NEH SF-424 Individual Burden Estimate

APPLICATION FOR FEDERAL ASSISTANCE SF 424 - INDIVIDUAL

1. NAME OF FEDERAL AGENCY

Pre-populated from the Application cover sheet.

2. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:

Pre-populated from the Application cover sheet.

CFDA TITLE:

Pre-populated from the Application cover sheet.

3. DATE RECEIVED

Completed by Grants.gov upon submission.

4. FUNDING OPPORTUNITY NUMBER:

Pre-populated from the Application cover sheet.

TITLE:

Pre-populated from the Application cover sheet.

5. APPLICANT INFORMATION

a. Name and Contact Information

Prefix:

Select the Prefix from the provided list or enter a new Prefix not provided on the list.

First Name:

Enter the First Name. This field is required.

Middle Name:

Enter the Middle Name.

Last Name:

Enter the Last Name. This field is required.

Suffix:

Select the Suffix from the provided list or enter a new Suffix not provided on the list.

Fax Number:

Enter the Fax Number.

Email:

Enter a valid Email Address.

Telephone Number (Daytime):

Enter the daytime Telephone Number. This field is required.

Telephone Number (Evening):

Enter the evening Telephone Number.

b. Address

Street1:

Enter the first line of the Street Address. This field is required.

Street2:

Enter the second line of the Street Address.

City:

Enter the City. This field is required.

County / Parish:

Enter the County or Parish.

State:

Select the state, US possession or military code from the provided list. This field is required if Country is the United States.

Province:

Enter the Province.

Country:

Select the Country from the provided list. This field is required.

Zip / Postal Code:

Enter the nine-digit Postal Code (e.g., ZIP code). This field is required if Country is the United States.

c. Citizenship Status:

U.S. Citizenship? Yes / No

Select Yes if applicant is a citizen of the United States. Select No if applicant is a permanent resident and enter the Alien Registration #. Select No if applicant is a foreign national and enter the country of citizenship and start date of most recent residency in the United States.

If No

If permanent resident of U.S., enter the Alien Registration #

Enter the Alien Registration Number.

If foreign national, enter country of citizenship:

Select the Country from the provided list. This field is required if the applicant is not a U.S. Citizen.

If foreign national, enter start date of most recent residency in U.S.:

Enter the start date of the most recent residency in the U.S. Enter in the format MM/DD/YYYY. This field is required if the applicant is not a U.S. Citizen.

d. 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.

6. PROJECT INFORMATION

a. Project Title

Enter a brief, descriptive title of the project.

b. Project Description

Enter a brief description of the project. This field is required.

c. Proposed Project

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.

7. * 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 fradulent statements or claims may subject me to criminal, civil, or administrative penalties (U.S. Code, Title 218, Section 1001)

** I AGREE

Check to select. This field is required.

** 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.

Signature

Completed by Grants.gov upon submission.

Date Signed

Completed by Grants.gov upon submission.