Please include the following 3 photos (Filetypes accepted: JPG, PNG)

LEA’s may choose from one of the options as described below:

Option 1 (Funding-Only Grant):

MED-Project will provide an annual funding grant of $1300 in support of the LEA’s existing program for unwanted household medicine collection kiosk at the LEA site where unwanted medicine is collected and subsequently disposed of at a disposal site. The purpose of this grant is to pay for the collection and disposal of unwanted household medicines where the LEA directly manages the disposal of the collected medicine. MED-Project will provide $1300 to LEAs who submit a complete application between January 1st and July 1st of each year. Any complete applications received between July 2nd and December 31st of each year, will receive $650. Funding grants will be renewable each year provided a new complete application is submitted and the program is still in effect.

OR

Option 2 (Kiosk and Funding Grant):

MED-Project will provide an unwanted medicine kiosk*** and an annual funding grant of $1300. The purpose of this grant is to pay for the collection and disposal of unwanted household medicines where the LEA directly manages the disposal of the collected medicine. MED-Project will provide $1300 to LEAs who submit a complete application between January 1st and July 1st of each year. Any complete applications received between July 2nd and December 31st of each year, will receive $650. Funding grants will be renewable each year provided a new complete application is submitted and the program is still in effect.

or

Option 3 (Service Grant):

MED-Project will fund up to 12 unwanted household medicine collection box and liner kits per year. All box and liner shipping and disposal is included in the service grant. MED-Project will also supply an unwanted medicine collection kiosk***. LEAs may request more than 12 box and liner kits in a year by entering into a separate, self-paid agreement with the vendor. Prior to being awarded a service grant, the LEA will be required to apply to the Massachusetts Department of Environmental Protection for a Waiver of the Household Hazardous Waste Collection Requirements for a Permanent Residential Waste Medication Collection Kiosk ("MassDEP Waiver") in accordance with 310 CMR 30.1102. More information about the MassDEP Waiver can be found at https://www.mass.gov/how-to/apply-for-a-waste-medications-collection-waiver. The LEA will be required to provide documentation of the approved MassDEP Waiver to MED-Project via email to massachusetts@med-project.org. To qualify for the service grant, the LEA will operate an unwanted household medicine collection kiosk, and package and ship full unwanted household medicine collection kiosk box and liner to authorized disposal facilities. This Grant is valid for twelve (12) months from the date of application ("Initial Term") and will automatically renew for twelve (12) months ("Renewal Term")(collectively the "Term") unless you notify MED-Project thirty (30) days prior to the expiration of the Term. This Grant will terminate seven (7) days after written notification from MED-Project to LEA that this Grant is terminated without cause.

***For Options 2-3, if the LEA has already received a kiosk via a previous grant application to MED-Project, it will not receive an additional kiosk as part of the grant option it selects and will only receive the funding or service component of the selected grant option.

To complete the application, an authorized official will need to electronically sign a certification statement that:

By signing below, I certify that the following are true:

• On behalf of the law enforcement agency, I understand the information and responsibilities for participating in the Massachusetts MED-Project Service or Funding Grant program, as provided in the Program Overview and Program Essentials of this application and immediately following this section;
• The law enforcement agency will fulfill the responsibilities for participating in the Massachusetts MED- Project Service or Funding Grant program, including operating a collection kiosk for household medicine and disposing of collected household medicine at authorized disposal facilities;
• The application is complete, true and accurate;
• The law enforcement agency will comply with all applicable laws, rules and regulations, including applicable regulations promulgated by the United States Drug Enforcement Administration and Massachusetts Department of Environmental Protection; and
• The law enforcement agency acknowledges that MED-Project LLC is the organization implementing the Massachusetts Opioid and Benzodiazepine Product Stewardship Plan.
• If I am requesting a Service Grant, the law enforcement agency shall sign a standard service agreement with vendor and obtain and maintain a MassDEP Waiver. Documentation of the approved MassDEP Waiver must be provided to MED-Project via email to massachusetts@med-project.org.

Applicants for this stewardship program must accept the LEA Responsibilities listed below and comply with the Program Essentials listed in the following section.

All Options:

1. Sign certification statement to receive grant;
2. Read and understand Title 21 Code of Federal Regulations Part 1317 - Disposal;
3. Ensure proper placement of the unwanted household medicine collection kiosk according to Drug Enforcement Administration (“DEA”) requirements.
4. Ensure proper operation of the unwanted household medicine collection kiosk which includes: periodic monitoring to determine when it is full; removing and replacing the inner box and liner when full;
5. Authorize MED-Project to verify the Employment Identification Number / Tax Identification Number of the LEA;
6. Maintain all records as required by DEA regulations; and
7. Follow all applicable laws, rules and regulations.

Option 2 (Kiosk and Funding Grant) In addition to All Options 1-7 above:

1. Receive and install the unwanted household medicine collection kiosk according to DEA requirements.

Option 3 (Service Grant): In addition to All Options 1-7 above:

1. Sign agreement to receive service grant with MED-Project;
2. Sign standard service agreement with vendor
3. Receive and install (or request installation of) the unwanted household medicine collection kiosk according to DEA requirements and Mass DEP; and
4. Operate the unwanted household medicine collection kiosk in accordance with the LEA's MassDEP Waiver; and
5. Ensure proper operation of the unwanted household medicine collection kiosk which includes: periodic monitoring to determine when it is full; removing and replacing the inner box and liner when full; contacting common carrier to arrange for liner pickup; and securely storing the liner until it is retrieved by common carrier.