Attachement #1 - SF424 Institutions + Instr..pdf

OMB Number: 4040-0004 Expiration Date: 11/30/2025

* 1. Type of Submission: * 2. Type of Application:

* 3. Date Received: 4. Applicant Identifier:

5a. Federal Entity Identifier: 5b. Federal Award Identifier:

6. Date Received by State: 7. State Application Identifier:

* a. Legal Name:

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

* Street1:

Street2:

* City:

County/Parish:

* State:

Province:

* Country:

* Zip / Postal Code:

Department Name: Division Name:

Prefix: * First Name:

Middle Name:

* Last Name:

Suffix:

Title:

Organizational Affiliation:

* Telephone Number: Fax Number:

* Email:

* If Revision, select appropriate letter(s):

* Other (Specify):

State Use Only:

8. APPLICANT INFORMATION:

d. Address:

e. Organizational Unit:

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

Application for Federal Assistance SF-424

Preapplication

Application

Changed/Corrected Application

New

Continuation

Revision

USA: UNITED STATES

* 9. Type of Applicant 1: Select Applicant Type:

Type of Applicant 2: Select Applicant Type:

Type of Applicant 3: Select Applicant Type:

* Other (specify):

* 10. Name of Federal Agency:

11. Assistance Listing Number:

Assistance Listing Title:

* 12. Funding Opportunity Number:

* Title:

13. Competition Identification Number:

Title:

14. Areas Affected by Project (Cities, Counties, States, etc.):

* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.

Application for Federal Assistance SF-424

Form Attachments:

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Done

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* a. Federal

* b. Applicant

* c. State

* d. Local

* e. Other

* f. Program Income

* g. TOTAL

Prefix: * First Name:

Middle Name:

* Last Name:

Suffix:

* Title:

* Telephone Number:

* Email:

Fax Number:

* Signature of Authorized Representative: * Date Signed:

18. Estimated Funding ($):

21. *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 18, Section 1001)

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

Authorized Representative:

Application for Federal Assistance SF-424

* a. Applicant

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

* b. Program/Project

* a. Start Date: * b. End Date:

16. Congressional Districts Of:

17. Proposed Project:

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a. This application 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 the State for review.

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

Yes No

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** I AGREE

* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.)

* 19. Is Application Subject to Review By State Under Executive Order 12372 Process?

If "Yes", provide explanation and attach

OMB Number: 4040-0004 1 OMB Expiration Date: 11/30/2025

Grants.gov Form Instructions Form Identifiers Information

Agency Owner Grants.gov

Form Name Application for Federal Assistance (SF-424) V4.0 OMB Number 4040-0004

OMB Expiration Date 11/30/2025

Form Field Instructions Field Number

Field Name Required or Optional

Information

1. Type of Submission: Required Select one type of submission in accordance with agency instructions.

• Pre-application

• Application

• Changed/Corrected Application -

Check if this submission is to change or correct a previously submitted application. Unless requested by the agency, applicants may not use this form to submit changes after the closing date.

OMB Number: 4040-0004 2

Field Number

Field Name Required or Optional

Information

2. Type of Application Required Select one type of application in accordance with agency instructions.

• New - An application that is being submitted to an agency for the first time.

• Continuation - An extension for an additional funding/budget period for a project with a projected completion date. This can include renewals.

• Revision - Any change in the federal government's financial obligation or contingent liability from an existing obligation. If a revision, enter the appropriate letter(s). More than one may be selected.

A: Increase Award B: Decrease Award C: Increase Duration D: Decrease Duration E: Other (specify) AC: Increase Award, Increase Duration AD: Increase Award, Decrease Duration BC: Decrease Award, Increase Duration BD: Decrease Award, Decrease Duration

3. Date Received: Required Enter date if form is submitted through other means as instructed by the Federal agency.

The date received is completed electronically if submitted via Grants.gov.

4. Applicant Identifier: Enter the entity identifier assigned by the Federal agency, if any, or the applicant’s control number if applicable.

5a. Federal Entity Identifier:

Enter the number assigned to your organization by the federal agency, if any.

OMB Number: 4040-0004 3

Field Number

Field Name Required or Optional

Information

5b. Federal Award Identifier:

For new applications, leave blank. For a continuation or revision to an existing award, enter the previously assigned federal award identifier number. If a changed/corrected application, enter the federal identifier in accordance with agency instructions.

6. Date Received by State: Leave this field blank. This date will be assigned by the state, if applicable

7. State Application Identifier:

Leave this field blank. This identifier will be assigned by the state, if applicable.

8. Applicant Information: Enter the following in accordance with agency instructions.

a. Legal Name: Required Enter the legal name of the applicant that will undertake the assistance activity. This is the organization that has registered with the System for Award Management (SAM).

Information on registering with SAM may be obtained by visiting SAM.gov.

