Attachment A - SF 424 - Application for Federal Assistance.pdf
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- Opportunity number
- W912EF-26-2-A001
About this file
This is the SF-424, Application for Federal Assistance form (OMB Number 4040-0004), a standard federal template with an expiration date of December 31, 2022. The form serves as the primary application document for organizations seeking federal grants and funding opportunities across all federal agencies.
The form collects comprehensive applicant information including legal name, Employer Identification Number (EIN), organizational DUNS number, complete address, and contact details for the primary point of contact. It requires specification of the applicant type (such as state government, local government, nonprofit, higher education, or business), identification of the federal agency and funding opportunity, and the Catalog of Federal Domestic Assistance (CFDA) number. Applicants must provide the funding opportunity number, competition identification number, and a descriptive project title, along with identification of geographic areas affected by the proposed project. The form requires proposed project start and end dates, detailed estimated funding amounts broken down by source (federal, applicant, state, local, other, and program income), and congressional district information for both the applicant and program/project. The form includes a certification section requiring the authorized representative's signature, acknowledgment of compliance with federal certifications and assurances, and confirmation that all statements are true and complete. The form also addresses whether the application is subject to Executive Order 12372 review and requires disclosure of any federal debt delinquency. Supporting documentation must be attached as specified in individual agency instructions.
Attachment A - SF 424 - Application for Federal Assistance
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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.
Add Attachments Delete Attachments View Attachments
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:
| Add Attachment Delete Attachment View Attachment |
| a. This application was made available to the State under the Executive Order 12372 Process for review on . |
| Yes No |
| ** I AGREE |
| Preapplication: Off |
| Application: Off |
| ChangedCorrected Application: Off |
| New: Off |
| Continuation: Off |
| Revision: Off |
| If Revision select appropriate letters: |
| Other Specify: |
| 3 Date Received: |
| 4 Applicant Identifier: |
| 5a Federal Entity Identifier: |
| 5b Federal Award Identifier: |
| 6 Date Received by State: |
| undefined: |
| a Legal Name: |
| b EmployerTaxpayer Identification Number EINTIN: |
| undefined_2: |
| undefined_3: |
| undefined_4: |
| undefined_5: |
| CountyParish: |
| undefined_6: |
| undefined_7: |
| Zip Postal Code: |
| Department Name: |
| Division Name: |
| Prefix Middle Name Last Name Suffix: |
| First Name: |
| Prefix Middle Name Last Name Suffix_2: |
| Title: |
| Organizational Affiliation: |
| Telephone Number: |
| Fax Number: |
| 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_2: |
| 13 Competition Identification Number: |
| Title_3: |
| 14 Areas Affected by Project Cities Counties States etc: |
| 15 Descriptive Title of Applicants Project: |
| Attach supporting documents as specified in agency instructions Add Attachments Delete Attachments View Attachments: |
| Attach an additional list of ProgramProject Congressional Districts if needed: |
| a Federal b Applicant c State d Local e Other f Program Income g TOTAL: |
| b Applicant: |
| undefined_8: |
| undefined_9: |
| f Program Income: |
| a This application was made available to the State under the Executive Order 12372 Process for review on: Off |
| b Program is subject to EO 12372 but has not been selected by the State for review: Off |
| c Program is not covered by EO 12372: Off |
| undefined_10: |
| 20 Is the Applicant Delinquent On Any Federal Debt If Yes provide explanation in attachment: Off |
| If Yes provide explanation and attach: |
| I AGREE: |
| undefined_11: |
| First Name_2: |
| Middle Name: |
| undefined_12: |
| Title_4: |
| Telephone Number_2: |
| Fax Number_2: |
| CD_1: |
| CD_2: |
| Start Date: |
| End Date: |
| Federal: |
| Applicant: |
| State: |
| Local: |
| Other: |
| Date Signed: |
| Name: |
| Last Name: |
| Email: |
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