Application for Federal Assistance

OMB Number: 4040-0004
Expiration Date: 01/31/2009

Application for Federal Assistance SF-424
* 1. Type of Submission:

* 2. Type of Application:

Preapplication

New

Application

Continuation

Changed/Corrected Application

Revision

* 3. Date Received:

Version 02
* If Revision, select appropriate letter(s):

• Other (Specify)

4. Applicant Identifier:

* 5b. Federal Award Identifier:

5a. Federal Entity 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:
• Street 1:
Street 2:
* City:
County:
* State:
Province:
* Country:

USA: UNITED STATES

• 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:

Middle Name:
• Last Name:
Suffix:
Title:
Organizational Affiliation:

* Telephone Number:
* Email:

Fax Number:

OMB Number: 4040-0004
Expiration Date: 01/31/2009

Application for Federal Assistance SF-424
9. Type of Applicant I - Select Applicant Type:

Type of Applicant 2- Select Applicant Type:

Type of Applicant 3- Select Applicant Type:

* Other (specify):

* 10. Name of Federal Agency:
NGMS Agency
11. Catalog of Federal Domestic Assistance Number:

CFDA Title:

* 12. Funding Opportunity Number:
MBL-SF424 FAMILY-ALL FORMS
* Title:
MBL-SF424 FAMILY - ALL FORMS

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: 01/31/2009

Application for Federal Assistance SF-424

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16. Congressional Districts Of:
* a. Applicant

* b. Program/Project

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

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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

Explanation

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:

Middle Name:
* Last Name:
Suffix:
* Title:
*Telephone Number:

Fax Number:

* Email:
* Signature of Authorized Representative:
Authorized for Local Reproduction

* Date Signed:
Standard Form 424 (Revised 10/2005)
Prescribed by OMB Circular A-1 02

OMB Number: 4040-0004
Expiration Date: 01/31/2009

Application for Federal Assistance SF-424
* Applicant Federal Debt Delinquency Explanation
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.

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