Contribution Program to Combat Serious and Organized Crime (CPCSOC) - Application Form - At-Risk Youth Pilot projects

Section 1: Applicant Organization Name

Section 2:  Applicant Eligibility

1. Please check the box corresponding to the legal status of your organization:

•  ☐ National, provincial, territorial, municipal, Indigenous, community or professional organization, societies and associations which have voluntarily associated themselves for a not-for-profit purpose, and which have a mandate to represent their membership or community
•  ☐ Not-for-profit organization or association serving the private sector
•  ☐ A Canadian university or an educational institution
•  ☐ A provincial, municipal or Indigenous police service
•  ☐ Indigenous and non-status governments, organization or communities:
•  ☐ A provincial, territorial, municipal or regional government:
•  ☐ International non-governmental organizations:

Section 3: Organization information

2. Applicant information:

• 1. Organization legal name:
• 2. Organization operating name (if different than legal name):
• 3. Street Address:
• 4. City/Town/First Nation:
• 5. Province/Territory:
• 6. Postal Code:
• 7. Website:

3. What is the mandate of your organization?

4. Please describe your organization’s experience in providing awareness-raising initiatives related to human trafficking to at-risk youth. This would include awareness activities such as identifying indicators of human trafficking, preventive actions, or empowering youth to be active participants in the prevention of their own potential victimization.

5. Please describe the administrative/governing body of your organization (e.g., a board, council, steering committee, etc.).

6. If your organization is incorporated, please indicate the date of incorporation.

7. What is your organization’s Business Number (if applicable)?

8. What is your organization’s Charitable Status Number (if applicable)?

9. Is your organization registered under the Lobbyist Registry?

Yes ☐ No ☐

10. In the last 5 years, has the federal government audited your organization? (if yes, you will be asked to provide a copy of the audit report(s))

Yes ☐ No ☐

11. Does your organization receive a GST/HST rebate from the federal government?

Yes ☐ No ☐

12. For Quebec organizations only

Are the majority of your members from the Quebec public sector, that is, appointed by the Government of Quebec, a minister, a government agency, a municipal body, a school board or another public agency?

Yes ☐ No ☐

Is your personnel appointed in accordance with the Public Service Act (of Quebec – Chapter F-3.1.1)?

Yes ☐ No ☐

Is more than half of your financing derived from Quebec public funds, that is, from the consolidated revenue fund, a government agency, a municipal body, a school body or another public agency?

Yes ☐ No ☐

If you answer “yes” to any one of the three funding options in this section, your organization is required to provide a copy of the Ministerial Order allowing your organization to negotiate and enter into an agreement with Public Safety Canada either with your completed funding application or before a formal agreement will be offered by Public Safety Canada. For more information about this requirement, please see: “An Act Respecting the Ministère du Conseil Exécutif” (chapter M-30) on the Government of Quebec’s website.

Section 4: Contact Information

13. Name of person with legal signing authority (binding) for your organization:

• h. Name:
• i. Position/Title:
• j. Telephone:
• k. Email Address:

14. Name of person with financial signing authority for your organization:

• l. Name:
• m. Position/Title:
• n. Telephone:
• o. Email Address: 

15. Name of contact person:

• p.      Name:
  
• q.      Executive Director:
  
• r.      Telephone:
  
• s.      Email Address:       

16. Project title

17. What is your project’s anticipated start date? (Note – Official start dates dependent on review process and signing of agreements) (it is anticipated that funding will be available starting in fiscal year 2020-21 until March 31, 2024.)

18. What is your project’s duration (months)? _____ months

Anticipated start date:
Anticipated end date:

19. Will this funding application be submitted to another federal department? (please validate)

Yes ☐ No ☐

20. Is this application for a continuation/next phase of a previously funded application? (please validate)

Yes ☐ No ☐

21. Project Description

• Please provide a detailed description of your project and/or initiative, including the anticipated reach to a target group(s), expected results and how it meets the objectives of the CPCSOC (maximum five pages) (Please refer to requirement #2 and #6 of the applicant guide for more information)

22. In point form, identify the objectives of your project:

1.

2.

3.

4.

5.

6.

23. In point form, identify the expected outcomes of your project:

Outcomes :

1.

2.

3.

4.

5.

6.

24. What is the overall budget of your project, inclusive of all revenue sources and in-kind contributions? 

Project total funding requested from Public Safety Canada (through CPCSOC) for the duration of the project. 

