SF424_Mandatory_1_2-V1.2.pdf

PDF 105 KB Posted Dec 22, 2020

Attached to: U.S. Embassy Nairobi, PDS Annual Program Statement - Small Grants Program Federal grant opportunity
Opportunity number: DOS-NBO-PAS-FY21-002
Issued by: Department of State US Embassy Nairobi

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From the source

SF424 - Application form for organizations

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Other files for this federal grant opportunity

Other files attached to U.S. Embassy Nairobi, PDS Annual Program Statement - Small Grants Program, newest first.
File	Type	Posted
SF424_Individual_1_1-V1.1.pdf	PDF	Dec 22, 2020
Full Announcement - FY21 Annual Program Statement Final.docx	DOCX document	Dec 22, 2020
Full Announcement - FY21 Annual Program Statement.docx	DOCX document	Dec 22, 2020

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SF424_Mandatory_1_2 Page 1 mhughes D:20061227100528- 05'00' D:20061227100528- 05'00'

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY

OMB Number: 4040-0020 Expiration Date: 01/31/2023 1.a. Type of Submission:

Other (specify):

1.b. Frequency:

Other (specify):

1.d. Version:

2. Date Received:

3. Applicant Identifier:

4a. Federal Entity Identifier:

4b. Federal Award Identifier:

5. Date Received by State:

6. State Application Identifier:

c. Organizational DUNS:

Department Name:

Division Name:

Street1:

Street2:

City:

County / Parish:

State:

Province:

Zip / Postal Code:

Country:

b. Employer/Taxpayer Identification Number (EIN/TIN):

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Title:

Organizational Affiliation:

Telephone Number:

Fax Number:

Email:

STATE USE ONLY:

7. APPLICANT INFORMATION:

d. Address:

a. Legal Name:

e. Organizational Unit:

f. Name and contact information of person to be contacted on matters involving this submission:

Type of Submission: Select one type of submission in accordance with agency instructions. This field is required.

Type of Submission is required: Select one type of submission in accordance with agency instructions.

Frequency: Select the applicable frequency for the type of submission. This field is required.

Frequency is required: Select the applicable frequency for the type of submission.

1.c. Consolidated Application/Plan/Funding Request?

Consolidated Application/Plan/Funding Request: Indicate if the submission is a consolidated application/plan/funding request.

Version: Select the applicable version for the type of submission. This field is required.

Version is required: Select the applicable version for the type of submission.

8a. TYPE OF APPLICANT:

Other (specify):

b. Additional Description:

9. Name of Federal Agency:

10. Catalog of Federal Domestic Assistance Number:

CFDA Title:

a. Applicant:

b. Program/Project:

a. Start Date:

b. End Date:

a. Federal ($):

b. Match ($):

16. IS SUBMISSION SUBJECT TO REVIEW BY STATE UNDER EXECUTIVE ORDER 12372 PROCESS?

Is Submission Subject to Review: Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process. This field is required.

13. CONGRESSIONAL DISTRICTS OF:

14. FUNDING PERIOD:

15. ESTIMATED FUNDING:

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY

Attach an additional list of Program/Project Congressional Districts if needed.

11. Descriptive Title of Applicant's Project:

12. Areas Affected by Funding:

Is Submission Subject to Review is required: Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process.

17. Is The Applicant Delinquent On Any Federal Debt?

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Title:

Organizational Affiliation:

Telephone Number:

Email:

Fax Number:

Signature of Authorized Representative:

Date Signed:

18. By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001) Authorized Representative:

Attach supporting documents as specified in agency instructions.

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY

** This list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions.

Is The Applicant Delinquent On Any Federal Debt: This question applies to the applicant organization, not the person who signs as the authorized representative. This field is required.

Is The Applicant Delinquent On Any Federal Debt is required: This question applies to the applicant organization, not the person who signs as the authorized representative.

