SF424 Application for Federal Assistance

OMB Approved No. 3076-0006

APPLICATION FOR
FEDERAL ASSISTANCE
1. TYPE OF SUBMISSION:
Application

Version 7/03

2. DATE SUBMITTED

Applicant Identifier

3. DATE RECEIVED BY STATE

State Application Identifier

4. DATE RECEIVED BY FEDERAL AGENCY

Federal Identifier

Pre-application

Construction

Construction

✔ Non-Construction
5. APPLICANT INFORMATION
Legal Name:

Non-Construction
Organizational Unit:
Department:

Organizational DUNS:

Division:

Address:
Street:

Name and telephone number of person to be contacted on matters
involving this application (give area code)
Prefix:
First Name:

City:

Middle Name

County:

Last Name

State:

Zip Code

Suffix:

Country:

Email:

6. EMPLOYER IDENTIFICATION NUMBER (EIN):

Phone Number (give area code)

-

Fax Number (give area code)

7. TYPE OF APPLICANT: (See back of form for Application Types)

8. TYPE OF APPLICATION:
New
Continuation
If Revision, enter appropriate letter(s) in box(es)
(See back of form for description of letters.)

Revision
Other (specify)

Other (specify)

9. NAME OF FEDERAL AGENCY:
Federal Mediation and Conciliation Service

10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:

11. DESCRIPTIVE TITLE OF APPLICANT’S PROJECT:

-

3 4 0 0 2
TITLE (Name of Program):
Labor Management Cooperation Program
12. AREAS AFFECTED BY PROJECT (Cities, Counties, States, etc.):

13. PROPOSED PROJECT
Start Date:

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

Ending Date:

15. ESTIMATED FUNDING:
00

a. Federal

$

.

b. Applicant

$

.

c. State

$

.

00

00

d. Local

$

.

00

e. Other

$

.

00

16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE
ORDER 12372 PROCESS?
THIS PREAPPLICATION/APPLICATION WAS MADE
a. Yes.
AVAILABLE TO THE STATE EXECUTIVE ORDER 12372
PROCESS FOR REVIEW ON
DATE:
b. No.

00

f. Program Income

$

.

g. TOTAL

$

.

PROGRAM IS NOT COVERED BY E. O. 12372

OR PROGRAM HAS NOT BEEN SELECTED BY STATE
FOR REVIEW
17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?

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. THE
DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE
ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.
a. Authorized Representative
Prefix
First Name
Middle Name
Last Name

Suffix

b. Title

c. Telephone Number (give area code)

d. Signature of Authorized Representative

e. Date Signed

Previous Edition Usable
Authorized for Local Reproduction

Standard 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 reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing 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 THE
ADDRESS 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 Federal
assistance. It will be used by Federal agencies to obtain applicant certification that States which have established a review and comment
procedure in response to Executive Order 12372 and have selected the program to be included in their process, have been given an
opportunity to review the applicant’s submission.
Item:
1.

Entry:
Select Type of Submission.

Item:
11.

2.

Date application submitted to Federal agency (or State if applicable)
and applicant’s control number (if applicable).

12.

3.

State use only (if applicable).

13

Enter the proposed start date and end date of the project.

4.

Enter Date Received by Federal Agency
Federal identifier number: If this application is a continuation or
revision to an existing award, enter the present Federal Identifier
number. If for a new project, leave blank.
Enter legal name of applicant, name of primary organizational unit
(including division, if applicable), which will undertake the
assistance activity, enter the organization’s DUNS number
(received from Dun and Bradstreet), enter the complete address of
the applicant (including country), and name, telephone number, email and fax of the person to contact on matters related to this
application.

14.

List the applicant’s Congressional District and any District(s)
affected by the program or project

15

Amount requested or to be contributed during the first
funding/budget period by each contributor. Value of in kind
contributions should be included on appropriate lines as
applicable. If the action will result in a dollar change to an
existing award, indicate only the amount of the change. For
decreases, enclose the amounts in parentheses. If both basic
and supplemental amounts are included, show breakdown on
an attached sheet. For multiple program funding, use totals
and show breakdown using same categories as item 15.
Applicants should contact the State Single Point of Contact
(SPOC) for Federal Executive Order 12372 to determine
whether the application is subject to the State
intergovernmental review process.
This question applies to the applicant organization, not the
person who signs as the authorized representative. Categories
of debt include delinquent audit disallowances, loans and
taxes.

