0236-Sup.State. SCBGP FR 08-31-06

Version 02

OMB Number: 4040-0004

Expiration Date: 07/31/2006

* 1. Type of Submission:

Preapplication

Application

Changed/Corrected Application

* 2. Type of Application:

New

Continuation

Revision

Completed by Grants.gov upon submission.

* 3. Date Received:

4. Applicant Identifier:

5a. Federal Entity Identifier:

5b. Federal Award Identifier:

6. Date Received by State:

7. State Application Identifier:

* a. Legal Name:

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

* c. Organizational DUNS:

* Street1:

Street2:

* City:

County:

* State:

Province:

* Country:

USA: UNITED STATES

* Zip / Postal Code:

Department Name:

Division Name:

Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

Title:

Organizational Affiliation:

* Telephone Number:

Fax Number:

* Email:

* If Revision, select appropriate letter(s):

State Use Only:

8. APPLICANT INFORMATION:

d. Address:

e. Organizational Unit:

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

Application for Federal Assistance SF-424

* Other (Specify)

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.):

* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.

Add Attachments

Delete Attachments

View Attachments

Version 02

OMB Number: 4040-0004

Expiration Date: 07/31/2006

Application for Federal Assistance SF-424

* 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

Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

* Title:

* Telephone Number:

* Email:

Fax Number:

Completed by Grants.gov upon submission.

* Signature of Authorized Representative:

Completed by Grants.gov upon submission.

* Date Signed:

18. Estimated Funding ($):

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)

** 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:

Authorized for Local Reproduction

Standard Form 424 (Revised 10/2005)

Prescribed by OMB Circular A-102

OMB Number: 4040-0004

Expiration Date: 07/31/2006

Explanation

** I AGREE

Application for Federal Assistance SF-424

* a. Applicant

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

* b. Program/Project

Add Attachment

Delete Attachment

View Attachment

* a. Start Date:

* b. End Date:

16. Congressional Districts Of:

17. Proposed Project:

Version 02

Version 02

OMB Number: 4040-0004

Expiration Date: 07/31/2006

The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debt. Maximum number of

characters that can be entered is 4,000. Try and avoid extra spaces and carriage returns to maximize the availability of space.

Application for Federal Assistance SF-424

* Applicant Federal Debt Delinquency Explanation