sf 424 cover page june 2009.doc

OMB Number: 4040-0004 Expiration Date: 01/31/2009 Application for Federal Assistance SF-424

Version 02

*1. Type of Submission:

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Preapplication

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Application

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Changed/Corrected Application *2. Type of Application

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New

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Continuation

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Revision

* If Revision, select appropriate letter(s)

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*Other (Specify)

3. Date Received

4. Applicant Identifier:

5a. Federal Entity Identifier:

*5b. Federal Award Identifier:

State Use Only:

8. APPLICANT INFORMATION:

*a. Legal Name:

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

*c. Organizational DUNS:

d. Address:

*Street 1:

Street 2:

*City:

County:

*State:

Province:

*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:

OMB Number: 4040-0004

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.):

*15. Descriptive Title of Applicant’s Project:

OMB Number: 4040-0004

Application for Federal Assistance SF-424

16. Congressional Districts Of:

*a. Applicant:

*b. Program/Project:

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?

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a. This application was made available to the State under the Executive Order 12372 Process for review on

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b. Program is subject to E.O. 12372 but has not been selected by the State for review.

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c. Program is not covered by E. O. 12372

*20. Is the Applicant Delinquent On Any Federal Debt? (If “Yes”, provide explanation.)

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Yes

No

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:

*First Name:

Middle Name:

*Last Name:

Suffix:

*Title:

* Email:

Authorized for Local Reproduction Standard Form 424 (Revised 10/2005) Prescribed by OMB Circular A-102

OMB Number: 4040-0004

Application for Federal Assistance SF-424

*Applicant Federal Debt Delinquency Explanation

The following should contain an explanation if the Applicant organization is delinquent of any Federal Debt.