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2. DATE SUBMITTED
Applicant Identifier
3. DATE RECEIVED BY STATE
State Application Identifier
APPLICATION FOR FEDERAL ASSISTANCE
SF 424 (R&R)
1. * TYPE OF SUBMISSION
Pre-application
4. Federal Identifier
Application
Changed/Corrected Application
5. APPLICANT INFORMATION
* Organizational DUNS:
* Legal Name:
Department:
Division:
* Street1:
Street2:
* City:
County:
Province:
* State:
* Country: USA: UN
* ZIP / Postal Code:
Person to be contacted on matters involving this application
Prefix:
* First Name:
Middle Name:
* Phone Number:
* Last Name:
Fax Number:
Suffix:
Email:
7. * TYPE OF APPLICANT:
6. * EMPLOYER IDENTIFICATION (EIN) or (TIN):
Please select one of the following
8. * TYPE OF APPLICATION:
Resubmission
Renewal
Other (Specify):
New
Continuation
Revision
Women Owned
If Revision, mark appropriate box(es).
A. Increase Award
D. Decrease Duration
B. Decrease Award
Small Business Organization Type
Socially and Economically Disadvantaged
9. * NAME OF FEDERAL AGENCY:
C. Increase Duration
E. Other (specify):
10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:
* Is this application being submitted to other agencies? Yes
No
TITLE:
What other Agencies?
11. * DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:
12. * AREAS AFFECTED BY PROJECT (cities, counties, states, etc.)
13. PROPOSED PROJECT:
* Start Date
* Ending Date
14. CONGRESSIONAL DISTRICTS OF:
a. * Applicant
b. * Project
15. PROJECT DIRECTOR/PRINCIPAL INVESTIGATOR CONTACT INFORMATION
Prefix:
* First Name:
Middle Name:
Position/Title:
* Organization Name:
Department:
Division:
* Street1:
Street2:
* City:
Province:
* Phone Number:
* Last Name:
County:
* Country: USA: UN
Fax Number:
Suffix:
* State:
* ZIP / Postal Code:
* Email:
OMB Number: 4040-0001
Expiration Date: 04/30/2008
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SF 424 (R&R)
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APPLICATION FOR FEDERAL ASSISTANCE
16. ESTIMATED PROJECT FUNDING
17. * IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE
ORDER 12372 PROCESS?
THIS PREAPPLICATION/APPLICATION WAS MADE
AVAILABLE TO THE STATE EXECUTIVE ORDER 12372
PROCESS FOR REVIEW ON:
a. YES
a. * Total Estimated Project Funding
b. * Total Federal & Non-Federal Funds
DATE:
c. * Estimated Program Income
b. NO
PROGRAM IS NOT COVERED BY E.O. 12372; OR
PROGRAM HAS NOT BEEN SELECTED BY STATE FOR
REVIEW
18. 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 18, 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.
19. Authorized Representative
* First Name:
Prefix
Middle Name:
* Last Name:
* Position/Title:
* Organization:
Department:
Division:
* Street1:
Street2:
County:
* City:
* State:
* Country: USA: UN
Province:
* Phone Number:
Suffix:
* ZIP / Postal Code:
Fax Number:
* Email:
* Signature of Authorized Representative
* Date Signed
Completed on submission to Grants.gov
Completed on submission to Grants.gov
20. Pre-application
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21. Attach an additional list of Project Congressional Districts if needed.
Add Attachment
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OMB Number: 4040-0001
Expiration Date: 04/30/2008
File Type | application/pdf |
File Modified | 2007-09-07 |
File Created | 2007-09-07 |