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[Document C, 1 of 5 pages] <br />Mental Health Transformation State Incentive Grant (MHT SIG) <br />Uluakupu Awards — Community Grants Program <br />Please fill in all of the information to complete the application <br />OFFICE USE: <br />Date recd: <br />Date re,/d <br />County: <br />Grant Application Cover Sheet <br />Date of Application 10/31/08 <br />Organization Name: BIG ISLAND TASK FORCE ON CRIMINAL JUSTICE: 704 Handbook Committee, Hawaii <br />County <br />Contact Person: Hawaii County Police Officer William Derr <br />Address: 349 Kapi'olani St. <br />City: Hilo <br />Zip Code: 96720 <br />Island (PlaceXnlntais/ond) <br />Kauai <br />Oahu <br />Molokai <br />Lanai <br />Maul <br />Hawaii <br />X <br />Phone: (day) 808-961-8121 <br />(evening) None <br />Fax: 808-933-4000 <br />Email: hilocp176@yahoo.com <br />Organizational web site address <br />Project Title: Training on SPMI Populations: Their Interface with the Criminal Justice Tracks <br />Grant Request Amount: $24,999.00 <br />Ekahi <br /><SSK <br />Elua <br />lOK <br />Ekolu <br />15K <br />Eha <br />20K <br />Elima <br />aSK <br />X <br />Organization's Fiscal Status <br />Do you have an IRS tax exempt status? (Circle yes or No) <br />If YES, please attach one copy of your IRS determination letter. If no, please complete the <br />remaining sections. <br />Yes <br />No <br />X <br />Do you have a fiscal sponsor who will administer your funds? (Circle yes or No) <br />If yes, please include information on a fiscal sponsor below and attach a letter of permission fromX <br />fiscal sponsor and one copy of their IRS letter. <br />Yes <br />No <br />Fiscal Sponsor Organization: Hawaii County Office of the Prosecuting Attorney <br />Contact Person & Position: Charlene Iboshi, First Deputy Prosecuting Attorney <br />Address: 655 Kilauea St. Hilo HI 96720 <br />Phone(s) 808-961-0466 <br />Email <br />(Please place X next to all that apply to your proposal) <br />Major Strategy(s) of MHT SIG <br />Government Performance Results Act (GPRA) <br />#1: Educating the Public <br />#1: Policy Change <br />#2: System Integration <br />X <br />#2: Training <br />X <br />#3: Professional and Consumer Workforce <br />Development and Training <br />X <br />#3: Financing Policy <br />#4: Research, Evaluation and Dissemination <br />#4: Organizational Changes <br />#5: Finance and Sustainability <br />#5: Data Collection <br />#6: Criminal Justice <br />X <br />#6 Statewide Consumer- and Family- Run Networks <br />Other: Encouraging Collaboration and Innovation <br />X <br />#7 Program Implementation <br />Mental Health Transformation State Incentive Grant (MHT SIG) <br />EXHIBIT "A" <br />Revised 081808 <br />