SF 424 Application for Federal Assistance

OMB Number: 4040-0004
Expiration Date: 12/31/2019

Application for Federal Assistance SF-424
* 1. Type of Submission: I

* 2. Type of Application: I * If Revision, select appropriate letter(s):

Preapplication

a

LI New

Application

Continuation

Changed/Corrected Application

Revision

* 3. Date Received:

* Other (Specify):

4. Applicant Identifier:

5a. Federal Entity Identifier:

5b. Federal Award Identifier:

State Use Only:
6. Date Received by State:

7. State Application Identifier:

8. APPLICANT INFORMATION:
* a. Legal Name:
* b. Employer/Taxpayer Identification Number (EIN/TIN):

* c. Organizational DUNS:

d. Address:
* Streetl:

1

i

Street2:
* City:
1
County/Parish:
* State:

El

Province:
* Country:

L
pSA: UNITED STATES

* Zip / Postal Code:
e. Organizational Unit:
Department Name:

Division Name:

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

El

* First Name:

'

Middle Name:
* Last Name:
Suffix:

la

Title:
Organizational Affiliation:

* Telephone Number:
* Email:

L

( Fax Number:

Application for Federal Assistance SF-424
* 9. Type of Applicant 1: Select Applicant Type:
{d
Type of Applicant 2: Select Applicant Type:
,
Type of Applicant 3: Select Applicant Type:

* Other (specify):

* 10. Name of Federal Agency:

11. Catalog of Federal Domestic Assistance Number:

CFDA Title:

* 12. Funding Opportunity Number:
I
* Title:

[
13. Competition Identification Number:

Title:

14. Areas Affected by Project (Cities, Counties, States, etc.):
Add Attachment

* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.
Add Attachments

Delete Attachments

View Attachments

Delete Attachment

View Attachment

Application for Federal Assistance SF-424
16. Congressional Districts Of:
* a. Applicant

* b. Program/Project

Attach an additional list of Program/Project Congressional Districts if needed.
Add Attachment

Delete Attachment

View Attachment

17.Proposed Project:
* a. Start Date:

* b. End Date:

18. Estimated Funding ($):
* a. Federal
* b. Applicant
* c. State
,

* d. Local
* e. Other
* f. Program Income

1

* g. TOTAL

I

* 19.1s Application Subject to Review By State Under Executive Order 12372 Process?!
a. This application 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 the State for review.
c. Program is not covered by E.O. 12372.

I

* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.) I
Yes

LINo

If "Yes", provide explanation and attach
Add Attachment

Delete Attachment

View Attachment

21. *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
** 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.
Authorized Representative:
Prefix:

la

* First Name:

Middle Name:
* Last Name:
Suffix:

IR

* Title:
* Telephone Number:

Fax Number:

* Email:
* Signature of Authorized Representative:

I
* Date Signed:

Grants.gov Form Instructions
Form identifiers
Agency Owner
Form Name
OMB Number
OMB Expiration Date

Information
Grants.gov
Application for Federal Assistance (SF-424) V2.1
4040-0004
10/31/2019

Form Field Instructions
Field
Number
1.

Field Name
Type of
Submission:

OMB Number: 4040-0004
OMB Expiration Date: 10/31/2019

Required or
Optional
Required

Information
Select one type of submission in
accordance with agency instructions.
• Pre-application
• Application
• Changed/Corrected Application Check if this submission is to
change or correct a previously
submitted application. Unless
requested by the agency,
applicants may not use this form
to submit changes after the
closing date.

Field
Number

Field Name

Required or
Optional

Information

2.