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

Required Enter the employer or taxpayer identification number (EIN or TIN) as assigned by the Internal Revenue Service. If your organization is not in the US, enter 44-4444444.

c. UEI: Required Enter the organization’s UEI received from SAM. The UEI is a unique 12 character organization identifier. Information on registering with System for Award Management (SAM.gov) may be obtained by visiting the Grants.gov website.

d. Address: Required Enter address: Street 1 (required); City (required); County/Parish, State (required if country is US); Province; Country (required);

9-digit ZIP/Postal Code (required if country is US). If +4 does not exist for the address, enter “0000”.

e. Organizational Unit Enter the name of the primary organizational unit, department, or division that will undertake the assistance activity.

OMB Number: 4040-0004 4

Field Number

Field Name Required or Optional

Information

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

Required Enter the first and last name (required);

prefix, middle name, suffix, and title. Enter organizational affiliation if affiliated with an organization other than that in 7.a. Telephone number and email (required); fax number.

OMB Number: 4040-0004 5

Field Number

Field Name Required or Optional

Information

9. Type of Applicant:

Select Applicant Type

Required Select a minimum of one applicant type or select up to three applicant types in accordance with agency instructions. If “Other” is selected, then specify Other Type of Applicant in text box.

A: State Government B: County Government C: City or Township Government D: Special District Government E: Regional Organization F: U.S. Territory or Possession G: Independent School District H: Public/State Controlled Institution of Higher Education I: Indian/Native American Tribal Government (Federally Recognized) J: Indian/Native American Tribal Government (Other than Federally Recognized) K: Indian/Native American Tribally Designated Organization L: Public/Indian Housing Authority M: Nonprofit with 501C3 IRS Status (Other than Institution of Higher Education) N: Nonprofit without 501C3 IRS Status (Other than Institution of Higher Education) O: Private Institution of Higher Education P: Individual Q: For-Profit Organization (Other than Small Business) R: Small Business S: Hispanic-serving Institution T: Historically Black Colleges and Universities (HBCUs) U: Tribally Controlled Colleges and Universities (TCCUs) V: Alaska Native and Native Hawaiian Serving Institutions W: Non-domestic (non-US) Entity X: Other (specify)

10. Name of Federal Agency:

Required Enter the name of the federal agency from which assistance is being requested with this application. This information is pre-populated if submitting through Grants.gov.

OMB Number: 4040-0004 6

Field Number

Field Name Required or Optional

Information

11. Assistance Listing Number/Title

Required Enter the Assistance Listing number and title of the program under which assistance is requested, as found in the program announcement, if applicable. This information is pre-populated if using Grants.gov.

12. Funding Opportunity Number/Title

Required Enter the Funding Opportunity Number and title of the opportunity under which assistance is requested as found in the program announcement. This information is pre-populated if using Grants.gov.

13. Competition Identification Number/Title:

Enter the competition identification number and title of the competition under which assistance is requested, if applicable. These fields are pre-populated by Grants.gov if provided by the federal agency.

14. Areas Affected By Project:

This data element is intended for use only by programs for which the area(s) affected are likely to be different from the place(s) of performance reported on the SF-424 Project/Performance Site Location(s) Form.

Add attachment to enter additional areas, if needed.

15. Descriptive Title of Applicant’s Project:

Required Enter a brief descriptive title of the project.

Supporting documents may be attached if specified in agency instructions.

OMB Number: 4040-0004 7

Field Number

Field Name Required or Optional

Information

16. Congressional Districts Required 16a. Enter the applicant’s congressional district. 16b. Enter the primary district affected by the program or project. Enter in the following format: 2 character state abbreviation – 3 characters district number, e.g., CA-005 for California 5th district, CA-012 for California 12th district, NC-103 for North Carolina’s 103rd district. If all congressional districts in a state are affected, enter “all” for the district number, e.g., MD-all for all congressional districts in Maryland. If nationwide, i.e., all districts within all states are affected, enter US-all. If the program/project is outside the US, enter

00.000. This optional data element is

intended for use only by programs for which the area(s) affected are likely to be different than place(s) of performance reported on the SF-424 Project/Performance Site Location(s) form. Attach an additional list of program/project congressional districts, if needed.

17. Proposed Project Start and End Dates:

Required Enter the proposed start date and end date of the project.

18. Estimated Funding: Required Enter the amount requested, or to be contributed during the first funding/budget period by each contributor. Value of in-kind contributions should be included on appropriate lines, as applicable.

19. Is Application Subject to Review by State Under Executive Order

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. Select the appropriate box. If “A.” is selected, enter the date the application was submitted to the State.

OMB Number: 4040-0004 8

Field Number

Field Name Required or Optional

Information

20. Is the Applicant Delinquent on any Federal Debt?

Required Select the appropriate box. This question applies to the applicant organization, not the person who signs as the authorized representative. Categories of federal debt include; but may not be limited to: delinquent audit disallowances, loans, and taxes. If yes, include an explanation in an attachment.

21. Authorized Representative:

Required To be signed and dated by the authorized representative of the applicant organization.

Enter the first and last name (required);

prefix, middle name, and suffix. Enter title, telephone number, fax number, and email.

Fax number is not required. A copy of the governing body’s authorization for you to sign this application as the official representative must be on file in the applicant’s office.

(Certain federal agencies may require that this authorization be submitted as part of the application.) If the application is submitted via Grants.gov, the signature of the authorized representative and the date signed are completed upon submission.