Form 4040-0002 SF-424 Mandatory

OMB Number: 4040-0002

Expiration Date:

ATTACHMENT A - APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY
1.a. Type of Submission: Application Plan Funding Request Other Other (specify)		* 1.b. Frequency: Annual Quarterly Other * Other (specify)				* 1.d. Version: Initial Resubmission		Revision Update
						* 2. Date Received:		STATE USE ONLY:
						3. Applicant Identifier:		5. Date Received by State:
								6. State Application Identifier:
						4a. Federal Entity Identifier:
						4b. Federal Award Identifier:
1.c. Consolidated Application/Plan/Funding		Request?
Yes No Explanation
7. APPLICANT INFORMATION:
* a. Legal Name:
* b. Employer/Taxpayer Identification Number (EIN/TIN):						* c. Organizational DUNS:
d. Address:
* Street1:						Street2:
* City:						County:
* State:						Province:
* Country:						* Zip / Postal Code:
e. Organizational Unit:
Department Name:						Division Name:
f. Name and contact information of person to be contacted on matters involving this submission:
Prefix:	* First Name:					Middle Name:
* Last Name:						Suffix:
Title:
Organizational Affiliation:
* Telephone Number:						Fax Number:
* Email:

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY
* 8a. TYPE OF APPLICANT:
* Other (specify):
b. Additional Description:
* 9. Name of Federal Agency:
10. Catalog of Federal Domestic Assistance Number:
CFDA Title:
11. Descriptive Title of Applicant’s Project
12. Areas Affected by Funding:
13. CONGRESSIONAL DISTRICTS OF:
* a. Applicant: b. Program/Project:
Attach an additional list of Program/Project Congressional Districts if needed.
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14. FUNDING PERIOD:
a. Start Date: b. End Date:
15. ESTIMATED FUNDING:
* a. Federal ($): b. Match ($):
* 16. IS SUBMISSION SUBJECT TO REVIEW BY STATE UNDER EXECUTIVE ORDER 12372 PROCESS?
a. This submission 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 State for review. c. Program is not covered by E.O. 12372.

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY
* 17. Is The Applicant Delinquent On Any Federal Debt?
Yes No Explanation
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 218, Section 1001) ** I Agree ** This 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:
Suffix:	* Title:
Organizational Affiliation:
* Telephone Number:
Fax Number:
* Email:
* Signature of Authorized Representative:
* Date Signed:
Attach supporting documents as specified in agency instructions.
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APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY
* Consolidated Application/Plan/Funding Request Explanation:

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY
* Applicant Federal Debt Delinquency Explanation: