HHS burden estimate for the SF-424 Mandatory (M)

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OMB Number: 4040-0002
Expiration Date: 5/31/2014

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY
1.a. Type of Submission:

1.b. Frequency:

Application

Annual

Plan

Quarterly

Funding Request

Other

Other
Other (specify):

1.d. Version:
Initial

Resubmission

STATE USE ONLY:

3. Applicant Identifier:

5. Date Received by State:

Other (specify):

1.c. Consolidated Application/Plan/Funding Request?
No

4b. Federal Award Identifier:

Explanation

7. APPLICANT INFORMATION:
a. Legal Name:

b. Employer/Taxpayer Identification Number (EIN/TIN):

c. Organizational DUNS:

d. Address:
Street1:

Street2:

City:

County / Parish:

State:

Province:

Country:

Zip / Postal Code:

USA: UNITED STATES
e. Organizational Unit:
Department Name:

Division Name:

f. Name and contact information of person to be contacted on matters involving this submission:
Prefix:

Last Name:

First Name:

Middle Name:

Suffix:

Title:
Organizational Affiliation:

Telephone Number:
Email:

Update

2. Date Received:

4a. Federal Entity Identifier:

Yes

Revision

Fax Number:

6. State Application Identifier:

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.
Add Attachment

Delete Attachment

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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.
Add Attachments

Delete Attachments

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APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY
Consolidated Application/Plan/Funding Request Explanation:

APPLICATION
APPLICATIONFOR
FORFEDERAL
FEDERALASSISTANCE
ASSISTANCESF-424
SF-424--MANDATORY
MANDATORY
Applicant Federal Debt Delinquency Explanation: