SF424_Short_3_0-V3.0.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. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:

CFDA 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: 02/28/2025

* 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

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 218, Section 1001) ** 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

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.: