in writing, for itself and all its subcontractors that, as of the date of its execution of this Grant, neither the Contractor, nor any subcontractors, nor any suppliers are under suspension or debarment by the Commonwealth or any governmental entity, instrumentality, or authority and, if the contractor cannot so certify, then it agrees to submit, along with its Grant application, a written explanation of why such certification cannot be made.
  1. The Contractor must also certify, in writing, that, as of the date of its execution of this Grant, it has no tax liabilities or other Commonwealth obligations.
  1. The Contractor’s obligations pursuant to these provisions are ongoing from and after the effective date of the Grant through the termination or expiration date thereof. Accordingly, the Contractor shall have an obligation to inform the PLCB if, at any time during the term of the Grant, it becomes delinquent in the payment of taxes or other Commonwealth obligations, or if it or any of its sub-grantees or subcontractors are suspended or debarred by the Commonwealth, the federal government, or any other state or governmental entity. Such notification shall be made within fifteen (15) days of the date of suspension or debarment.
  1. The failure of the Contractor to notify the PLCB of its suspension or debarment by the Commonwealth, any other state, or the federal government shall constitute an event of default of the Grant with the PLCB.
  1. The Contractor agrees to reimburse the Commonwealth for the reasonable costs of investigation incurred by the Office of State Inspector General for investigations of the Contractor’s compliance with the terms of this or any other agreement between the Contractor and the Commonwealth, which results in the suspension or debarment of the Contractor. Such costs shall include, but shall not be limited to, salaries of investigators, including overtime; travel and lodging expenses; and expert witness and documentary fees. The Contractor shall not be responsible for investigative costs for investigations that do not result in the Contractor’s suspension or debarment.
  1. The Contractor may obtain a current list of suspended and debarred Commonwealth

contractors by either searching the Internet at

or contacting the:

Department of General Services

Office of Chief Counsel

603 North Office Building

Harrisburg, PA 17125

Telephone: (717) 783-6472

FAX: (717) 787-9138

  1. To comply with the following nondiscrimination/sexual harassment provision. During the term of this Grant, the Contractor agrees as follows:
  1. In the hiring of any employees for the manufacture of supplies, performance of work, or any other activity required under the Grant or any sub-grant, the Contractor, subcontractor or any person acting on behalf of the Contractor or subcontractor shall not, by reason of gender, race, creed or color, discriminate against any citizen of this Commonwealth who is qualified and available to perform the work to which the employment relates.
  1. Neither the Contractor nor any subcontractor nor any person on their behalf shall in any manner discriminate against or intimidate any employee involved in the manufacture of supplies, the performance of work or any other activity required under the Grant on account of gender, race, creed or color.
  1. The Contractor and any subcontractors shall establish and maintain a written sexual harassment policy and shall inform their employees of the policy. The policy must contain a notice that sexual harassment will not be tolerated, and employees who practice it will be disciplined.
  1. The Contractor shall not discriminate by reason of gender, race, creed or color against any subcontractor or supplier who is qualified to perform the work to which the Grant relates.
  2. The Contractor and each subcontractor shall furnish all necessary employment documents and records to and permit access to its books, records, and accounts by the PLCB and the Department of General Services, Bureau of Contract Administration and Business Development for purposes of investigation to ascertain compliance with the provisions of this Paragraph 16. If the Contractor or any subcontractor does not possess documents or records reflecting the necessary information requested, it shall furnish such information on reporting forms supplied by the PLCB or the Bureau of Contract Administration and Business Development.
  1. The Contractor shall include the provisions of this Paragraph 16 in every sub-grant so that such provisions will be binding upon each sub-grantee.
  1. The Commonwealth may cancel or terminate the Grant, and all money due or to become due under the Grant may be forfeited for a violation of the terms and conditions of this Paragraph 16.