Form 4040-0002 Application for Federal Assistance - SF-424 Mandatory

OMB Number 4040-xxxx
Expiration Date mm/dd/yyyy

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY
1.d. Version:

1.b. Frequency:

1.a. Type of Submission:

�Initial

�Annual

�Application
OPlan

0 Quarterly

0 Funding Request

Oother

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II
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Other (specify):

•

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5. Date Received by State:

3. Applicant Identifier:

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4b. Federal Award Identifier:

1.c. Consolidated Application/Plan/Funding Request?
Yes 0

I ExQlanation

No�

7. APPLICANT INFORMATION:
a. Legal Name:

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

c. Organizational DUNS:

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d. Address:

City:

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-

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County/ Parish:

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Province:

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Country:

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Zip/ Postal Code:

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USA: UNITED STATES
e. Organizational Unit:

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6. State Application Identifier:

Street2:

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State:

11

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Street1:

D Update

STATE USE ONLY:

4a. Federal Entity Identifier:

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0 Revision

2. Date Received:

0 Other
Other (specify):

0 Resubmission

Department Name:

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Division Name:

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

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Last Name:

Title: [

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First Name:

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Middle Name:

Suffix:

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Organizational Affiliation:

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Telephone Number:
Email:

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Fax Number: [

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 4040-xxxx. 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 collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: US Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave SW,
Suite 336 E, Washington DC, 20201, Attention: PRA Reports Clearance Officer