Sf 424 Form – Fill Out and Use This PDF

OMB Number: 4040-0004

Expiration Date: 04/31/2012

Application for Federal Assistance SF-424

Version 02

*1.

Type of Submission

*2. Type of Application

*If Revision, select appropriate letter(s):

Preapplication

New

Application

Continuation

* Other (Specify)

Changed/Corrected Application

Revision

*3.

Date Received:

4. Application 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:

Street 2:

*City:

County:

*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:

Midd le N a me:

*Last Name:

Suffix:

Title:

Organizational Affiliation:

*Telephone Number:

Fax Number:

*Email:

OMB Number: 4040-0004

Expiration Date: 04/31/2012

Application for Federal Assistance SF-424

Version 02

OMB Number: 4040-0004

Expiration Date: 04/31/2012

Application for Federal Assistance SF-424

Version 02

16. Congressional Districts Of:

*a. Applicant

*b. Program/Project:

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

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.)

Yes

No

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:

Midd le N ame:

*Last Name:

Suffix:

*Title:

*Telephone Number:

Fax Number:

*Email:

*Signature of Authorized Representative:

Date Signed:

OMB Number: 4040-0004

Expiration Date: 04/31/2012

Application for Federal Assistance SF-424

Version 02

Item

Entry:

Item

Entry:

1.

Type of Submission: (Required): Select one type of submission in

10.

Name Of Federal Agency: (Required) Enter the name of the

accordance with agency instructions.

Federal agency from which assistance is being requested with

Preapplication

this application.

Application

Changed/Corrected Application – If requested by the agency, check

11.

Catalog Of Federal Domestic Assistance Number/Title:

if this submission is to change or correct a previously submitted

Enter the Catalog of Federal Domestic Assistance number and

application. Unless requested by the agency, applicants may not

title of the program under which assistance is requested, as

use this to submit changes after the closing date.

found in the program announcement, if applicable.

2.

Type of Application: (Required) Select one type of application in

12.

Funding Opportunity Number/Title: (Required) Enter the

accordance with agency instructions.

Funding Opportunity Number and title of the opportunity under

New – An application that is being submitted to an agency for the

which assistance is requested, as found in the program

first time.

announcement.

Continuation - An extension for an additional funding/budget period

13.

Competition Identification Number/Title: Enter the

for a project with a projected completion date. This can include

Competition Identification Number and title of the competition

renewals.

under which assistance is requested, if applicable.

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.

14.

Areas Affected By Project: List the areas or entities using

the categories (e.g., cities, counties, states, etc.) specified in

A. Increase Award

B. Decrease Award

agency instructions. Use the continuation sheet to enter

C. Increase Duration

D. Decrease Duration

additional areas, if needed.

E. Other (specify)

3.

Date Received: Leave this field blank. This date will be assigned by the

15.

Descriptive Title of Applicant’s Project: (Required) Enter a

Federal agency.

brief descriptive title of the project. If appropriate, attach a

map showing project location (e.g., construction or real

4.

Applicant Identifier: Enter the entity identifier assigned by the Federal

property projects). For preapplications, attach a summary

agency, if any, or applicant’s control number, if applicable.

description of the project.

5a

Federal Entity Identifier: Enter the number assigned to your

16.

Congressional Districts Of: (Required) 16a. Enter the

organization by the Federal Agency, if any.

applicant’s Congressional District, and 16b. Enter all District(s)

5b.

Federal Award Identifier: For new applications leave blank. For a

affected by the program or project. Enter in the format: 2

continuation or revision to an existing award, enter the previously

characters State Abbreviation – 3 characters District Number,

assigned Federal award identifier number. If a changed/corrected

e.g., CA-005 for California 5th district, CA-012 for California 12th

application, enter the Federal Identifier in accordance with agency

district, NC-103 for North Carolina’s 103rd district.

instructions.

If all congressional districts in a state are affected, enter

6.

Date Received by State: Leave this field blank. This date will be

“all” for the district number, e.g., MD-all for all

assigned by the State, if applicable.

congressional districts in Maryland.

7.

