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pdfOMB 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
2. DATE SUBMITTED
Changed/Corrected Application
b. Agency Routing Identifier
Applicant Identifier
c. Previous Grants.gov
Tracking ID
5. APPLICANT INFORMATION
Organizational DUNS:
Legal Name:
Department:
Division:
Street1:
Street2:
County / Parish:
City:
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:
Position/Title:
Street1:
Street2:
City:
County / Parish:
Province:
State:
Country:
ZIP / Postal Code:
USA: UNITED STATES
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
8. TYPE OF APPLICATION:
New
Renewal
If Revision, mark appropriate box(es).
Resubmission
Continuation
Socially and Economically Disadvantaged
Women Owned
A. Increase Award
Revision
Is this application being submitted to other agencies?
B. Decrease Award
E. Other (specify):
Yes
No
What other Agencies?
10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:
TITLE:
9. NAME OF FEDERAL AGENCY:
11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:
12. PROPOSED PROJECT:
Start Date
Ending Date
C. Increase Duration
13. CONGRESSIONAL DISTRICT OF APPLICANT
D. Decrease Duration
SF 424 (R&R)
Page 2
APPLICATION FOR FEDERAL ASSISTANCE
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:
Province:
State:
Country:
ZIP / Postal Code:
USA: UNITED STATES
Phone Number:
Fax Number:
Email:
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 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.
18. SFLLL (Disclosure of Lobbying Activities) or other Explanatory Documentation
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19. Authorized Representative
Middle Name:
First Name:
Prefix:
Suffix:
Last Name:
Position/Title:
Organization:
Department:
Division:
Street1:
Street2:
County / Parish:
City:
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
Completed on submission to Grants.gov
20. Pre-application
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21. Cover Letter Attachment
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File Type | application/pdf |
File Title | C:\Documents and Settings\Laura\Local Settings\temp\_120o2147u407f50kh.pdf |
Author | Laura |
File Modified | 2012-06-12 |
File Created | 2012-06-12 |