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Equitable Sharing <br />~_~ h Agreement and <br />~° ~ Certification <br />~4~~a dt~~tr*~ <br />OMB Number 1123-0011 <br />Expires 7-31-2011 <br />Di Police Department ~ Sheriff s Office ~ Task Force (Complete Table A, page2) <br />Prosecutor's Office ~ Other (specify) <br />Agency Name: North Olmsted Police <br />NCIC/ORI/Tracking Number: O H 0 1 8 3 4 0 0 <br />Street Address: 27243 Lorain Rd. <br />City: North Olmsted <br />Contact: Title: Captain First: Jamie <br />Contact Phone: 440-777-3535 Contact Fax: <br />Contact a-mail: gallagherjC>north-olmsted.com <br />State:OH Zip: 44070 <br />Last: Gallagher <br />(440) 777-9189 <br />Last Fiscal Year End: ~ 12/31/2009 <br />O New Participant: Read the Equitable Sharing Agreement (page 4) and sign the Affidavit (page 5) <br />Existing Participant: Complete the Annual Certification Report, read the Equitable Sharing Agreement <br />(page 4), and sign the Affidavit (page 5) <br />Change in Administration: Select to report change to Agency or Governing Body head DURING the current fiscal <br />year. Read the Equitable Sharing Agreement (page 4) and sign the Affidavit (page 5). <br />O Amended Form: Revise the Annual Certification Report, read the Equitable Sharing Agreement (page <br />4), and sign the Affidavit (page S). <br />Annual Certification Report <br />Summary of Equitable Sharing Activity Justice Funds Treasury Funds <br />1 Beginning Equitable Sharing Fund Balance (must match <br />Ending Equitable Sharing Fund Balance from prior FY) <br />2 Federal Sharing Funds Received <br />3 Federal Sharing Funds Received from Other Law Enforcement <br />Agencies and Task Forces (complete Table B, page 2) <br />4 Other Income <br />5 Interest Income Accrued <br />Check box if non-interest-bearing account <br />6 Total Equitable Sharing Funds (total of lines 1 - 5) $0.00 $0.00 <br />7 Federal Sharing Funds Spent (total oflines a - n below) $0.00 $0.00 <br />8 Ending Balance (difference between line 7 and line 6) $0.00 $0.00 <br />Page 1 of 5 March 2009 <br />Version 1.7 <br />