Omb number: 4040-0004 Expiration Date: 03/31/2012

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OMB Number: 4040-0004

Expiration Date: 03/31/2012

Application for Federal Assistance SF-424

*1. Type of Submission:



 Changed/Corrected Application

*2. Type of Application:




* If Revision, select appropriate letter(s):


*Other (Specify):


Completed by upon submission
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:      


*a. Legal Name:      

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


*c. Organizational DUNS:


d. Address:

*Street 1:      

Street 2:      






*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:      



Organizational Affiliation:


*Telephone Number:       Fax Number:      


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:




13. Competition Identification Number:




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


*15. Descriptive Title of Applicant’s Project:


Attach supporting documents as specified in agency instructions.

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








*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.)

 Yes  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)


** 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:      



*Telephone Number:      

Fax Number:      

* Email:      

Completed by upon submission

Signature of Authorized Representative:

Completed by upon submission

Date Signed:

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