Fiscal Year: ___

Each fiscal year the State must sign these Certifications and Assurances that it complies with all requirements, including applicable Federal statutes and regulations that are in effect during the grant period.

In my capacity as the Governor's Representative for Highway Safety, I:

•  certify that, to the best of my personal knowledge, the information submitted to the National Highway Traffic Safety Administration in support of the State's application for Section 405 grants below is accurate and complete.

•  understand that incorrect, incomplete, or untimely information submitted in support of the State's application may result in the denial of an award under Section 405.

•  agree that, as condition of the grant, the State will use these grant funds in accordance with the specific requirements of Section 405(b), (c), (d), (e), (f) and (g), as applicable.

•  agree that, as a condition of the grant, the State will comply with all applicable laws and regulations and financial and programmatic requirements for Federal grants.

Signature Governor's Representative for Highway Safety

Date

Printed name of Governor's Representative for Highway Safety

Instructions: Check the box for each part for which the State is applying for a grant, fill in relevant blanks, and identify the attachment number or page numbers where the requested information appears in the HSP. Attachments may be submitted electronically.

□  Part 1: Occupant Protection (23 CFR 1200.21)

All States: [Fill in all blanks below.]

•  The State will maintain its aggregate expenditures from all State and local sources for occupant protection programs at or above the average level of such expenditures in fiscal years 2010 and 2011. (23 U.S.C. 405(a)(1)(H))

•  The State will participate in the Click it or Ticket national mobilization in the fiscal year of the grant. The description of the State's planned participation is provided as HSP attachment or page # __.

•  The State's occupant protection plan for the upcoming fiscal year is provided as HSP attachment or page # __.

•  Documentation of the State's active network of child restraint inspection stations is provided as HSP attachment or page # __.

•  The State's plan for child passenger safety technicians is provided as HSP attachment or page # __.

Lower Seat belt Use States: [Check at least 3 boxes below and fill in all blanks under those checked boxes.]

□  The State's primary seat belt use law, requiring all occupants riding in a passenger motor vehicle to be restrained in a seat belt or a child restraint, was enacted on __/__/__ and last amended on __/__/__, is in effect, and will be enforced during the fiscal year of the grant.

Legal citation(s):

□  The State's occupant protection law, requiring occupants to be secured in a seat belt or age-appropriate child restraint while in a passenger motor vehicle and a minimum fine of $25, was enacted on __/__/__ and last amended on __/__/__, is in effect, and will be enforced during the fiscal year of the grant.

Legal citations:

•  __________ Requirement for all occupants to be secured in seat belt or age appropriate child restraint

•  __________ Coverage of all passenger motor vehicles

•  __________ Minimum fine of at least $25

•  __________ Exemptions from restraint requirements

□  The State's seat belt enforcement plan is provided as HSP attachment or page # __.

□  The State's comprehensive occupant protection program is provided as HSP attachment # __.

[Check one box below and fill in any blanks under that checked box.]

□  The State's NHTSA-facilitated occupant protection program assessment was conducted on __/__/__;

OR

□  The State agrees to conduct a NHTSA-facilitated occupant protection program assessment by September 1 of the fiscal year of the grant. (This option is available only for fiscal year 2013 grants.)

□  Part 2: State Traffic Safety Information System Improvements (23 CFR 1200.22)

•  The State will maintain its aggregate expenditures from all State and local sources for traffic safety information system programs at or above the average level of such expenditures in fiscal years 2010 and 2011.

[Fill in at least one blank for each bullet below.]

•  A copy of [check one box only] the ☐ TRCC charter or the ☐ statute legally mandating a State TRCC is provided as HSP attachment # __ or submitted electronically through the TRIPRS database on __/__/__.

•  A copy of meeting schedule and all reports and other documents promulgated by the TRCC during the 12 months preceding the application due date is provided as HSP attachment # __ or submitted electronically through the TRIPRS database on __/__/__.

•  A list of the TRCC membership and the organization and function they represent is provided as HSP attachment # __ or submitted electronically through the TRIPRS database on __/__/__.

•  The name and title of the State's Traffic Records Coordinator is

•  A copy of the State Strategic Plan, including any updates, is provided as HSP attachment # __ or submitted electronically through the TRIPRS database on __/__/__.

•  [Check one box below and fill in any blanks under that checked box.]

