SF-424 (R&R) Application for Federal Assistance

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2. DATE SUBMITTED

Applicant Identifier

3. DATE RECEIVED BY STATE

State Application Identifier

APPLICATION FOR FEDERAL ASSISTANCE

SF 424 (R&R)
1. * TYPE OF SUBMISSION
Pre-application

4. Federal Identifier

Application

Changed/Corrected Application
5. APPLICANT INFORMATION

* Organizational DUNS:

* Legal Name:
Department:

Division:

* Street1:

Street2:

* City:

County:

Province:

* State:

* Country: USA: UN

* ZIP / Postal Code:

Person to be contacted on matters involving this application
Prefix:

* First Name:

Middle Name:

* Phone Number:

* Last Name:

Fax Number:

Suffix:

Email:
7. * TYPE OF APPLICANT:

6. * EMPLOYER IDENTIFICATION (EIN) or (TIN):

Please select one of the following
8. * TYPE OF APPLICATION:
Resubmission

Renewal

Other (Specify):

New
Continuation

Revision

Women Owned

If Revision, mark appropriate box(es).
A. Increase Award
D. Decrease Duration

B. Decrease Award

Small Business Organization Type
Socially and Economically Disadvantaged

9. * NAME OF FEDERAL AGENCY:
C. Increase Duration

E. Other (specify):

10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:

* Is this application being submitted to other agencies? Yes

No
TITLE:

What other Agencies?
11. * DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:

12. * AREAS AFFECTED BY PROJECT (cities, counties, states, etc.)

13. PROPOSED PROJECT:
* Start Date
* Ending Date

14. CONGRESSIONAL DISTRICTS OF:
a. * Applicant
b. * Project

15. PROJECT DIRECTOR/PRINCIPAL INVESTIGATOR CONTACT INFORMATION
Prefix:
* First Name:
Middle Name:

Position/Title:

* Organization Name:

Department:

Division:

* Street1:

Street2:

* City:
Province:
* Phone Number:

* Last Name:

County:
* Country: USA: UN
Fax Number:

Suffix:

* State:
* ZIP / Postal Code:
* Email:
OMB Number: 4040-0001
Expiration Date: 04/30/2008

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SF 424 (R&R)

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APPLICATION FOR FEDERAL ASSISTANCE

16. ESTIMATED PROJECT FUNDING

17. * IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE
ORDER 12372 PROCESS?
THIS PREAPPLICATION/APPLICATION WAS MADE
AVAILABLE TO THE STATE EXECUTIVE ORDER 12372
PROCESS FOR REVIEW ON:

a. YES

a. * Total Estimated Project Funding
b. * Total Federal & Non-Federal Funds

DATE:

c. * Estimated Program Income
b. NO

PROGRAM IS NOT COVERED BY E.O. 12372; OR
PROGRAM HAS NOT BEEN SELECTED BY STATE FOR
REVIEW

18. 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)
* 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.

19. Authorized Representative
* First Name:

Prefix

Middle Name:

* Last Name:

* Position/Title:

* Organization:

Department:

Division:

* Street1:

Street2:
County:

* City:

* State:

* Country: USA: UN

Province:
* Phone Number:

Suffix:

* ZIP / Postal Code:

Fax Number:

* Email:

* Signature of Authorized Representative

* Date Signed

Completed on submission to Grants.gov

Completed on submission to Grants.gov

20. Pre-application

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21. Attach an additional list of Project Congressional Districts if needed.
Add Attachment

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OMB Number: 4040-0001
Expiration Date: 04/30/2008