State Application Identifier: Leave this field blank. This identifier will

If nationwide, i.e. all districts within all states are affected,

be assigned by the State, if applicable.

enter US-all.

If the program/project is outside the US, enter 00-000.

8.

Applicant Information: Enter the following in accordance with agency

instructions:

a. Legal Name: (Required): Enter the legal name of applicant that will

17.

Proposed Project Start and End Dates: (Required) Enter the

undertake the assistance activity. This is the name that the organization

proposed start date and end date of the project.

has registered with the Central Contractor Registry. Information on

registering with CCR may be obtained by visiting the Grants.gov website.

b. Employer/Taxpayer Number (EIN/TIN): (Required): Enter the

Employer or Taxpayer Identification Number (EIN or TIN) as assigned by

18.

Estimated Funding: (Required) Enter the amount requested

the Internal Revenue Service. If your organization is not in the US, enter

or to be contributed during the first funding/budget period by

44-4444444.

each contributor. Value of in-kind contributions should be

c. Organizational DUNS: (Required) Enter the organization’s DUNS or

included on appropriate lines, as applicable. If the action will

DUNS+4 number received from Dun and Bradstreet. Information on

result in a dollar change to an existing award, indicate only the

obtaining a DUNS number may be obtained by visiting the Grants.gov

amount of the change. For decreases, enclose the amounts in

website.

parentheses.

d. Address: Enter the complete address as follows: Street address (Line

1 required), City (Required), County, State (Required, if country is US),

19.

Is Application Subject to Review by State Under Executive

Province, Country (Required), Zip/Postal Code (Required, if country is

Order 12372 Process? Applicants should contact the State

US).

Single Point of Contact (SPOC) for Federal Executive Order

e. Organizational Unit: Enter the name of the primary organizational

12372 to determine whether the application is subject to the

unit (and department or division, if applicable) that will undertake the

assistance activity, if applicable.

State intergovernmental review process. Select the

f. Name and contact information of person to be contacted on

appropriate box. If “a.” is selected, enter the date the

matters involving this application: Enter the name (First and last name

application was submitted to the State

required), organizational affiliation (if affiliated with an organization other

than the applicant organization), telephone number (Required), fax

20.

Is the Applicant Delinquent on any Federal Debt?

number, and email address (Required) of the person to contact on

(Required) Select the appropriate box. This question applies to

matters related to this application.

the applicant organization, not the person who signs as the

authorized representative. Categories of debt include

delinquent audit disallowances, loans and taxes.

If yes, include an explanation on the continuation sheet.

9.

Type of Applicant: (Required)

21.

Authorized Representative: (Required) To be signed and

Select up to three applicant type(s) in accordance with agency

dated by the authorized representative of the applicant

instructions.

organization. Enter the name (First and last name required)

A.

State Government

M.

Nonprofit with 501C3 IRS

title (Required), telephone number (Required), fax number,

B.

County Government

Status (Other than Institution

and email address (Required) of the person authorized to sign

C.

City or Township Government

of Higher Education)

for the applicant.

D.

Special District Government

N.

Nonprofit without 501C3 IRS

A copy of the governing body’s authorization for you to sign

E.

Regional Organization

Status (Other than Institution

this application as the official representative must be on file in

F.

U.S. Territory or Possession

of Higher Education)

the applicant’s office. (Certain Federal agencies may require

G.

Independent School District

O.

Private Institution of Higher

that this authorization be submitted as part of the application.)

H.

Public/State Controlled

Education

Institution of Higher Education

P.

Individual

I.

Indian/Native American Tribal

Q.

For-Profit Organization

Government (Federally

(Other than Small Business)

Recognized)

R.

Small Business

J.

Indian/Native American Tribal

S.

Hispanic-serving Institution

Government (Other than

T.

Historically Black Colleges

Federally Recognized)

and Universities (HBCUs)

K.

Indian/Native American

U.

Tribally Controlled Colleges

Tribally Designated

and Universities (TCCUs)

Organization

V.

Alaska Native and Native

L.

Public/Indian Housing

Hawaiian Serving Institutions

Authority

W.

Non-domestic (non-US)

Entity

X.

Other (specify)