Form FS 1500-0046 FS 1500-0046 Application for Federal Assistance 424

OMB Control No. 0596-xxxx
Expiration Date: xx-xx-xxxx
FS-1500-0046

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

* 2. Type of Application:

Preapplication

New

Application

Continuation

Changed/Corrected Application

Revision

* 3. Date Received:

* If Revision, select appropriate letter(s):

* 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:
* Street1:
Street2:
* City:
County/Parish:
* State:
Province:
* Country:
* 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:

* First Name:

Middle Name:
* Last Name:
Suffix:
Title:
Organizational Affiliation:

* Telephone Number:
* Email:

Fax Number:

Application for Federal Assistance SF-424
* 9. Type of Applicant 1: Select Applicant Type:

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:

* 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
* g. TOTAL

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

Yes

No

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:

* First Name:

Middle Name:
* Last Name:
Suffix:
* Title:
* Telephone Number:

Fax Number:

* Email:
* Signature of Authorized Representative:

* Date Signed:

Instructions for Application for Federal Assistance (SF-424)
This is a standard form required for use as a cover sheet for submission of pre-applications and applications and
related information under discretionary programs. Some of the items are required and some are optional at the
discretion of the applicant or the federal agency (agency). Required fields on the form are identified with an asterisk
(*) and are also specified as "Required" in the instructions below. In addition to these instructions, applicants must
consult agency instructions to determine other specific requirements.
Item

Field Name

Information

1.

Type of Submission:

(Required) 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.

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. If "Other" is
selected, please specify in text box provided.
A. Increase Award
B. Decrease Award
C. Increase Duration
D. Decrease Duration
E. Other (specify)

3.

Date Received:

Leave this field blank. This date will be assigned by the Federal agency.

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.

5b. Federal Award Identifier:

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.

6.

Date Received by State:

Leave this field blank. This date will be assigned by the state, if applicable.

7.

State Application Identifier:

Leave this field blank. This identifier will be assigned by the state, if applicable.

8.

Applicant Information:

Enter the following in accordance with agency instructions:

a. Legal Name:

(Required) Enter the legal name of applicant that will undertake the assistance
activity. This is the organization that has registered with the Central Contractor
Registry (CCR). Information on registering with CCR may be obtained by visiting
www.Grants.gov.

b. Employer/Taxpayer Number (Required) Enter the employer or taxpayer identification number (EIN or TIN) as
(EIN/TIN):
assigned by the Internal Revenue Service. If your organization is not in the US,
enter 44-4444444.
c. Organizational DUNS:

(Required) Enter the organization's DUNS or DUNS+4 number received from

Dun and Bradstreet. Information on obtaining a DUNS number may be obtained
by visiting www.Grants.gov.
d. Address:

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 US).

e. Organizational Unit:

Enter the name of the primary organizational unit, department or division that
will undertake the assistance activity.

f. Name and contact
Enter the first and last name (Required); prefix, middle name, suffix, title. Enter
information of person to be
organizational affiliation if affiliated with an organization other than that in 7.a.
contacted on matters involving Telephone number and email (Required); fax number.
this application:
9.

Type of Applicant: (Required)
Select up to three applicant
type(s) in accordance with
agency instructions.

A. State Government
B. County Government
C. City or Township Government
D. Special District Government
E. Regional Organization
F. U.S. Territory or Possession
G. Independent School District
H. 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
O. 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)

10. Name Of Federal Agency:

(Required) Enter the name of the federal agency from which assistance is being
requested with this application.

11. Catalog Of Federal Domestic
Assistance Number/Title:

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.

12. Funding Opportunity
Number/Title:

(Required) Enter the Funding Opportunity Number and title of the opportunity
under which assistance is requested, as found in the program announcement.

13. Competition Identification
Number/Title:

Enter the competition identification number and title of the competition under
which assistance is requested, if applicable.

14. Areas Affected By Project:

This data element is intended for use only by programs for which the area(s)
affected are likely to be different than the place(s) of performance reported on
the SF-424 Project/Performance Site Location(s) Form. Add attachment to enter
additional areas, if needed.

15. Descriptive Title of Applicant's (Required) Enter a brief descriptive title of the project. If appropriate, attach a
Project:
map showing project location (e.g., construction or real property projects). For
pre-applications, attach a summary description of the project.
16. Congressional Districts Of:

15a. (Required) Enter the applicant's congressional district. 15b. Enter all
district(s) affected by the program or project. Enter in the format: 2 characters
state abbreviation - 3 characters district number, e.g., CA-005 for California 5th
district, CA-012 for California 12 district, NC-103 for North Carolina's 103
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.
17. Proposed Project Start and
End Dates:

(Required) Enter the proposed start date and end date of the project.

18. Estimated Funding:

(Required) 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.

19. Is Application Subject to
Review by State Under
Executive Order 12372
Process?

(Required) Applicants should contact the State Single 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 (Required) Select the appropriate box. This question applies to the applicant
any Federal Debt?
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:

To be signed and dated by the authorized representative of the applicant
organization. Enter the first and last name (Required); prefix, middle name,
suffix. Enter title, telephone number, email (Required); and fax number. 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.)

Burden Statement
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 0596-0XXX. The time required to complete this information collection is estimated to average 1.25 hours
per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color,
national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation,
genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance.
(Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of
program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and
TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington,
DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at
(800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.