Type of Application

Required

Select one type of application in
accordance with agency instructions.
• New - An application that is being
submitted to an agency for the
first time.
• Continuation - An extension for an
additional funding/budget period
for a project with a projected
completion date. This can include
renewals.
• Revision - Any change in the
federal government's financial
obligation or contingent liability
from an existing obligation. If a
revision, enter the appropriate
letter(s). More than one may be
selected.
A: Increase Award
B: Decrease Award
C: Increase Duration
D: Decrease Duration
E: Other (specify)
AC: Increase Award, Increase
Duration
AD: Increase Award, Decrease
Duration
BC: Decrease Award, Increase
Duration
BD: Decrease Award, Decrease
Duration

Required

Enter date if form is submitted through
other means as instructed by the Federal
agency. The date received is completed
electronically if submitted via Grants.gov.

3.

Date Received:

4.

Applicant
Identifier:

Enter the entity identifier assigned by the
Federal agency, if any, or the applicant's
control number if applicable.

5a.

Federal Entity
Identifier:

Enter the number assigned to your
organization by the federal agency, if any.

OMB Number: 4040-0004
OMB Expiration Date: 10/31/2019

2

Field
Number
5b.

6.
7.
8.

Field Name

Required or
Optional

Federal Award
Identifier:

Date Received by
State:
State Application
Identifier:
Applicant
Information:
a. Legal Name:

Required

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

Required

c. Organizational
DUNS:

Required

d. Address:

Required

e. Organizational
Unit

OMB Number: 4040-0004
OMB Expiration Date: 10/31/2019

Information
For new applications, leave blank. For a
continuation or revision to an existing
award, enter the previously assigned
federal award identifier number. If a
changed/corrected application, enter the
federal identifier in accordance with
agency instructions.
Leave this field blank. This date will be
assigned by the state, if applicable
Leave this field blank. This identifier will
be assigned by the state, if applicable.
Enter the following in accordance with
agency instructions.
Enter the legal name of the applicant that
will undertake the assistance activity. This
is the organization that has registered
with the System for Award Management
(SAM). Information on registering with
SAM may be obtained by visiting
SAM.gov.
Enter the employer or taxpayer
identification number (EIN or TIN) as
assigned by the Internal Revenue Service.
If your organization is not in the US, enter
44-4444444.
Enter the organization's DUNS number
received from DUN and Bradstreet. The
DUNS number may be either 9 or 13
numeric digits. Information on obtaining
a DUNS number may be obtained by
visiting Grants.gov
Enter address: Street 1 (required); City
(required); County/Parish, State (required
if country is US); Province; Country
(required); 9-digit ZIP/Postal Code
(required if country is US). If +4 does not
exist for the address, enter "0000".
Enter the name of the primary
organizational unit, department, or
division that will undertake the assistance
activity.
3

Field
Number

Field Name

Required or
Optional

f. Name and

Required

contact
information of
person to be
contacted on
matters involving
this application

OMB Number: 4040-0004
OMB Expiration Date: 10/31/2019

Information
Enter the first and last name (required);
prefix, middle name, suffix, and title.
Enter organizational affiliation if affiliated
with an organization other than that in
7.a. Telephone number and email
(required); fax number.

4

Field
Number
9.

Field Name
Type of Applicant:
Select Applicant
Type

Required or
Optional
Required

Information
Select a minimum of one applicant type
or select up to three applicant types in
accordance witagency instructions. If
"Other" is selected, then specify Other
Type of Applicant in text box.
A.
B.
C.
D.
E.
F.
G.
H.

State Government
County Government
City or Township Government
Special District Government
,Regional Organization
U.S. Territory or Possession
Independent School District
Public/State Controlled Institution
of Higher Education
I. Indian/Native American Tribal
Government (Federally
Recognized)
J. Indian/Native American Tribal
Government (Other than Federally
Recognized)
K. Indian/Native American Tribally
Designated Organization
L. Public/Indian Housing
M. Nonprofit
N. Private Institution of Higher
Education
0. Individual
P. For-Profit Organization (Other
• than Small Business)
Q. Small Business
R. Hispanic-serving Institution
S. Historically Black Colleges and
Universities (HBCUs)
• T. Tribally Controlled Colleges and
Universities (TCCUs)
U Alaska Native and Native Hawaiian
Serving Institutions
V. Non-US Entity
W. Other (specify)

OMB Number: 4040-0004
OMB Expiration Date: 10/31/2019

Field
Number
10.

