Attachment A - SF 424 - Application for Federal Assistance.pdf

OMB Number: 4040-0004 View Burden Statement Expiration Date: 12/31/2022

Application for Federal Assistance SF-424

* 1. Type of Submission: * 2. Type of Application: * If Revision, select appropriate letter(s):

Preapplication

Application

Changed/Corrected Application

New

Continuation * Other (Specify):

Revision

* 3. Date Received: 4. Applicant Identifier:

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

State Use Only:

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

8. APPLICANT INFORMATION:

* a. Legal Name:

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

d. Address:

* Street1:

Street2:

* City:

County/Parish:

* State:

Province:

* Country: USA: UNITED STATES

* Zip / Postal Code:

e. Organizational Unit:

Department Name: Division Name:

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

Prefix:

Middle Name:

* Last Name:

Suffix:

* First Name:

Title:

Organizational Affiliation:

* Telephone Number: Fax Number:

* Email:

Application for Federal Assistance SF-424

* 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. Catalog of Federal Domestic Assistance Number:

CFDA Title:

* 12. Funding Opportunity Number:

* Title:

13. Competition Identification Number:

Title:

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

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* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.

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Application for Federal Assistance SF-424

16. Congressional Districts Of:

* a. Applicant

* b. Program/Project

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

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17. Proposed Project:

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

18. Estimated Funding ($):

* a. Federal

* b. Applicant

* c. State

* d. Local

* e. Other

* f. Program Income

* g. TOTAL

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

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.

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

Yes No

If "Yes", provide explanation and attach

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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 218, Section 1001)

** I AGREE

** 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:

Prefix:

Middle Name:

* Last Name:

Suffix:

* Title:

* Telephone Number:

* Email:

* First Name:

Fax Number:

* Signature of Authorized Representative: * Date Signed: