Attachment 1_RR_SF424_5_0-V5.0.pdf

State Application Identifier

Applicant Identifier

1. TYPE OF SUBMISSION 4. a. Federal Identifier

5. APPLICANT INFORMATION UEI:

Legal Name:

Department:

Division:

Street1:

Street2:

City:

State:

ZIP / Postal Code:Country:

Person to be contacted on matters involving this application

First Name: Middle Name:

Last Name: Suffix:

Phone Number: Fax Number:

Email:

6. EMPLOYER IDENTIFICATION (EIN) or (TIN):

7. TYPE OF APPLICANT:

Other (Specify):

Women Owned Socially and Economically DisadvantagedSmall Business Organization Type

If Revision, mark appropriate box(es).

9. NAME OF FEDERAL AGENCY:

A. Increase Award B. Decrease Award C. Increase Duration D. Decrease Duration

E. Other (specify):

10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:

Is this application being submitted to other agencies?

TITLE:

11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:

2. DATE SUBMITTED

3. DATE RECEIVED BY STATEAPPLICATION FOR FEDERAL ASSISTANCE

SF 424 (R&R)

County / Parish:

Province:

Prefix:

What other Agencies?

Pre-application Application Changed/Corrected Application

USA: UNITED STATES

USA: UNITED STATES

Please select one of the following

New Resubmission

Renewal Continuation Revision

Yes No

8. TYPE OF APPLICATION:

OMB Number: 4040-0001 Expiration Date: 11/30/2025

b. Agency Routing Identifier

12. PROPOSED PROJECT:

Start Date Ending Date

13. CONGRESSIONAL DISTRICT OF APPLICANT

c. Previous Grants.gov Tracking ID

Country:

Position/Title:

Province:

County / Parish:

State:

City:

Street2:

Street1:

ZIP / Postal Code:

APPLICATION FOR FEDERAL ASSISTANCESF 424 (R&R) Page 2

15. ESTIMATED PROJECT FUNDING

a. Total Federal Funds Requested

17. 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)

19. Authorized Representative

First Name: Middle Name:

Last Name: Suffix:

Position/Title:

Organization:

Department:

Division:

Street1:

Street2:

City:

State:

ZIP / Postal Code:Country:

Phone Number: Fax Number:

Email:

Signature of Authorized Representative Date Signed

20. Pre-application

*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.

County / Parish:

c. Total Federal & Non-Federal Funds

18. SFLLL (Disclosure of Lobbying Activities) or other Explanatory Documentation

Province:

b. Total Non-Federal Funds

Prefix:

First Name: Middle Name:

Last Name: Suffix:

Position/Title:

Organization Name:

Department:

Division:

Street1:

Street2:

City:

ZIP / Postal Code:Country:

Phone Number: Fax Number:

Email:

State:

County / Parish:

Province:

Prefix:

USA: UNITED STATES

a. YES

b. NO

16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER

12372 PROCESS?

I agree

USA: UNITED STATES

View AttachmentDelete AttachmentAdd Attachment

Add Attachment Delete Attachment View Attachment

DATE:

THIS PREAPPLICATION/APPLICATION WAS MADE

AVAILABLE TO THE STATE EXECUTIVE ORDER 12372

PROCESS FOR REVIEW ON:

PROGRAM HAS NOT BEEN SELECTED BY STATE FOR

REVIEW

PROGRAM IS NOT COVERED BY E.O. 12372; OR

Completed on submission to Grants.gov Completed on submission to Grants.gov

d. Estimated Program Income

View AttachmentDelete AttachmentAdd Attachment21. Cover Letter Attachment

14. PROJECT DIRECTOR/PRINCIPAL INVESTIGATOR CONTACT INFORMATION