5.

6.

Enter Employer Identification Number (EIN) as assigned by the
Internal Revenue Service.

16.

7.

Select the appropriate letter in
the space provided.
I.
State Controlled
A. State
Institution of Higher
B. County
Learning
C. Municipal
J. Private University
D. Township
K. Indian Tribe
E. Interstate
L. Individual
F. Intermunicipal
M. Profit Organization
G. Special District
N. Other (Specify)
H. Independent School
O. Not for Profit
District
Organization
Select the type from the following list:
•
"New" means a new assistance award.
•
“Continuation” means an extension for an additional
funding/budget period for a project with a projected completion
date.
•
“Revision” means any change in the Federal Government’s
financial obligation or contingent liability from an existing
obligation. If a revision enter the appropriate letter:
A. Increase Award
B. Decrease Award
C. Increase Duration
D. Decrease Duration
Name of Federal agency from which assistance is being requested
with this application.

17.

8.

9.

10.

18

Entry:
Enter a brief descriptive title of the project. If more than one
program is involved, you should append an explanation on a
separate sheet. If appropriate (e.g., construction or real
property projects), attach a map showing project location. For
preapplications, use a separate sheet to provide a summary
description of this project.
List only the largest political entities affected (e.g., State,
counties, cities).

To be signed by the authorized representative of the applicant.
A copy of the governing body’s authorization for you to sign
this application as official representative must be on file in the
applicant’s office. (Certain Federal agencies may require that
this authorization be submitted as part of the application.)

Use the Catalog of Federal Domestic Assistance number and title of
the program under which assistance is requested.

SF-424 (Rev. 7-97) Back

OMB Approval No. 0348-0044

BUDGET INFORMATION - Non-Construction Programs
SECTION A - BUDGET SUMMARY
Grant Program
Function
or Activity
(a)

Catalog of Federal
Domestic Assistance
Number
(b)

1.

Estimated Unobligated Funds
Federal
(c)

New or Revised Budget

Non-Federal
(d)

Federal
(e)

Non-Federal
(f)

Total
(g)

$

$

$

$

$

$

$

$

$

$

2.
3.
4.
5.

Totals

SECTION B - BUDGET CATEGORIES
GRANT PROGRAM, FUNCTION OR ACTIVITY

6. Object Class Categories
a. Personnel

Total

(1)

(2)

(3)

(4)

(5)

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

b. Fringe Benefits
c. Travel
d. Equipment
e. Supplies
f. Contractual
g. Construction
h. Other
i. Total Direct Charges (sum of 6a-6h)
j. Indirect Charges
k. TOTALS (sum of 6i and 6j)

7. Program Income

Authorized for Local Reproduction
Previous Edition Usable

Standard Form 424A (Rev. 7-97)
Prescribed by OMB Circular A-102

SECTION C - NON-FEDERAL RESOURCES
(b) Applicant
(c) State

(a) Grant Program
8.

(d) Other Sources

(e) TOTALS

$

$

$

$

$

$

$

$

9.
10.
11.
12. TOTAL (sum of lines 8-11)

SECTION D - FORECASTED CASH NEEDS
Total for 1st Year

13. Federal

1st Quarter

2nd Quarter

3rd Quarter

4th Quarter

$

$

$

$

$

$

$

$

$

$

14. Non-Federal
15. TOTAL (sum of lines 13 and 14)

SECTION E - BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT
(a) Grant Program

FUTURE FUNDING PERIODS (Years)
(c) Second
(d) Third

(b) First
16.