Field Name
Name of Federal
Agency:

Required or
Optional
Required

..

11.

Catalog Of Federal
Domestic
Assistance
Number/Title

Required

12.

Funding
Opportunity
Number/Title

Required

13.

Competition
Identification
Nymber/Title:

14.

Areas Affected By
Project:

t5.

Descriptive Title of
Applicant's Project:

Required

OMB Number: 4040-0004
OMB Expiration Date: 10/31/2019

Information
Enter the name of the federal agency
from which assistance is being requested
with this application. This information is
pre-populated if submitting through
Grants.gov.
Enter the Catalog of Federal Domestic
Assistance number and title of the
program under which assistance is
requested, as found in the program
announcement, if applicable. This
information is pre-populated if using'
Grants.gov.
Enter the Funding Opportunity Number
and title of the opportunity under which
assistance is requested as found in the
program announcement. This information
is pre-populated if using Grants.gov.
Enter the competition identification
number and title of the competition
under which assistance is requested, if
applicable. These fields are pre-populated
by Grants.gov if provided by the federal
agency.
This data element is intended for use only
by programs for which the area(s)
affected are likely to be different from
the place(s) of performance reported on
the SF-424 Project/Performance Site
Location(s) Form. Add attachment to
enter additional areas, if needed.
Enter a brief descriptive title of the
project. Supporting documents may be
attached if specified in agency
instructions.

6

Field
Number
16.

17.

18.

Required or
Optional
Required

Field Name
Congressional
Districts

Proposed Project
Start and End
Dates:
Estimated Funding:

Required

Required

OMB Number: 4040-0004
OMB Expiration Date: 10/31/2019

Information
16a. Enter the applicant's congressional
district. 16b. Enter the primary district
affected by the program or project. Enter
in the following format: 2 character state
abbreviation — 3 characters district
number, e.g., CA-005 for California 5th
district, CA-012 for California 12th district,
NC-103 for North Carolina's 103rd district.
If all congressional districts in a state are
affected, enter "all" for the district
number, e.g., MD-all for all congressional
districts in Maryland. If nationwide, i.e.,
all districts within all states are affected,
enter US-all. If the program/project is
outside the US, enter 00.000. This
optional data element is intended for use
only by programs for which the area(s)
affected are likely to be different than
place(s) of performance reported on the
SF-424 Project/Performance Site
Location(s) form. Attach an additional list
of program/project congressional
districts, if needed.
Enter the proposed start date and end
date of the project.
Enter the 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. For zero
funding, enter 0.

7

Field
Number
19.

Field Name

Required or
Optional

Information

Is Application

Required

Applicants should contact the State Single

Subject to Review
by State Under
Executive Order

Point of Contact (SPOC) for Federal
Executive Order 12372 to determine
whether the application is subject to the
State intergovernmental review process.
Select the appropriate box. If "A." is
selected, enter the date the application
was submitted to the State.

20.

Is the Applicant
Delinquent on any
Federal Debt?

Required

Select the appropriate box. This question
applies to the applicant organization, not
the person who signs as the authorized
representative. Categories of federal debt
include; but may not be limited to:
delinquent audit disallowances, loans,
and taxes. If yes, include an explanation
in an attachment.

21.

Authorized
Representative:

Required

OMB Number: 4040-0004
OMB Expiration Date: 10/31/2019

To be signed and dated by the authorized
representative of the applicant
organization. Enter the first and last
name (required); prefix, middle name,
and suffix. Enter title, telephone number,
fax number, and email. Fax number is
not required. A copy of the governing
body's authorization for you to sign this
application as the 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.) If the application
is submitted via Grants.gov, the signature
of the authorized representative and the
date signed are completed upon
submission.

8