** I Agree Form Attachments:

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY

Consolidated Application/Plan/Funding Request Explanation:

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY

Applicant Federal Debt Delinquency Explanation:

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY

XDPFirstField:

Mandatory:

ViewBurdenStatement:

TextField1:

Type of Submission: Select one type of submission in accordance with agency instructions. This field is required.

Application: Select if the type of submission is an Application.:

Type of Submission: Select one type of submission in accordance with agency instructions. This field is required.

Plan: Select if the type of submission is a Plan.:

Type of Submission: Select one type of submission in accordance with agency instructions. This field is required.

Funding Request: Select if the type of submission is a Funding Request.:

Type of Submission: Select one type of submission in accordance with agency instructions. This field is required.

Other: Select "Other" if submission is not an application, plan, or funding request.:

Other (specify): Specify the type of submission in the text box.:

Frequency: Select the applicable frequency for the type of submission. This field is required.

Annual: Select if the frequency of the submission is Annual.:

Frequency: Select the applicable frequency for the type of submission. This field is required.

Quarterly: Select if the frequency of the submission is Quarterly.:

Frequency: Select the applicable frequency for the type of submission. This field is required.

Other: Select "Other" if the frequency of the submission is other than quarterly or annual.:

Other (specify): Specify the frequency of the submission.:

Consolidated Request: Indicate if the submission is a consolidated application/plan/funding request.

Yes: Select if the submission is a consolidated application/plan/funding request.:

Consolidated Request: Indicate if the submission is a consolidated application/plan/funding request.

No: Select if the submission is not a consolidated application/plan/funding request.:

Version: Select the applicable version for the type of submission. This field is required.

Update: Select if this is a change to an accepted or approved submission.:

Date Received: Enter the date received. Enter in the format mm/dd/yyyy. This field is required.:

Applicant Identifier: If you wish to use a unique identification number for your own purposes, enter it here.:

Federal Entity ID: Enter the number assigned to your organization by the Federal agency.:

Federal Award ID: Enter the award number previously assigned by the Federal agency, if any.:

Date Received State: Enter the date received by the State, if applicable. Enter in the format mm/dd/yyyy.:

State Application ID: Enter the identifier assigned by the State, if applicable.:

Delinquent Federal Debt Explanation Button: Please indicate the amount of the debt(s) owed and to whom.:

Organization Name: Enter the legal name of the applicant that will undertake the assistance activity. This field is required.:

EIN/TIN: Enter either TIN or EIN as assigned by the Internal Revenue Service. If your organization is not in the US, enter 44-4444444. This field is required.:

DUNS Number: Enter the DUNS or DUNS+4 number of the applicant organization. This field is required.:

Street1: Enter the first line of the Street Address. This field is required.:

Street2: Enter the second line of the Street Address.:

City: Enter the City. This field is required.:

County / Parish: Enter the County / Parish.:

State: Select the state, US possession or military code from the provided list. This field is required if Country is the United States.:

Province: Enter the Province.:

Country: Select the Country from the provided list. This field is required.:

ZIP/ Postal Code: Enter the nine-digit Postal Code (e.g., ZIP code). This field is required if the country is the United States.:

Department Name: Enter the name of primary organizational department, service, laboratory, or equivalent level within the organization which will undertake the assistance activity.:

Division Name: Enter the name of primary organizational division, office, or major subdivision which will undertake the assistance activity.:

Prefix: Select the Prefix from the provided list or enter a new Prefix not provided on the list.:

First Name: Enter the First Name. This field is required.:

Middle Name: Enter the Middle Name.:

Last Name: Enter the Last Name. This field is required.:

Suffix: Select the Suffix from the provided list or enter a new Suffix not provided on the list.:

Title: Enter the position title.:

Organizational Affiliation: Enter the Organizational Affiliation of the person to contact on matters related to this application.:

Telephone Number: Enter the daytime Telephone Number. This field is required.:

Fax Number: Enter the Fax Number.:

Email: Enter a valid Email Address. This field is required.:

Type of Applicant: Select the appropriate applicant type code. This field is required.:

Other (specify): If you selected "Other" in 8a, specify your applicant type here.:

Additional Description: Enter a secondary description of applicant type, if required by the agency.:

Name of Federal Agency: Enter the Name of Federal Agency. This field is required.:

CFDA Number: Enter the Catalog of Federal Domestic Assistance Number.:

CFDA Title: Enter the Catalog of Federal Domestic Assistance Title.:

Descriptive Title of Applicant Project: Enter a descriptive title of the project. This field is required.:

Areas Affected by Funding: Enter areas or entities affected using categories specified in the agency instructions.:

Applicant: Enter the Congressional District in the format: 2 character State Abbreviation - 3 character District

Number. Examples: CA-005 for California's 5th district, CA-012 for California's 12th district.

If outside the US, enter 00-000.

This field is required.:

Project: Enter the Congressional District in the format: 2 character State Abbreviation - 3 character District Number. Examples: CA-005 for California's 5th district, CA-012 for California's 12th district.

If all districts in a state are affected, enter "all" for the district number. Example: MD-all for all congressional districts in Maryland.

If nationwide (all districts in all states), enter US-all.

If the program/project is outside the US, enter 00-000.:

Start Date: Enter the start date of the funding period for this submission. Enter in the format mm/dd/yyyy. This field is required.:

End Date: Enter the end date of the funding period for this submission. Enter in the format mm/dd/yyyy. This field is required.:

Federal: Enter the dollar amount. This field is required.:

Match: Enter the dollar amount.:

State Review Date: Enter the date the submission was provided to the State for review. Enter in the format mm/dd/yyyy.:

State Review Available: Select if this submission was made available to the State Executive Order 12372 process for review.:

State Review not selected: Select if the program is subject to E.O. 12372 but has not been selected by State for review.:

State Review not needed: Select if the program is not covered by E.O. 12372.:

Additional Congressional Districts - View Attachment Button: Select to view attachment.:

Additional Congressional Districts - Delete Attachment Button: Select to delete attachment.:

Additional Congressional Districts - Add Attachment Button: Select to add attachment.:

Additional Congressional Districts: Attach a file using the appropriate buttons.:

FileName:

MimeType:

href:

hashAlgorithm:

HashValue_data:

Attachment Check Box: Indicates whether an Attachment is attached:

Is The Applicant Delinquent On Any Federal Debt: This question applies to the applicant organization, not the person who signs as the authorized representative. This field is required.

Yes: Select if the applicant is delinquent on any Federal debt.:

Is The Applicant Delinquent On Any Federal Debt: This question applies to the applicant organization, not the person who signs as the authorized representative. This field is required.

No: Select if the applicant is not delinquent on any Federal debt.:

I Agree is required: Check to select.:

I Agree: Check to select. This field is required.:

Prefix: Select the Prefix from the provided list or enter a new Prefix not provided on the list.:

First Name: Enter the First Name. This field is required.:

Middle Name: Enter the Middle Name.:

Last Name: Enter the Last Name. This field is required.:

Suffix: Select the Suffix from the provided list or enter a new Suffix not provided on the list.:

Title: Enter the position title. This field is required.:

Organizational Affiliation: Enter the Organizational Affiliation of the person to contact on matters related to this application.:

Telephone Number: Enter the daytime Telephone Number. This field is required.:

Fax Number: Enter the Fax Number.:

Email: Enter a valid Email Address. This field is required.:

Authorized Signature: Signature of Authorized Representative. This field is required.:

Signature Date: Enter the Date Signed. Enter in the format mm/dd/yyyy. This field is required.:

View Attachment Button: Select to view attachment(s).:

Delete Attachment Button: Select to delete attachment(s).:

Add Attachment Button: Select to add attachment(s).:

ObjList:

FNList:

AttCount:

Add:

Delete:

View:

Done:

goNext:

TextField2:

TextField3:

Consolidated Request Explanation: If this is a Consolidated Application/Plan/Funding Request, please identify the programs covered by the consolidated submission as required in agency instructions. :

Delinquent Federal Debt Explanation: Provide an explanation of Delinquent Federal Debt in the text box.:

LastField:

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