(e) Fourth

$

$

$

$

$

$

$

$

17.
18.
19.
20. TOTAL (sum of lines 16-19)

SECTION F - OTHER BUDGET INFORMATION
21. Direct Charges:

22. Indirect Charges:

23. Remarks:
Authorized for Local Reproduction

Standard Form 424A (Rev. 7-97) Page 2

INSTRUCTIONS FOR THE SF-424A
Public reporting burden for this collection of information is estimated to average 180 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0044), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.
SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
General Instructions
This form is designed so that application can be made for funds
from one or more grant programs. In preparing the budget,
adhere to any existing Federal grantor agency guidelines which
prescribe how and whether budgeted amounts should be
separately shown for different functions or activities within the
program. For some programs, grantor agencies may require
budgets to be separately shown by function or activity. For other
programs, grantor agencies may require a breakdown by function
or activity. Sections A, B, C, and D should include budget
estimates for the whole project except when applying for
assistance which requires Federal authorization in annual or
other funding period increments. In the latter case, Sections A, B,
C, and D should provide the budget for the first budget period
(usually a year) and Section E should present the need for
Federal assistance in the subsequent budget periods. All
applications should contain a breakdown by the object class
categories shown in Lines a-k of Section B.

For continuing grant program applications , submit these forms
before the end of each funding period as required by the grantor
agency. Enter in Columns (c) and (d) the estimated amounts of
funds which will remain unobligated at the end of the grant
funding period only if the Federal grantor agency instructions
provide for this. Otherwise, leave these columns blank. Enter in
columns (e) and (f) the amounts of funds needed for the
upcoming period. The amount(s) in Column (g) should be the
sum of amounts in Columns (e) and (f).
For supplemental grants and changes to existing grants, do not
use Columns (c) and (d). Enter in Column (e) the amount of the
increase or decrease of Federal funds and enter in Column (f) the
amount of the increase or decrease of non-Federal funds. In
Column (g) enter the new total budgeted amount (Federal and
non-Federal) which includes the total previous authorized
budgeted amounts plus or minus, as appropriate, the amounts
shown in Columns (e) and (f). The amount(s) in Column (g)
should not equal the sum of amounts in Columns (e) and (f).

Section A. Budget Summary Lines 1-4 Columns (a) and (b)
Line 5 - Show the totals for all columns used.
For applications pertaining to a single Federal grant program
(Federal Domestic Assistance Catalog number) and not requiring
a functional or activity breakdown, enter on Line 1 under Column
(a) the Catalog program title and the Catalog number in Column
(b).
For applications pertaining to a single program requiring budget
amounts by multiple functions or activities, enter the name of
each activity or function on each line in Column (a), and enter the
Catalog number in Column (b). For applications pertaining to
multiple programs where none of the programs require a
breakdown by function or activity, enter the Catalog program title
on each line in Column (a) and the respective Catalog number on
each line in Column (b).
For applications pertaining to multiple programs where one or
more programs require a breakdown by function or activity,
prepare a separate sheet for each program requiring the
breakdown. Additional sheets should be used when one form
does not provide adequate space for all breakdown of data
required. However, when more than one sheet is used, the first
page should provide the summary totals by programs.
Lines 1-4, Columns (c) through (g)

For new applications , leave Column (c) and (d) blank. For each
line entry in Columns (a) and (b), enter in Columns (e), (f), and
(g) the appropriate amounts of funds needed to support the
project for the first funding period (usually a year).

Section B Budget Categories
In the column headings (1) through (4), enter the titles of the
same programs, functions, and activities shown on Lines 1-4,
Column (a), Section A. When additional sheets are prepared for
Section A, provide similar column headings on each sheet. For
each program, function or activity, fill in the total requirements for
funds (both Federal and non-Federal) by object class categories.
Line 6a-i - Show the totals of Lines 6a to 6h in each column.
Line 6j - Show the amount of indirect cost.
Line 6k - Enter the total of amounts on Lines 6i and 6j. For all
applications for new grants and continuation grants the total
amount in column (5), Line 6k, should be the same as the total
amount shown in Section A, Column (g), Line 5. For
supplemental grants and changes to grants, the total amount of
the increase or decrease as shown in Columns (1)-(4), Line 6k
should be the same as the sum of the amounts in Section A,
Columns (e) and (f) on Line 5.
Line 7 - Enter the estimated amount of income, if any, expected
to be generated from this project. Do not add or subtract this
amount from the total project amount, Show under the program

SF-424A (Rev. 7-97) Page 3

INSTRUCTIONS FOR THE SF-424A (continued)
narrative statement the nature and source of income. The
estimated amount of program income may be considered by the
Federal grantor agency in determining the total amount of the
grant.

