Standard Form 424 – Fill Out and Use This PDF

Item:

Entry:

Item:

Entry:

1.

Select Type of Submission.

11.

Enter a brief descriptive title of the project. If more than one

program is involved, you should append an explanation on a

separate sheet. If appropriate (e.g., construction or real

property projects), attach a map showing project location. For

preapplications, use a separate sheet to provide a summary

description of this project.

2.

Date application submitted to Federal agency (or State if applicable)

12.

List only the largest political entities affected (e.g., State,

and applicant’s control number (if applicable).

counties, cities).

3.

State use only (if applicable).

13

Enter the proposed start date and end date of the project.

4.

Enter Date Received by Federal Agency

14.

List the applicant’s Congressional District and any District(s)

Federal identifier number: If this application is a continuation or

affected by the program or project

revision to an existing award, enter the present Federal Identifier

number. If for a new project, leave blank.

5.

Enter legal name of applicant, name of primary organizational unit

15

Amount requested or to be contributed during the first

(including division, if applicable), which will undertake the

funding/budget period by each contributor. Value of in kind

assistance activity, enter the organization’s DUNS number

contributions should be included on appropriate lines as

(received from Dun and Bradstreet), enter the complete address of

applicable. If the action will result in a dollar change to an

the applicant (including country), and name, telephone number, e-

existing award, indicate only the amount of the change. For

mail and fax of the person to contact on matters related to this

decreases, enclose the amounts in parentheses. If both basic

application.

and supplemental amounts are included, show breakdown on

an attached sheet. For multiple program funding, use totals

and show breakdown using same categories as item 15.

6.

Enter Employer Identification Number (EIN) as assigned by the

16.

Applicants should contact the State Single Point of Contact

Internal Revenue Service.

(SPOC) for Federal Executive Order 12372 to determine

whether the application is subject to the State

intergovernmental review process.

7.

Select the appropriate letter in

17.

This question applies to the applicant organization, not the

the space provided.

I.

State Controlled

person who signs as the authorized representative. Categories

A.

State

Institution of Higher

of debt include delinquent audit disallowances, loans and

B.

County

Learning

taxes.

C.

Municipal

J.

Private University

D.

Township

K.

Indian Tribe

E.

Interstate

L.

Individual

F.

Intermunicipal

M.

Profit Organization

G.

Special District

N.

Other (Specify)

H.

Independent School

O.

Not for Profit

District

Organization

8.

Select the type from the following list:

18

To be signed by the authorized representative of the applicant.

•

"New" means a new assistance award.

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

•

“Continuation” means an extension for an additional

this application as official representative must be on file in the

funding/budget period for a project with a projected completion

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

date.

this authorization be submitted as part of the application.)

•

“Revision” means any change in the Federal Government’s

financial obligation or contingent liability from an existing

obligation. If a revision enter the appropriate letter:

A. Increase Award

B. Decrease Award

C. Increase Duration

D. Decrease Duration

9.

Name of Federal agency from which assistance is being requested

with this application.

10.

Use the Catalog of Federal Domestic Assistance number and title of

the program under which assistance is requested.