Form OMB Number 1123-XX OMB Number 1123-XX Equitable Sharing Agreement and Certification

OMB Number 1123-XXXX
expires XX-XX-XX

Equitable Sharing
Agreement and
Certification

Police Department
Sheriff’s Office
Task Force (Complete Table A, page 2)
District Attorney
Other (specify)
Agency Name:
NCIC/ORI/Tracking Number:
Street Address:
City:

State:

Zip: 0

Contact Name:
Contact Phone:

Contact Fax:

Contact e-mail:
New Participant:

Read the Equitable Sharing Agreement (page -1) and sign the Affidavit (page -1)

Existing Participant:

Complete the Annual Certification Report, read the Equitable Sharing Agreement
(page -1), and sign the Affidavit (page -1)

Change in Administration: Changes to the Agency head and/or Governing Body head. Read the Equitable

Sharing Agreement (page -1) and sign the Affidavit (page -1).

Amended Form:

Revise the Annual Certification Report, read the Equitable Sharing Agreement (page
-1), and sign the Affidavit (page -1).

Annual Certification Report
Summary of Equitable Sharing Activity
Fiscal Year End (mm/dd/yyyy)

Justice
Funds

Treasury
Funds

1

Beginning Equitable Sharing Fund Balance (must match
Ending Equitable Sharing Fund Balance from prior FY)

2

Federal Sharing Funds Received

3

Federal Sharing Funds Received from Other Law Enforcement
Agencies and Task Forces (complete Table B, page -1)

4

Other Income

5

Interest Income Accrued
(
check if non-interest-bearing account)

6

Total Equitable Sharing Funds (total of lines 1 - 5)

$0.00

$0.00

7

Federal Sharing Funds Spent (total of lines a - n below)

$0.00

$0.00

8

Ending Balance (subtract line 7 from line 6)

$0.00

$0.00

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June 2008

Summary of Shared Monies Spent

Justice Funds

a

Total spent on salaries for new, temporary, not-to-exceed
one year, employees

b

Total spent on overtime

c

Total spent on informant and "buy money"

d

Total spent on travel and training

e

Total spent on communications and computers

f

Total spent on firearms and weapons

g

Total spent on body armor and protective gear

h

Total spent on electronic surveillance equipment

i

Total spent on building and improvements

j

Total spent on other law enforcement expenses (complete
Table C, page -1)

k

Total transfers to other state and local law enforcement
agencies (complete Table D, page -1)

l

Total 15% Expenditures in Support of Community-based
Programs (complete Table E, page -1)

m

Total 25% Windfall Transfers to Other Government Agencies
(complete Table F, page -1)

n

Total spent on matching grants (complete Table G, page -1)
Total

Treasury Funds

$0.00

$0.00

Miscellaneous Data
o

Agency's budget for current fiscal year

p

Jurisdiction's budget for current fiscal year

q

Appraised Value of Other Assets Received

Table A: Members of Task Force
Agency Name

Add Task Force Member

Address

X

Table B: Equitable Sharing Funds Received from other Agencies
Transferring Agency Name, City, and State

Add Equitable Sharing Fund
Justice Funds

Treasury Funds

Agency Name
X

Agency Address

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June 2008

Add Other Law Enforcement Expense

Table C: Other Law Enforcement Expenses
Description of Expense

Justice Funds

Treasury Funds

X

Add Receiving Agency

Table D: Equitable Sharing Funds Transferred to Other Agencies
Receiving Agency Name, City, and State

Justice Funds

Treasury Funds

Agency Name
X

Agency Address

Add Receiving Agency

Table E: 15% Expenditures in Support of Community-based Programs
Recipient

Justice Funds

Treasury Funds

X
Add Receiving Agency

Table F: 25% Windfall Transfers to Other Government Agencies
Recipient

Justice Funds

Treasury Funds

X
Add Matching Grant

Table G: Matching Grants
Matching Grant Name

Justice Funds

Treasury Funds

X

Add Civil Rights Case

Table H: Civil Rights Cases
Name of Case

Type of Discrimination Alleged

Status

Race

Color

National
Origin

Disability

Age

Other

X

Gender

Settled
Pending

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it
displays a valid OMB control number. We try to create accurate and easily understood forms that impose the least
possible burden on you to complete. The estimated average time to complete this form is 30 minutes. If you have
comments regarding the accuracy of this estimate, or suggestions for making this form simpler, please write to the
Asset Forfeiture and Money Laundering Section, Program Unit, 1400 New York Avenue, N.W., Second Floor,
Washington, DC 20005.