Other sources of funds (amount and source) for the duration of the project :

• Source of funding:
• Cash:
• In-kind:
  

(repeat as required)

Note:

Total government (federal/provincial/territorial/municipal) funding cannot exceed 95 percent of the eligible and supported expenditures. 

In-Kind contributions are non-cash input which is given a cash value

*Please provide detailed information in the attached Project Budget template*

Section 7: Work Plan

25. Please provide a detailed work plan describing the project and/or initiative, including the activities that will be undertaken and how they contribute to expected results, an implementation plan with timelines, and an approach/strategy to ensuring that results achieved through this funding will be sustained during the project duration and beyond (maximum three pages).

Section 8: Gender-based Analysis +
(Please refer to requirement 6 of the applicant guide for more information)

26. Please provide an overview of the findings of your Gender-based Analysis Plus and how these findings are incorporated in the project design, including how members of Indigenous and northern communities, children and youth, LGBTQ2+ persons, as well as victims and survivors of human trafficking, will be engaged and included in their approach and service delivery (maximum three pages).

Failure to demonstrate consideration of gender and diversity in the proposal will result in the application being rejected

Section 9: Collaboration Plan
(Please refer to requirement number 5 of the applicant guide for more information)

27. Please provide a collaboration plan outlining key partners who will be involved in the project delivery, including their roles and contribution to the achievement of the expected outcomes (maximum two pages).

Section 10: Performance and Evaluation Plan

28. Please describe how the project will be evaluated, including how the objectives of the project will be measured. Using the table below, for each phase of your project, please identify the outcomes, performance indicators, the type of data that will be collected (maximum two pages).

Section 11: Official Languages

29. Please describe how the Official Languages Act and the federal government policies on official languages will be respected.

Section 12: Confidential and Personal Information

30. If applicable, describe how any confidential and/or personal information will be protected in accordance with applicable federal, provincial or territorial legislation.

Section 13: Signatures

CONDITIONS

In the event that your funding application is successful, you will be required to provide binding information to process electronic payments (if not already provided).

Departmental funding may be used only for the purposes specified in this application.  Once the Department has agreed to provide financial support to your project, no major change can be made without departmental approval (in each case, the Department shall determine what constitutes a major change).  Funds not used for these purposes must be returned to the Department.

The organization bears full responsibility for its debts. The Department will not consider any request for assistance in settling debts.  The organization must agree to comply with all provincial, territorial and federal legislation.  The Department’s financial contribution must be explicitly acknowledged and must be mentioned in publications funded by the Department.  A typical form of acknowledgement is:  “We acknowledge the financial support of the Department of Public Safety Canada”.

With respect to the project or programming for which funding is requested, the organization shall agree to comply with the spirit and intent of the Official Languages Act by implementing the appropriate linguistic measures indicated on the call for proposals.

The Applicant must be in accordance with the terms and conditions regarding intellectual property rights described in the call for proposals.

By signing this application, the organization authorizes Public Safety Canada to disclose any information received in this application within the Department and the Government of Canada or to outside entities for the following purposes:  to reach a decision on this application; to administer and monitor the implementation of the project or programming; or to evaluate the results of the project or programming after the project completion.  The disclosure of any information received in this application may also be used to reach a decision on any other application of the applicant for funding under any other departmental program.

In the event of Access to Information requests regarding the present funding application or any relevant information about the organization in the Department’s possession, the information provided to the Department will be entirely disclosed, with the exception of personal information, which will be treated in accordance with the Privacy Act.

DECLARATIONS:

I declare that:

• The information in this application is accurate and complete;
• The application is made on behalf of the organization named, the name of which appears in Section 1, with its full knowledge and consent;
• If financial assistance is granted, the organization shall undertake to provide financial statements and reports on results pursuant to the requirements of Public Safety Canada;
• If financial assistance is provided, the organization shall agree to an assessment of the funded project or programming pursuant to the requirements of Public Safety Canada;
• No public servant or holder of public office, past or present, shall derive a direct benefit from the requested funding; in breach of the Values and Ethics Code for the Public Sector or the Conflict of Interest Act;
• This organization has not paid or agreed to pay, directly or indirectly, and agrees that it shall not pay, directly or indirectly, any contingency fees for the solicitation, negotiation or acquisition of funding for the purposes of this application.

Name of person with organizational signing authority:

Name and Title:       

 ☐ I agree to these conditions and declarations.

Signature:       

Date: