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Local Alcohol and Drug Planning Committee (LADPC)

  1. Funding Tier Requested*

    Select the funding tier for which you are applying

  2. Letter of intent*

    Did you submit a letter of intent and receive approval to proceed from the LADPC board? (only applicable to tiers 2-4)

  3. Applicant Type*

    Please check one

  4. Please provide an overview of your proposed workplan. A detailed workplan should be uploaded with other supporting documentation. 

  5. Please provide a detailed budget narrative with justifications for each line item (ex. personnel, materials, contracts etc.)

  6. Tiers 3 and 4 only: Please describe how this project will be sustained over time

  7. All documents must be uploaded into ONE PDF file. Required documents include:

    - Agency W9

    - Line Item Budget

    - Detailed Work Plan (include timeframe for each activity)

    - Letter(s) of support (Optional)

  8. Please include each of the project's goals and objectives. Must be S.M.A.R.T. (specific, measurable, achievable, relevant, and time-bound) goals

  9. Describe how this project meets LADPC requirements (establish, operate, and maintain alcohol and drug abuse prevention, early intervention, or treatment services) as established under ORS 430.355

  10. Describe how this project demonstrates health equity and cultural/linguistically appropriate services

  11. Specify if this project serves a minority population and the estimated total number of people served.

  12. Certifications and Representations

    The information in this application, including all attachments and certifications, are, to the best of the knowledge of the undersigned, complete, current and accurate. The application presents fairly the conditions of the eligibility of the undersigned. Proceeds of the award are intended to solely support the operations and reopening expenses of the applicant business.

    Should the Federal Government determine that a misrepresentation exists creating a default, the award may be forfeited and subject to repayment. Failure to repay or cure a default will result in any and all collection actions permissible by law, including through third party collection services or the Oregon Department of Revenue. The applicant agrees to allow the State to pursue such collection actions.

  13. Insurance Requirements

    Depending on the funding level and nature of the project, insurance may be required.

    Insurance Acord 25-S with County required minimums (General Liability; Each Occurrence $2,000,000; Aggregate $4,000,000), Klamath County as additional insured, additional insured endorsement, proof of workers comp and auto coverage (if needed). If no employees or autos will be used for grant fulfillment, a document on letterhead stating no employees or autos will be used for grant fulfilment must be submitted (include it in the Supporting Documents section below). Proof of insurance will be required after the applicant has been awarded funding.

  14. Acknowledgement *

    Submission of application does not guarantee funding. If funded, you will be required to report on progress and completion of the project. You will also be required to submit all financial backup documents demonstrating how funds are spent. By checking the box below you acknowledge your understanding.

  15. Electronic Signature Agreement*

    I certify to the best of my knowledge that all information, contained in this application, including all attachments and certifications, is valid and accurate. I further certify that, to the best of my knowledge:

    1.  The application has been reviewed and approved by the authorized owner(s), managers with appropriately delegated authority, and/or in accordance with the organization’s articles of incorporation, articles of organization or bylaws, and

    2.  Signature authority is verified.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

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  17. This field is not part of the form submission.