SF-424 R&R Application for Federal Assistance (SF-424) Research & R

OMB Number: 4040-0001
Expiration Date: 6/30/2016

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:
City:

County / Parish:
Province:

State:
Country:

USA: UNITED STATES

ZIP / Postal Code:

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:
Other (Specify):
Small Business Organization Type

Women Owned

8. TYPE OF APPLICATION:
New
Renewal

If Revision, mark appropriate box(es).

Resubmission
Continuation

Socially and Economically Disadvantaged

A. Increase Award
Revision

Is this application being submitted to other agencies?

B. Decrease Award

E. Other (specify):
Yes

9. NAME OF FEDERAL AGENCY:

No

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

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:

State:
Country:

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

a. Total Federal Funds Requested
b. Total Non-Federal Funds

DATE:

c. Total Federal & Non-Federal Funds

PROGRAM IS NOT COVERED BY E.O. 12372; OR

d. Estimated Program Income

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
Prefix:

First Name:

Middle Name:
Suffix:

Last Name:
Position/Title:
Organization:
Department:

Division:

Street1:
Street2:
City:

County / Parish:
Province:

State:
Country:

ZIP / Postal Code:

USA: UNITED STATES

Phone Number:

Fax Number:

Email:
Date Signed

Signature of Authorized Representative

20. Pre-application

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21. Cover Letter Attachment

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