Form 4040-0001 SF 424 (R&R) Application for Federal Assistance (Cover)

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

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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