Form 4040-0003 Application for Federal Domestic Assistance - Short Orga

0MB Number: 4040·0003
Expiration Date: mm/dd/yyyy

APPLICATION FOR FEDERAL DOMESTIC ASSISTANCE - Short Organizational
• 1. NAME OF FEDERAL AGENCY:

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2. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:

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CFDA TITLE:

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• 3. DATE RECEIVED:

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I SYSTEM USE ONLy

!Completed Upon Subrn1s5,1on to Granls.gov

• 4. FUNDING OPPORTUNITY NUMBER:

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• TITLE:

5. APPLICANT INFORMATION
• a. Leaal Name:

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b. Address:
• Street1:

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Street2:

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• City:

County/Parish:

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• State:

Province:

• Country:

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' Zie/Postal Code:

USA: UNlTE:D STATES

c. Web Address:
http://

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• d. Type of Applicant: Select Applicant Type Code(s):

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Type of Applicant:

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Type of Applicant:
• Other (specify):

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• f_ Organizational DUNS:

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• g, Congressional District of Applicant:

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6. PROJECT INFORMATION

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• c. Employer/Taxpayer Identification Number (EIN/TIN):

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• a. Project Title:

• b. Project Description:

c. Proposed Project:

• Start Date: I

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• End Date:

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The time required to complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
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