Line 15 - Enter the totals of amounts on Lines 13 and 14.

Section C. Non-Federal Resources

Lines 16-19 - Enter in Column (a) the same grant program titles
shown in Column (a), Section A. A breakdown by function or
activity is not necessary. For new applications and continuation
grant applications, enter in the proper columns amounts of Federal
funds which will be needed to complete the program or project over
the succeeding funding periods (usually in years). This section
need not be completed for revisions (amendments, changes, or
supplements) to funds for the current year of existing grants.

Lines 8-11 Enter amounts of non-Federal resources that will be
used on the grant. If in-kind contributions are included, provide a
brief explanation on a separate sheet.
Column (a) - Enter the program titles identical to
Column (a), Section A. A breakdown by function or
activity is not necessary.
Column (b) - Enter the contribution to be made by the
applicant.
Column (c) - Enter the amount of the State’s cash and
in-kind contribution if the applicant is not a State or
State agency. Applicants which are a State or State
agencies should leave this column blank.
Column (d) - Enter the amount of cash and in-kind
contributions to be made from all other sources.
Column (e) - Enter totals of Columns (b), (c), and (d).

Line 12 - Enter the total for each of Columns (b)-(e). The amount
in Column (e) should be equal to the amount on Line 5, Column
(f), Section A.
Section D. Forecasted Cash Needs

Section E. Budget Estimates of Federal Funds Needed for
Balance of the Project

If more than four lines are needed to list the program titles, submit
additional schedules as necessary.
Line 20 - Enter the total for each of the Columns (b)-(e). When
additional schedules are prepared for this Section, annotate
accordingly and show the overall totals on this line.
Section F. Other Budget Information
Line 21 - Use this space to explain amounts for individual direct
object class cost categories that may appear to be out of the
ordinary or to explain the details as required by the Federal grantor
agency.
Line 22 - Enter the type of indirect rate (provisional, predetermined,
final or fixed) that will be in effect during the funding period, the
estimated amount of the base to which the rate is applied, and the
total indirect expense.
Line 23 - Provide any other explanations or comments deemed
necessary.

Line 13 - Enter the amount of cash needed by quarter from the
grantor agency during the first year.
Line 14 - Enter the amount of cash from all other sources needed
by quarter during the first year.

SF-424A (Rev. 7-97) Page 4

OMB Approval No. 0348-0040

ASSURANCES - NON-CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.
SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
NOTE: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the
awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such
is the case, you will be notified.
As the duly authorized representative of the applicant, I certify that the applicant:
1.

Has the legal authority to apply for Federal assistance
and the institutional, managerial and financial capability
(including funds sufficient to pay the non-Federal share
of project cost) to ensure proper planning, management
and completion of the project described in this
application.

2.

Will give the awarding agency, the Comptroller General
of the United States and, if appropriate, the State,
through any authorized representative, access to and
the right to examine all records, books, papers, or
documents related to the award; and will establish a
proper accounting system in accordance with generally
accepted accounting standards or agency directives.

3.

Will establish safeguards to prohibit employees from
using their positions for a purpose that constitutes or
presents the appearance of personal or organizational
conflict of interest, or personal gain.

4.

Will initiate and complete the work within the applicable
time frame after receipt of approval of the awarding
agency.

5.

Will comply with the Intergovernmental Personnel Act of
1970 (42 U.S.C. §§4728-4763) relating to prescribed
standards for merit systems for programs funded under
one of the 19 statutes or regulations specified in
Appendix A of OPM's Standards for a Merit System of
Personnel Administration (5 C.F.R. 900, Subpart F).

6.