□  The following pages in the State's Strategic Plan provides a written description of the performance measures, and all supporting data, that the State is relying on to demonstrate achievement of the quantitative improvement in the preceding 12 months of the application due date in relation to one or more of the significant data program attributes: pages _____.

OR

□  If not detailed in the State's Strategic Plan, the written description is provided as HSP attachment # __.

•  The State's most recent assessment or update of its highway safety data and traffic records system was completed on __/__/__.

□  Part 3: Impaired Driving Countermeasures (23 CFR 1200.23)

All States:

•  The State will maintain its aggregate expenditures from all State and local sources for impaired driving programs at or above the average level of such expenditures in fiscal years 2010 and 2011.

•  The State will use the funds awarded under 23 U.S.C. 405(d) only for the implementation of programs as provided in 23 CFR 1200.23(i) in the fiscal year of the grant.

Mid-Range State:

•  [Check one box below and fill in any blanks under that checked box.]

□  The statewide impaired driving plan approved by a statewide impaired driving task force was issued on __/__/__ and is provided as HSP attachment # __.

OR

□  For this first year of the grant as a mid-range State, the State agrees to convene a statewide impaired driving task force to develop a statewide impaired driving plan and submit a copy of the plan to NHTSA by September 1 of the fiscal year of the grant.

•  A copy of information describing the statewide impaired driving task force is provided as HSP attachment # __.

High-Range State:

[Check one box below and fill in any blanks under that checked box.]

□  A NHTSA-facilitated assessment of the State's impaired driving program was conducted on __/__/__;

OR

□  For the first year of the grant as a high-range State, the State agrees to conduct a NHTSA-facilitated assessment by September 1 of the fiscal year of the grant;

•  [Check one box below and fill in any blanks under that checked box.]

□  For the first year of the grant as a high-range State, the State agrees to convene a statewide impaired driving task force to develop a statewide impaired driving plan addressing recommendations from the assessment and submit the plan to NHTSA for review and approval by September 1 of the fiscal year of the grant;

OR

□  For subsequent years of the grant as a high-range State, the statewide impaired driving plan developed or updated on __/__/__ is provided as HSP attachment # __.

•  A copy of the information describing the statewide impaired driving task force is provided as HSP attachment # __.

Ignition Interlock Law: [Fill in all blanks below.]

•  The State's ignition interlock law was enacted on __/__/__ and last amended on __/__/__, is in effect, and will be enforced during the fiscal year of the grant.

Legal citation(s):

□  Part 4: Distracted Driving (23 CFR 1200.24)

[Fill in all blanks below.]

Prohibition on Texting While Driving

The State's texting ban statute, prohibiting texting while driving, a minimum fine of at least $25, and increased fines for repeat offenses, was enacted on __/__/__ and last amended on __/__/__, is in effect, and will be enforced during the fiscal year of the grant.

Legal citations:

•  __________ Prohibition on texting while driving

•  __________ Definition of covered wireless communication devices

•  __________ Minimum fine of at least $25 for first offense

•  __________ Increased fines for repeat offenses

•  __________ Exemptions from texting ban

Prohibition on Youth Cell Phone Use While Driving

The State's youth cell phone use ban statute, prohibiting youth cell phone use while driving, driver license testing of distracted driving issues, a minimum fine of at least $25, increased fines for repeat offenses, was enacted on __/__/__ and last amended on __/__/__, is in effect, and will be enforced during the fiscal year of the grant.

Legal citations:

•  __________ Prohibition on youth cell phone use while driving

•  __________ Driver license testing of distracted driving issues

•  __________ Minimum fine of at least $25 for first offense

•  __________ Increased fines for repeat offenses

•  __________ Exemptions from youth cell phone use ban

□  Part 5: Motorcyclist Safety (23 CFR 1200.25)

[Check at least 2 boxes below and fill in any blanks under those checked boxes.]

□  Motorcycle riding training course:

•  Copy of official State document (e.g., law, regulation, binding policy directive, letter from the Governor) identifying the designated State authority over motorcyclist safety issues is provided as HSP attachment # __.

•  Document(s) showing the designated State authority approving the training curriculum that includes instruction in crash avoidance and other safety-oriented operational skills for both in-class and on-the-motorcycle is provided as HSP attachment # __.

•  Document(s) regarding locations of the motorcycle rider __.

•  Document showing that certified motorcycle rider training instructors teach the motorcycle riding training course is provided as HSP attachment # __.

•  Description of the quality control procedures to assess motorcycle rider training courses and instructor training courses and actions taken to improve courses is provided as HSP attachment #__.

