Form 1122-0001 Certification of Compliance with the Statutory Eligibili

OMB Number – 1122-0001
Expiration Date:04/30/2022

U.S. Department of Justice
Office on Violence Against Women

Certification of Compliance with the Statutory Eligibility
Requirements of the Violence Against Women Act as Amended,
STOP Formula Grant Program
Applicants should refer to the laws cited below for further information regarding the certifications
to which they are required to attest. Signature on this form certifies that the applicant is
qualified to receive the STOP Formula Grant Program funds and is in compliance with relevant
requirements under 34 U.S.C §§ 10441, 10446 through 10451 and 28 C.F.R. Part 90. These
certifications shall be treated as a material representation of fact upon which the Department of
Justice will rely if it determines to award the covered transaction, grant, or cooperative
agreement.
Upon complying with the application requirements set forth in the solicitation, any state (or
territory) shall be qualified for funds provided under the STOP Formula Grant Program upon
certification that:
(1) the funds will be used only for the statutory purposes described in 34 U.S.C. § 10441(a) and
(b);
(2) grantees and subgrantees will develop plans for implementation and will consult and
coordinate with:
(A) the State sexual assault coalition;
(B) the State domestic violence coalition;
(C) the law enforcement entities within the State;
(D) prosecution offices;
(E) State and local courts;
(F) Tribal governments in those States with State or federally recognized Indian tribes;
(G) representatives from underserved populations, including culturally specific
populations;
(H) victim service providers;
(I) population specific organizations; and
(J) other entities that the State or the Attorney General identifies as needed for the
planning process;
(3) grantees will coordinate the State implementation plan with the State plans described in
section 307 of the Family Violence Prevention and Services Act (42 U.S.C. 10407) and the
programs described in section 1404 of the Victims of Crime Act of 1984 (34 U.S.C. 20103) and
section 393A of the Public Health Service Act (42 U.S.C. 280b-1b).
(4) the amount granted will be allocated, without duplication, as follows: not less than 25 percent
for law enforcement, not less than 25 percent for prosecutors, not less than 30 percent for victim

OMB Number – 1122-0001
Expiration Date:04/30/2022

services (of which at least 10 percent will be distributed to culturally specific community-based
organizations), and not less than 5 percent to state and local courts;
(5) not later than 2 years after March 7, 2013, and every year thereafter, not less than 20
percent of the total amount granted to a State under this subchapter shall be allocated for
programs or projects in 2 or more allocations listed in paragraph (4) that meaningfully address
sexual assault, including stranger rape, acquaintance rape, alcohol or drug-facilitated rape, and
rape within the context of an intimate partner relationship; and
(6) any federal funds received under this subchapter will be used to supplement, not supplant,
nonfederal funds that would otherwise be available for activities funded under this chapter.
In addition, to be eligible for funding under the STOP Formula Grant Program, applicants must
certify compliance with the requirements in 34 U.S.C. §§ 10449, 10450, and 10451 and
implemented at 28 C.F.R. Part 90, as follows:
(1) Forensic Medical Examination Payment Requirement for Victims of Sexual Assault
(a) A state, Indian tribal government, or unit of local government shall not be entitled to funds
under the STOP Formula Grant Program unless the state, Indian tribal government, unit of local
government, or another governmental entity—
(1) incurs the full out-of-pocket cost of forensic medical exams for victims of sexual assault; and
(2) coordinates with health care providers in the region to notify victims of sexual assault of the
availability of rape exams at no cost to the victims.
(b) A state, Indian tribal government, or unit of local government shall be deemed to incur the
full out-of-pocket cost of forensic medical exams for victims of sexual assault if any government
entity:
(1) provides such exams to victims free of charge to the victim; or
(2) arranges for victims to obtain such exams free of charge to the victims.
(c) A state or Indian tribal government may use STOP Formula Grant Program funds to pay for
forensic medical exams performed by trained examiners for victims of sexual assault, except
that such funds may not be used to pay for forensic medical exams by any state, Indian tribal
government, or territorial government that requires victims of sexual assault to seek
reimbursement for such exams from their insurance carriers.
(d) (1) To be in compliance with this section, a state, Indian tribal government, or unit of local
government shall comply with subsection (b) without regard to whether the victim participates in
the criminal justice system or cooperates with law enforcement.
(2) States, territories, and Indian tribal governments shall have 3 years from March 7, 2013 to
come into compliance with this section.
(2) Filing Costs For Criminal Charges and Protection Orders
A state, Indian tribal government, or unit of local government will not be entitled to funds under
the STOP Formula Grant Program unless it certifies that its laws, policies, and practices do not

OMB Number – 1122-0001
Expiration Date:04/30/2022

require, in connection with the prosecution of any misdemeanor or felony sexual assault,
domestic violence, dating violence, or stalking offense, or in connection with the filing, issuance,
registration, modification, enforcement, dismissal, withdrawal or service of a protection order, or
a petition for a protection order, to protect a victim of sexual assault, domestic violence, dating
violence, or stalking, that the victim bear the costs associated with the filing of criminal charges
against the offender, or the costs associated with the filing, issuance, registration, modification,
enforcement, dismissal, withdrawal or service of a warrant, protection order, petition for a
protection order, or witness subpoena, whether issued inside or outside the State, tribal, or local
jurisdiction.
(3) Judicial Notification
A State or unit of local government shall not be entitled to funds under the STOP Formula Grant
Program unless the state or unit of local government-(a) certifies that its judicial administrative policies and practices include notification to domestic
violence offenders of the requirements delineated in section 922(g)(8) and (g)(9) of title 18,
United States Code, and any applicable related federal, state, or local laws; or
(b) gives the Attorney General assurances that its judicial administrative policies and practices
will be in compliance with the requirements of subparagraph (A) within the later of—
(1) the period ending on the date on which the next session of the state legislature ends; or
(2) January 5, 2008.
(4) Polygraph Testing Prohibition
(a) In order to be eligible for grants under the STOP Formula Grant Program, a state, Indian
tribal government, territorial government, or unit of local government shall certify that, not later
than January 5, 2009, their laws, policies, or practices will ensure that no law enforcement
officer, prosecuting officer or other government official shall ask or require an adult, youth, or
child victim of an alleged sex offense as defined under federal, tribal, state, territorial, or local
law to submit to a polygraph examination or other truth telling device as a condition for
proceeding with the investigation of such an offense.
(b) The refusal of a victim to submit to a polygraph or other truth telling examination shall not
prevent the investigation, charging, or prosecution of an alleged sex offense by a state, Indian
tribal government, territorial government, or unit of local government.
____________________________________________________________________________
As the duly authorized representative of the applicant, I hereby certify that the applicant will
comply with above certifications.
____________________________________________________________________________
Typed Name of Authorized Representative
Title
Telephone Number

OMB Number – 1122-0001
Expiration Date:04/30/2022

____________________________________________________________________________
Signature of Authorized Representative
Date Signed

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Agency Name