Will comply with all Federal statutes relating to
nondiscrimination. These include but are not limited to:
(a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352)
which prohibits discrimination on the basis of race, color
or national origin; (b) Title IX of the Education
Amendments of 1972, as amended (20 U.S.C. §§16811683, and 1685-1686), which prohibits discrimination on
the basis of sex; (c) Section 504 of the Rehabilitation

Act of 1973, as amended (29 U.S.C. §794), which
prohibits discrimination on the basis of handicaps; (d)
the Age Discrimination Act of 1975, as amended (42
U.S.C. §§6101-6107), which prohibits discrimination
on the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.L. 92-255), as amended,
relating to nondiscrimination on the basis of drug
abuse; (f) the Comprehensive Alcohol Abuse and
Alcoholism Prevention, Treatment and Rehabilitation
Act of 1970 (P.L. 91-616), as amended, relating to
nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) §§523 and 527 of the Public Health
Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee3), as amended, relating to confidentiality of alcohol
and drug abuse patient records; (h) Title VIII of the
Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as
amended, relating to nondiscrimination in the sale,
rental or financing of housing; (i) any other
nondiscrimination provisions in the specific statute(s)
under which application for Federal assistance is being
made; and, (j) the requirements of any other
nondiscrimination statute(s) which may apply to the
application.
7.

Will comply, or has already complied, with the
requirements of Titles II and III of the Uniform
Relocation Assistance and Real Property Acquisition
Policies Act of 1970 (P.L. 91-646) which provide for
fair and equitable treatment of persons displaced or
whose property is acquired as a result of Federal or
federally-assisted programs. These requirements apply
to all interests in real property acquired for project
purposes regardless of Federal participation in
purchases.

8.

Will comply, as applicable, with provisions of the
Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328)
which limit the political activities of employees whose
principal employment activities are funded in whole or
in part with Federal funds.

Previous Edition Usable

Standard Form 424B (Rev. 7-97)

Authorized for Local Reproduction

Prescribed by OMB Circular A-102

9.

10.

11.

Will comply, as applicable, with the provisions of the DavisBacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act
(40 U.S.C. §276c and 18 U.S.C. §874), and the Contract
Work Hours and Safety Standards Act (40 U.S.C. §§327333), regarding labor standards for federally-assisted
construction subagreements.
Will comply, if applicable, with flood insurance purchase
requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234) which requires
recipients in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of
insurable construction and acquisition is $10,000 or more.
Will comply with environmental standards which may be
prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National
Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating
facilities pursuant to EO 11738; (c) protection of wetlands
pursuant to EO 11990; (d) evaluation of flood hazards in
floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved State management
program developed under the Coastal Zone Management
Act of 1972 (16 U.S.C. §§1451 et seq.); (f) conformity of
Federal actions to State (Clean Air) Implementation Plans
under Section 176(c) of the Clean Air Act of 1955, as
amended (42 U.S.C. §§7401 et seq.); (g) protection of
underground sources of drinking water under the Safe
Drinking Water Act of 1974, as amended (P.L. 93-523);
and, (h) protection of endangered species under the
Endangered Species Act of 1973, as amended (P.L. 93205).

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

APPLICANT ORGANIZATION

12.

Will comply with the Wild and Scenic Rivers Act of
1968 (16 U.S.C. §§1271 et seq.) related to protecting
components or potential components of the national
wild and scenic rivers system.

13.

Will assist the awarding agency in assuring compliance
with Section 106 of the National Historic Preservation
Act of 1966, as amended (16 U.S.C. §470), EO 11593
(identification and protection of historic properties), and
the Archaeological and Historic Preservation Act of
1974 (16 U.S.C. §§469a-1 et seq.).

14.

Will comply with P.L. 93-348 regarding the protection of
human subjects involved in research, development, and
related activities supported by this award of assistance.

15.

Will comply with the Laboratory Animal Welfare Act of
1966 (P.L. 89-544, as amended, 7 U.S.C. §§2131 et
seq.) pertaining to the care, handling, and treatment of
warm blooded animals held for research, teaching, or
other activities supported by this award of assistance.

16.

Will comply with the Lead-Based Paint Poisoning
Prevention Act (42 U.S.C. §§4801 et seq.) which
prohibits the use of lead-based paint in construction or
rehabilitation of residence structures.

17.

Will cause to be performed the required financial and
compliance audits in accordance with the Single Audit
Act Amendments of 1996 and OMB Circular No. A-133,
"Audits of States, Local Governments, and Non-Profit
Organizations."

18.

Will comply with all applicable requirements of all other
Federal laws, executive orders, regulations, and policies
governing this program.

TITLE

DATE SUBMITTED

Standard Form 424B (Rev. 7-97) Back