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

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

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

1.b. Frequency:

�Application

�Annual

OPlan

0 Quarterly

0 Funding Request

Oother

1.d. Version:
�Initial

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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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