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June 2008

Equitable Sharing Agreement
This Federal Equitable Sharing Agreement, entered into among (1) the Federal Government, (2) the above-stated law
enforcement agency (“Agency”), and (3) the governing body, sets forth the requirements for participation in the
federal equitable sharing program and the restrictions upon the use of federally forfeited cash, property, proceeds,
and any interest earned thereon, which are equitably shared with participating law enforcement agencies. By its
signatures, the Agency agrees that it will be bound by the statutes and guidelines that regulate shared assets and the
following requirements for participation in the federal equitable sharing program. Receipt of the signed Equitable
Sharing Agreement and Certification (this “Document”) is a prerequisite to receiving any equitably shared cash,
property, or proceeds.

1. Submission. This Document must be submitted to aca.submit@usdoj.gov within 60 days of the end of the
Agency’s fiscal year. This Document must be submitted electronically with the Affidavit/Signature page (page -1)
submitted by fax. This will constitute submission to the Department of Justice and the Department of Treasury.

2. Signatories. This agreement must be signed by the head of the Agency and the head of the governing body.
Examples of Agency heads include police chief, sheriff, director, commissioner, superintendent, administrator,
chairperson, secretary, city attorney, county attorney, district attorney, prosecuting attorney, state attorney,
commonwealth attorney, and attorney general. Examples of governing body heads include city manager, mayor, city
council chairperson, county executive, county council chairperson, director, secretary, administrator, commissioner,
and governor.

3. Uses. Any shared asset shall be used for law enforcement purposes in accordance with the statutes and
guidelines that govern the federal equitable sharing program as set forth in the current edition of the Department of
Justice's Guide to Equitable Sharing (Justice Guide), and the Department of the Treasury's Guide to Equitable
Sharing for Foreign Countries and Federal, State, and Local Law Enforcement Agencies (Treasury Guide).

4. Transfers. Before the Agency transfers cash, property, or proceeds to other state or local law enforcement
agencies, it must first verify with the Department of Justice or the Department of Treasury, depending on the source
of the funds, that the receiving agency is a federal equitable sharing program participant and has a current Equitable
Sharing Agreement and Certification on file.

5. Internal Controls. The Agency agrees to account separately for federal equitable sharing funds received from
the Department of Justice and the Department of the Treasury. Funds from state and local forfeitures and other
sources must not be commingled with federal equitable sharing funds. The Agency shall establish a separate
revenue account or accounting code for state, local, Department of Justice, and Department of the Treasury forfeiture
funds. Interest income generated must be accounted for in the appropriate federal forfeiture fund account.
The Agency agrees that such accounting will be subject to the standard accounting requirements and practices
employed for other public monies as supplemented by requirements set forth in the current edition of the Justice
Guide and the Treasury Guide.
The misuse or misapplication of shared resources or the supplantation of existing resources with shared assets is
prohibited. Failure to comply with any provision of this agreement shall subject the recipient agency to the sanctions
stipulated in the current edition of the Justice or Treasury Guides, depending on the source of the funds/property.
6. Audit Report. Audits will be conducted as provided by the Single Audit Act Amendments of 1996 and OMB
Circular A-133. The Department of Justice and Department of the Treasury reserve the right to conduct periodic
random audits.

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June 2008

Affidavit
Under penalty of perjury, the undersigned officials certify that they have read and understand their obligations under the
Equitable Sharing Agreement and that the information submitted in conjunction with this Document is an accurate
accounting of funds received and spent by the Agency under the Justice and/or Treasury Guides during the reporting period
and that the recipient Agency is in compliance with the National Code of Professional Conduct for Asset Forfeiture.
The undersigned certify that the recipient agency is in compliance with the nondiscrimination requirements of the following
laws and their Department of Justice implementing regulations: Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d et
seq.), Title IX of the Education Amendments of 1972 (20 U.S.C. § 1681 et seq.), Section 504 of the Rehabilitation Act of 1973
(29 U.S.C. § 794), and the Age Discrimination Act of 1975 (42 U.S.C. § 6101 et seq.), which prohibit discrimination on the
basis of race, color, national origin, disability, or age in any federally assisted program or activity, or on the basis of sex in any
federally assisted education program or activity.

During the past fiscal year, has the Agency been part of any proceedings
alleging discrimination by the Agency?
Yes
No
If you answered yes, complete Table H. Please disclose (1) all proceedings
pending before any court or administrative agency, (2) any nondiscrimination
laws the Agency has been found in violation of, and (3) any settlement
agreements the Agency has entered into during the last fiscal year.

Agency Head

Governing Body Head

Signature:

Signature:

Name:

Name:

Title:

Title:

Date:

Date:

Final Instructions:
Step 1: Save this file using the button below and e-mail the saved file as an attachment to
Save to File
aca.submit@usdoj.gov.
Step 2: Fax a signed copy of THIS PAGE ONLY to (202) 616-1344.

Print Form

Note: The Agency will not be in compliance until the e-mail and the fax of this page are received.
FOR AGENCY USE ONLY
Entered by ____________
Entered on ____________
FY ___________ NCIC _________________ STATE ___________
AGENCY NAME __________________________________________________________________________
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June 2008