WEST VIRGINIA
                                                                               GRANT APPLICATION
             Purdue Pharma Asset Forfeiture
                     Grant Program

Completed application must include:

Applicant:                       Name, address, phone and fax number of the agency applying for funds. Program
                                 funds are available to qualified units of local and state government agencies on
                                 behalf of law enforcement agencies.

Project Director:                Name, address and direct phone number of the individual charged with the
                                 implementation and day-to-day operations of the project. This person cannot also
                                 be listed as the Authorized Official or the Fiscal Officer.

Fiscal Officer:                  Name, address, direct phone and fax number of the person responsible for the fiscal
                                 records/reports of the project. This person cannot also be listed as the Project
                                 Director or the Authorized Official.

Program Title:                   Title of the program as listed on the Request for Proposal (RFP).          Incident Based
                                 Reporting Compliancy or Prescription Drug Investigations/Interventions.

Grant Funds Requested:           Funds requested from the Division of Justice and Community Services (see funding
                                 limitations in guidelines, and as indicated on the attached RFP).

Matching Funds:                  Funds committed by the applicant agency. There is no match requirement for any
                                 Purdue Pharma Asset Forfeiture Funds Grant Program; however, applicants are strongly
                                 encouraged to leverage any available funds to help support the effort and demonstrate
                                 state and/or local commitment.

Project Period:                  Project beginning and ending dates (e.g., July 1, 2012 – June 30, 2013).

Certification:                   Name of the Authorized Official: Agency Head, Mayor, or County Commission President.
                                 This is the individual who would be authorized to enter into a contractual agreement with
                                 the Division of Justice & Community Services. This person cannot also be listed as
                                 the Project Director or the Fiscal Officer.

Should you have questions or need further assistance in the preparation of this grant application, please contact Leslie S.
Boggess at (304) 558-8814, extension 53330, or via email at Leslie.S.Boggess@wv.gov.

The authorized official must sign where indicated on page 1 of the application and on the EEOP Certification where

                                       RETURN COMPLETED APPLICATION TO:

                                            Leslie S. Boggess, Deputy Director
                                       Division of Justice and Community Services
                                              1204 Kanawha Boulevard, East
                                             Charleston, West Virginia 25301

                                              DUE DATE MARCH 30, 2012

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