Budget Info-Non-construction Programs form

OMB Number: 4040-0001
Expiration Date: 06/30/2011

APPLICATION FOR FEDERAL ASSISTANCE

3. DATE RECEIVED BY STATE

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

State Application Identifier

4. a. Federal Identifier

Application

Changed/Corrected Application

b. Agency Routing Identifier

Applicant Identifier

2. DATE SUBMITTED

5. APPLICANT INFORMATION

* Organizational DUNS:

* Legal Name:
Department:

Division:

* Street1:
Street2:
* City:

County / Parish:
Province:

* State:
* Country:

* ZIP / Postal Code:

USA: UNITED STATES

Person to be contacted on matters involving this application
Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

* Phone Number:

Fax Number:

Email:
6. * EMPLOYER IDENTIFICATION (EIN) or (TIN):
7. * TYPE OF APPLICANT:

Please select one of the following

Other (Specify):
Small Business Organization Type

Women Owned

8. * TYPE OF APPLICATION:
New

If Revision, mark appropriate box(es).

Resubmission

Renewal

Socially and Economically Disadvantaged

Continuation

A. Increase Award
Revision

B. Decrease Award

C. Increase Duration

E. Other (specify):

* Is this application being submitted to other agencies? Yes

No

9. * NAME OF FEDERAL AGENCY:

What other Agencies?

10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:
TITLE:

11. * DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:

12. PROPOSED PROJECT:
* Start Date
* Ending Date

* 13. CONGRESSIONAL DISTRICT OF APPLICANT

14. PROJECT DIRECTOR/PRINCIPAL INVESTIGATOR CONTACT INFORMATION
Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

Position/Title:
* Organization Name:
Department:

Division:

* Street1:
Street2:
* City:

County / Parish:

* State:
* Country:
* Phone Number:
* Email:

Province:
USA: UNITED STATES
Fax Number:

* ZIP / Postal Code:

D. Decrease Duration

SF 424 (R&R)

Page 2

APPLICATION FOR FEDERAL ASSISTANCE

15. ESTIMATED PROJECT FUNDING

16. * IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE
ORDER 12372 PROCESS?

a. Total Federal Funds Requested

a. YES

THIS PREAPPLICATION/APPLICATION WAS MADE
AVAILABLE TO THE STATE EXECUTIVE ORDER 12372
PROCESS FOR REVIEW ON:

b. Total Non-Federal Funds
DATE:

c. Total Federal & Non-Federal Funds
b. NO
d. Estimated Program Income

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

17. 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 penalities. (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.

18. SFLLL or other Explanatory Documentation
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19. Authorized Representative
Prefix:

* First Name:

Middle Name:
Suffix:

* Last Name:
* Position/Title:
* Organization:
Department:

Division:

* Street1:
Street2:
* City:

County / Parish:
Province:

* State:
* Country:

USA: UNITED STATES

* Phone Number:

* ZIP / Postal Code:

Fax Number:

* Email:
* Date Signed

* Signature of Authorized Representative
Completed on submission to Grants.gov
20. Pre-application

Completed on submission to Grants.gov

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