Attachement #2 - SF424-I Individual + Instr..pdf

* 3. DATE RECEIVED:

5. APPLICANT INFORMATION

* 1. NAME OF FEDERAL AGENCY:

2. ASSISTANCE LISTING NUMBER:

* 4. FUNDING OPPORTUNITY NUMBER:

* TITLE:

ASSISTANCE LISTING TITLE:

Prefix: * First Name: Middle Name:

* Last Name: Suffix:

* Telephone Number (Daytime):

Fax Number:* Email:

* Street1: Street2:

* City: County/Parish:

* State: Province:

* Zip/Postal Code:* Country:

b. Address

Telephone Number (Evening):

APPLICATION FOR FEDERAL ASSISTANCE SF 424 - INDIVIDUAL

OMB Number 4040-0005 Expiration Date: 02/28/2026

a. Name and Contact Information

USA: UNITED STATES

* c. Citizenship Status:

U.S. Citizenship

If No

6. PROJECT INFORMATION

If permanent resident of U.S., enter the Alien Registration #:

* If foreign national, enter country of citizenship:

* If foreign national, enter start date of most recent residency in U.S.:

d. * Congressional District of Applicant:

* a. Project Title:

* b. Project Description:

APPLICATION FOR FEDERAL ASSISTANCE SF 424 - INDIVIDUAL

Yes No

* c. Proposed Project:

7. * 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.

* Date Signed:

Start Date: End Date:

* Signature:

** I AGREE

OMB Number: 4040-0005 1 OMB Expiration Date: 02/28/2026

Grants.gov Form Instructions Form Identifiers Information

Agency Owner Grants.gov

Form Name Application for Federal Assistance SF-424 – Individual V2.0 OMB Number 4040-0005

OMB Expiration Date 02/28/2026

Form Field Instructions Field Number

Field Name Required or Optional

Information

1. NAME OF FEDERAL

AGENCY

Required Pre-populated from the Application cover sheet

2. ASSISTANCE

LISTING NUMBER

Pre-populated from the Application cover sheet

ASSISTANCE

LISTING TITLE

Pre-populated from the Application cover sheet

3. DATE RECEIVED Completed by Grants.gov upon submission

4. FUNDING

OPPORTUNITY

NUMBER:

Pre-populated from the Application cover sheet

TITLE: Pre-populated from the Application cover sheet

5. APPLICANT

INFORMATION

Name and Contact Information

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

First Name: Required Enter the First Name.

Middle Name: Enter the Middle Name.

Last Name: Required Enter the Last Name.

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

Fax Number: Enter the Fax Number.

Email: Enter a valid Email Address.

Telephone Number

(Daytime):

Required Enter the Daytime Telephone Number.

Telephone Number (Evening):

Enter the Evening Telephone Number.

Address

OMB Number: 4040-0005 2

Field Number

Field Name Required or Optional

Information

Street 1: Required Enter the first line of the Street Address.

Street 2: Enter the second line of the Street Address.

City: Required Enter the City.

County/Parish: Enter the County or 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: Required Select the Country from the provided list.

Zip / Postal Code Enter the nine-digit Postal Code (e.g., ZIP

Code). This field is required if Country is the United States.

Citizenship Status

U.S. Citizenship?

Yes/No

Required Select Yes if applicant is a citizen of the United States. Select No if applicant is a permanent resident and enter the Alien Registration #. Select No if applicant is a foreign national and enter the country of citizenship and start date of most recent residency in the United States.

If No If permanent resident of U.S., enter the Alien Registration #

Enter the Alien Registration Number.

If foreign national, enter country of citizenship:

Select the Country from the provided list.

This field is required if the applicant is not a U.S. Citizen.

If foreign national, enter start date of most recent residency in U.S.:

Required Enter the start date of the most recent residency in the U.S. Enter in the format MM/DD/YYYY. This field is required if the applicant is not a U.S. Citizen.

Congressional District of Applicant:

Required 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, NC-103 for North Carolina’s 103rd district. If outside the US, enter 00-000.

6. Project Information

OMB Number: 4040-0005 3

Field Number

Field Name Required or Optional

Information

Project Title Enter a brief, descriptive title of the project.

Project Description Required Enter a brief description of the project.

Proposed Project Required Start Date: Enter the start date for the proposed project. Enter in the format MM/DD/YYYY. End Date: Enter the end date for the proposed project. Enter in the format MM/DD/YYYY.

7. * 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) ** I

AGREE

Required Check to select.

OMB Number: 4040-0005 4

Field Number

Field Name Required or Optional

Information

** 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

Signature Required Completed by Grants.gov upon submission

Date Signed Required Completed by Grants.gov upon submission