☐  Motorcyclist awareness program:

•  Copy of official State document (e.g., law, regulation, binding policy directive, letter from the Governor) identifying the designated State authority over motorcyclist safety issues is provided as HSP attachment #__.

•  Letter from the Governor's Representative for Highway Safety regarding the development of the motorcyclist awareness program is provided as HSP attachment #__.

•  Data used to identify and prioritize the State's motorcyclist safety program areas is provided as HSP attachment or page #__.

•  Description of how the State achieved collaboration among agencies and organizations regarding motorcycle safety issues is provided as HSP attachment # or page #__.

•  Copy of the State strategic communications plan is provided as HSP attachment #__.

☐  Reduction of fatalities and crashes involving motorcycles:

•  Data showing the total number of motor vehicle crashes involving motorcycles is provided as HSP attachment or page #__.

•  Description of the State's methods for collecting and analyzing data is provided as HSP attachment or page #__.

☐  Impaired driving program:

•  Data used to identify and prioritize the State's impaired driving and impaired motorcycle operation problem areas is provided as HSP attachment or page #__.

•  Detailed description of the State's impaired driving program is provided as HSP attachment or page #__.

•  The State law or regulation defines impairment. Legal citation(s):

☐  Reduction of fatalities and accidents involving impaired motorcyclists:

•  Data showing the total number of reported crashes involving alcohol-impaired and drug-impaired motorcycle operators is provided as HSP attachment or page #__.

•  Description of the State's methods for collecting and analyzing data is provided as HSP attachment or page #__.

•  The State law or regulation defines impairment. Legal citation(s):

☐  Use of fees collected from motorcyclists for motorcycle programs: [Check one box below and fill in any blanks under the checked box.]

☐  Applying as a Law State—

•  The State law or regulation requires all fees collected by the State from motorcyclists for the purpose of funding motorcycle training and safety programs are to be used for motorcycle training and safety programs. Legal citation(s):

AND

•  The State's law appropriating funds for FY __ requires all fees collected by the State from motorcyclists for the purpose of funding motorcycle training and safety programs be spent on motorcycle training and safety programs. Legal citation(s):

☐  Applying as a Data State—

•  Data and/or documentation from official State records from the previous fiscal year showing that all fees collected by the State from motorcyclists for the purpose of funding motorcycle training and safety programs were used for motorcycle training and safety programs is provided as HSP attachment #__.

☐  Part 6: State Graduated Driver Licensing Laws (23 CFR 1200.26)

[Fill in all applicable blanks below.]

The State's graduated driver licensing statute, requiring both a learner's permit stage and intermediate stage prior to receiving a full driver's license, was enacted on __/__/__ and last amended on __/__/__, is in effect, and will be enforced during the fiscal year of the grant.

Learner's Permit Stage—requires testing and education, driving restrictions, minimum duration, and applicability to novice drivers younger than 21 years of age.

Legal citations:

•  __________ Testing and education requirements

•  __________ Driving restrictions

•  __________ Minimum duration

•  __________ Applicability to notice drivers younger than 21 years of age

•  __________ Exemptions from graduated driver licensing law

Intermediate Stage—requires driving restrictions, minimum duration, and applicability to any driver who has completed the learner's permit stage and who is younger than 18 years of age.

Legal citations:

•  __________ Driving restrictions

•  __________ Minimum duration

•  __________ Applicability to any driver who has completed the learner's permit stage and is younger than 18 years of age

•  __________ Exemptions from graduated driver licensing law

Additional Requirements During Both Learner's Permit and Intermediate Stages

Prohibition enforced as a primary offense on use of a cellular telephone or any communications device by the driver while driving, except in case of emergency. Legal citation(s):

Requirement that the driver who possesses a learner's permit or intermediate license remain conviction-free for a period of not less than six consecutive months immediately prior to the expiration of that stage. Legal citation(s):

License Distinguishability (Check one box below and fill in any blanks under that checked box.)

☐  Requirement that the State learner's permit, intermediate license, and full driver's license are visually distinguishable. Legal citation(s):

OR

☐  Sample permits and licenses containing visual features that would enable a law enforcement officer to distinguish between the State learner's permit, intermediate license, and full driver's license, are provided as HSP attachment #____.

OR

☐  Description of the State's system that enables law enforcement officers in the State during traffic stops to distinguish between the State learner's permit, intermediate license, and full driver's license, are provided as HSP attachment #____.