sf424 application for federal assistance.pdf

OMB Number: 4040-0004 Expiration Date: 01/31/2009

Application for Federal Assistance SF-424 Version 02

*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:

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:

Application for Federal Assistance SF-424 Version 02

*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:

Application for Federal Assistance SF-424 Version 02

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?

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.)

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:

*Telephone Number: Fax Number:

* Email:

*Signature of Authorized Representative: *Date Signed:

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

Application for Federal Assistance SF-424 Version 02

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