SF424_Application_Form_Organizations.pdf

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:

Application

Plan

Funding Request

Other

Annual

Quarterly

Other

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

Yes No

Initial Resubmission Revision Update

Completed by Grants.gov upon submission.

Explanation

USA: UNITED STATES

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?

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:

a. This submission was made available to the State under the Executive Order 12372 Process for review on:

b. Program is subject to E.O. 12372 but has not been selected by State for review.

c. Program is not covered by E.O. 12372.

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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.

Yes No Explanation

** I Agree

Completed by Grants.gov upon submission.

Completed by Grants.gov upon submission.

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Consolidated Application/Plan/Funding Request Explanation:

Applicant Federal Debt Delinquency Explanation: