SF424_7.31.2028.pdf

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Application for Federal Domestic Assistance-Short Organizational mhughes D:20061227115055- 05'00' D:20061227115055- 05'00'

* 1. NAME OF FEDERAL AGENCY:

2. ASSISTANCE LISTING NUMBER:

ASSISTANCE LISTING TITLE:

* 3. DATE RECEIVED:

* 4. FUNDING OPPORTUNITY NUMBER:

* TITLE:

5. APPLICANT INFORMATION

b. Address:

* Street1:

Street2:

* City:

County/Parish:

* State:

Province:

* Country:

* Zip/Postal Code:

c. Web Address:

http://

* d. Type of Applicant: Select Applicant Type Code(s):

Type of Applicant:

* Other (specify):

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

* f. UEI:

* g. Congressional District of Applicant:

* a. Project Title:

* b. Project Description:

* Start Date:

* End Date:

Type of Applicant:

6. PROJECT INFORMATION

SYSTEM USE ONLY

APPLICATION FOR FEDERAL DOMESTIC ASSISTANCE - Short Organizational

c. Proposed Project:

OMB Number: 4040-0003 Expiration Date: 07/31/2028

* a. Legal Name:

Same as Project Director (skip to item 9):

8. PRIMARY CONTACT/GRANTS ADMINISTRATOR

Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

* Title:

* Email:

* Telephone Number:

Fax Number:

* Street1:

Street2:

* City:

County/Parish:

* State:

Province:

* Country:

* Zip/Postal Code:

Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

* Title:

* Email:

* Telephone Number:

Fax Number:

* Street1:

Street2:

* City:

County/Parish:

* State:

Province:

* Country:

* Zip/Postal Code:

7. PROJECT DIRECTOR

APPLICATION FOR FEDERAL DOMESTIC ASSISTANCE - Short Organizational ** 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:

* Telephone Number:

Fax Number:

* Signature of Authorized Representative:

* Date Signed:

APPLICATION FOR FEDERAL DOMESTIC ASSISTANCE - Short Organizational ** I Agree

9. * 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)

Service. If your organization is not in the US, enter 44-4444444.

This field is required.:

Congressional District of Applicant: Enter the Congressional District in the format: 2 character State Abbreviation - 3 character District Number. Examples: CA-005 for California's 5th district, CA-012 for California's 12th district, NC-103 for North Carolina's 103rd district. This field is required.

If outside the US, enter 00-000.:

This field is required if Country is the United States.:

Start Date: Enter the start date for the proposed project. Enter in the format MM/DD/YYYY.

This field is required.:

End Date: Enter the end date for the proposed project. Enter in the format MM/DD/YYYY.

This field is required. :

director and skip to item 9. If Primary Contact/Grants Administrator is same as Authorizing Official, please complete both 8 and 9.: N: No

This field is required if Country is the United States.:

This field is required if Country is the United States.: