Ex2_Application Form_FY24FOA_v4.pdf

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

Section A: Application for Federal Assistance SF-424

*1. Type of Submission:

Preapplication

Application

Changed/Corrected Application

*2. Type of Application:

New

Continuation

Revision

* If Revision, select appropriate letter(s):

*Other (Specify):

* 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:

*Street 1:

Street 2:

*City:

*State:

*Country:

*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: *First Name:

Middle Name:

*Last Name:

Suffix:

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:

Denali Commission

11. Catalog of Federal Domestic Assistance Number:

90.100

CFDA Title:

Denali Commission Program Grants

*12 Funding Opportunity Number:

DC-WP-24-001

*Title:

Denali Commission Program Grants

13. Competition Identification Number:

NOT APPLICABLE

Title:

NOT APPLICABLE

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

15. Descriptive Title of Applicant’s Project:

Y

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.

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.)

es No

If “Yes”, provide explanation and attach.

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:

*First Name: Middle Name: *Last Name:

Suffix:

*Title:

*Telephone Number: Fax Number:

* Email:

*Signature of Authorized Representative: *Date Signed:

Section B: Project Information

Project Executive Summary: Provide an overview of your proposed infrastructure project

Program Area Classification - select the program area that best fits your project:

Economic Development Workforce Development Other

Transportation Surface Transportation Waterfront Energy Healthcare/Community Wellness

Village Infrastructure Protection Sanitation / Water

Housing Broadband

The Community served by the proposed project is considered by the 2023 Distressed Communities Report:

( ) Distressed ( ) Not Distressed The Community served by the proposed project is considered Disadvantaged:

( ) Disadvantaged ( ) Not Disadvantaged

In the 2019 Statewide Threat Assessment, the community served by the proposed project is considered (check all boxes that apply):

Threatened Group 2 Threatened Group 3 Not Threatened

Project Narrative:

Description of Community Served/Place of Performance (population, demographics, culture, background, etc):

Project purpose with problem it intends to solve and intended outcomes:

Threatened Group 1

Are you Applying Under the Infrastructure Fund? Yes No

Project Description/Scope of Work:

(Project background, impact/value, scope, and schedule by task with milestones and deliverables)

Project Description/Scope of Work (continued):

Organization, capacity, and delivery method (describe organization, experience with grants/projects, and who will complete the project):

Partnerships and Leveraged Funds:

Budget and Funding Narrative (explain budget and funding in words), including Financial Contact name, email, and phone number:

________________________ Budget and Funding Summary

Item/Activity Denali Match Total

Personnel & Fringe

Travel

Equipment

Supplies

Contractors

Other

Indirect

TOTAL

Denali TOTAL

Source Reference Amount

Denali Commission This Action

Budget - By Category

Budget - By Task

Funding Source

Item/Activity (Match Tasks listed in Scope)

TOTAL

Notes (Details on how Applicant Determined Estimated Costs)

TOTAL

Notes

Priority of Applications (ONLY if submitting more than one application)

Appendix (10 Pages Maximum) NOTE: If applying for energy and/or transportation specific projects, applicants are allowed an additional two pages to answer program-specific evaluation criteria, explained on Page 6 and 7 of the Funding Opportunity Announcement.

Project: ____________________________

Project: _____________________________

Project: _____________________________