Application for Federal Assistance

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APPLICATION FOR FEDERAL ASSISTANCE 1. TYPE OF SUBMISSION: Application Construction Non-Construction 5. APPLICANT INFORMATION Legal Name: Pre-application Construction Non-Construction Version 7/03 2. DATE SUBMITTED 3. DATE RECEIVED BY STATE 4. DATE RECEIVED BY FEDERAL AGENCY Applicant Identifier State Application Identifier Federal Identifier Organizational Unit: Department: Division: Name and telephone number of person to be contacted on matters involving this application (give area code) Pref
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  APPLICATION FOR Version 7/03 FEDERAL ASSISTANCE 2. DATE SUBMITTED Applicant Identifier 1. TYPE OF SUBMISSION: Application Pre-application 3. DATE RECEIVED BY STATE State Application Identifier  Construction      Construction  Non-Construction    Non-Construction4. DATE RECEIVED BY FEDERAL AGENCY Federal Identifier 5. APPLICANT INFORMATION   Organizational Unit :Legal Name:Department:Organizational DUNS: Division: Address :Street:  Name and telephone number of person to be contacted on mattersinvolving this application (give area code ) Prefix: First Name:  City: Middle NameCounty: Last NameState: Zip Code Suffix:Country: Email: 6. EMPLOYER IDENTIFICATION NUMBER (EIN):    -          Phone Number (give area code) Fax Number ( give area code)   8. TYPE OF APPLICATION:      New    Continuation  Revision7. TYPE OF APPLICANT: ( See back of form for Application Types)   If Revision, enter appropriate letter(s) in box(es)(See back of form for description of letters.)     Other (specify)Other (specify)   9. NAME OF FEDERAL AGENCY:   10.   CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:     -    TITLE (Name of Program):   12. AREAS AFFECTED BY PROJECT   (Cities, Counties, States, etc.):    11. DESCRIPTIVE TITLE OF APPLICANT’S PROJECT:   13. PROPOSED PROJECT   14. CONGRESSIONAL DISTRICTS OF:  Start Date:   Ending Date:   a. Applicant   b. Project  15. ESTIMATED FUNDING:   16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVEORDER 12372 PROCESS? a. Federal $ . 00 b. Applicant $ . 00 a. Yes.   THIS PREAPPLICATION/APPLICATION WAS MADEAVAILABLE TO THE STATE EXECUTIVE ORDER 12372PROCESS FOR REVIEW ONc. State   $   . 00 DATE:d. Local $   . 00 b. No.   PROGRAM IS NOT COVERED BY E. O. 12372e. Other $   . 00      OR PROGRAM HAS NOT BEEN SELECTED BY STATEFOR REVIEWf. Program Income $ . 00 17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?  g. TOTAL $ . 00    Yes If “Yes” attach an explanation.    No 18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT. THEDOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THEATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED. a. Authorized RepresentativePrefix First Name Middle NameLast Name Suffixb. Title   c. Telephone Number (give area code)  d. Signature of Authorized Representative e. Date SignedPrevious Edition UsableAuthorizedforLocalReroductionStandard Form 424 (Rev.9-2003)Prescribed by OMB Circular A-102   Reset Form  INSTRUCTIONS FOR THE SF-424 Public reporting burden for this collection of information is estimated to average 45 minutes per response, including time for reviewinginstructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection ofinformation. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions forreducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0043), Washington, DC 20503. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THEADDRESS PROVIDED BY THE SPONSORING AGENCY. This is a standard form used by applicants as a required face sheet for pre-applications and applications submitted for Federalassistance. It will be used by Federal agencies to obtain applicant certification that States which have established a review and commentprocedure in response to Executive Order 12372 and have selected the program to be included in their process, have been given anopportunity to review the applicant’s submission. Item: Entry: Item: Entry:1. Select Type of Submission. 11. Enter a brief descriptive title of the project. If more than oneprogram is involved, you should append an explanation on aseparate sheet. If appropriate (e.g., construction or realproperty projects), attach a map showing project location. Forpreapplications, use a separate sheet to provide a summarydescription of this project.2. Date application submitted to Federal agency (or State if applicable)and applicant’s control number (if applicable).12. List only the largest political entities affected (e.g., State,counties, cities).3. State use only (if applicable). 13 Enter the proposed start date and end date of the project.4. Enter Date Received by Federal AgencyFederal identifier number: If this application is a continuation orrevision to an existing award, enter the present Federal Identifiernumber. If for a new project, leave blank.14. List the applicant’s Congressional District and any District(s)affected by the program or project5. Enter legal name of applicant, name of primary organizational unit(including division, if applicable), which will undertake theassistance activity, enter the organization’s DUNS number(received from Dun and Bradstreet), enter the complete address ofthe applicant (including country), and name, telephone number, e-mail and fax of the person to contact on matters related to thisapplication.15 Amount requested or to be contributed during the firstfunding/budget period by each contributor. Value of in kindcontributions should be included on appropriate lines asapplicable. If the action will result in a dollar change to anexisting award, indicate only the amount of the change. Fordecreases, enclose the amounts in parentheses. If both basicand supplemental amounts are included, show breakdown onan attached sheet. For multiple program funding, use totalsand show breakdown using same categories as item 15.6. Enter Employer Identification Number (EIN) as assigned by theInternal Revenue Service.16. Applicants should contact the State Single Point of Contact(SPOC) for Federal Executive Order 12372 to determinewhether the application is subject to the Stateintergovernmental review process.7. Select the appropriate letter inthe space provided.A. StateB. CountyC. MunicipalD. TownshipE. InterstateF. IntermunicipalG. Special DistrictH. Independent SchoolDistrictI. State ControlledInstitution of HigherLearningJ. Private UniversityK. Indian TribeL. IndividualM. Profit OrganizationN. Other (Specify)O. Not for ProfitOrganization17. This question applies to the applicant organization, not theperson who signs as the authorized representative. Categoriesof debt include delinquent audit disallowances, loans andtaxes.8. Select the type from the following list: ã New means a new assistance award. ã “Continuation” means an extension for an additionalfunding/budget period for a project with a projected completiondate. ã “Revision” means any change in the Federal Government’sfinancial obligation or contingent liability from an existingobligation. If a revision enter the appropriate letter:A. Increase Award B. Decrease AwardC. Increase Duration D. Decrease Duration18 To be signed by the authorized representative of the applicant.A copy of the governing body’s authorization for you to signthis application as official representative must be on file in theapplicant’s office. (Certain Federal agencies may require thatthis authorization be submitted as part of the application.)9. Name of Federal agency from which assistance is being requestedwith this application.10. Use the Catalog of Federal Domestic Assistance number and title ofthe program under which assistance is requested.SF-424 (Rev. 7-97) Back
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