Form 424

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

Version 02

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:

* If Revision, select appropriate letter(s):

* Other (Specify)

4. Applicant Identifier:

Completed by Grants.gov upon submission.

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:
Street2:
* 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 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:
NGMS Agency

11. Catalog of Federal Domestic Assistance Number:

CFDA Title:

* 12. Funding Opportunity Number:
MBL-SF424FAMILY-ALLFORMS
* Title:
MBL-SF424Family-AllForms

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

Version 02

Application for Federal Assistance SF-424
16. Congressional Districts Of:
* a. Applicant

* b. Program/Project

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

Delete Attachment View Attachment

17. Proposed Project:
* b. End Date:

* a. Start 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

Completed by Grants.gov upon submission.

* Date Signed:

Completed by Grants.gov upon submission.

Standard Form 424 (Revised 10/2005)
Prescribed by OMB Circular A-102

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.

Version 02

INSTRUCTIONS FOR THE SF-424
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the
Office of Management and Budget, Paperwork Reduction Project (0348-0043), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS
PROVIDED BY THE SPONSORING AGENCY.

This is a standard form (including the continuation sheet) required for use as a cover sheet for submission of preapplications and applications and
related information under discretionary programs. Some of the items are required and some are optional at the discretion of the applicant or the
Federal agency (agency). Required items are identified with an asterisk on the form and are specified in the instructions below. In addition to the
instructions provided below, applicants must consult agency instructions to determine specific requirements.
Item
1.

2.

Entry:
Type of Submission: (Required): Select one type of submission in
accordance with agency instructions.
• Preapplication
• Application
• Changed/Corrected Application – If requested by the agency, check if this
submission is to change or correct a previously submitted application. Unless
requested by the agency, applicants may not use this to submit changes after
the closing date.

Item
10.

Entry:
Name Of Federal Agency: (Required) Enter the name of
the Federal agency from which assistance is being
requested with this application.

11.

Type of Application: (Required) Select one type of application in accordance
with agency instructions.

12.

Catalog Of Federal Domestic Assistance Number/Title:
Enter the Catalog of Federal Domestic Assistance number
and title of the program under which assistance is
requested, as found in the program announcement, if
applicable.
Funding Opportunity Number/Title: (Required) Enter the
Funding Opportunity Number and title of the opportunity
under which assistance is requested, as found in the
program announcement.
Competition Identification Number/Title: Enter the
Competition Identification Number and title of the
competition under which assistance is requested, if
applicable.

• New – An application that is being submitted to an agency for the first time.
• Continuation - An extension for an additional funding/budget period for a
project with a projected completion date. This can include renewals.
• 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.
A. Increase Award
B. Decrease Award
C. Increase Duration
D. Decrease Duration
E. Other (specify)

3.

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

4.

Applicant Identifier: Enter the entity identifier assigned buy the Federal
agency, if any, or the applicant’s control number if applicable.

5a.

Federal Entity Identifier: Enter the number assigned to your
organization by the Federal Agency, if any.

5b.

Federal Award Identifier: For new applications leave blank. For a
continuation or revision to an existing award, enter the previously assigned
Federal award identifier number. If a changed/corrected application, enter the
Federal Identifier in accordance with agency instructions.
Date Received by State: Leave this field blank. This date will be assigned by
the State, if applicable.

6.

7.

State Application Identifier: Leave this field blank. This identifier will be
assigned by the State, if applicable.

8.

Applicant Information: Enter the following in accordance with agency
instructions:

a. Legal Name: (Required): Enter the legal name of applicant that will
undertake the assistance activity. This is ththat the organization 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 the Internal
Revenue Service. If your organization is not in the US, enter 44-4444444.

13.

14.

15.

16.

Areas Affected By Project: List the areas or entities using
the categories (e.g., cities, counties, states, etc.) specified in
agency instructions. Use the continuation sheet to enter
additional areas, if needed.
Descriptive Title of Applicant’s Project: (Required) Enter
a brief descriptive title of the project. If appropriate, attach a
map showing project location (e.g., construction or real
property projects). For preapplications, attach a summary
description of the project.
Congressional Districts Of: (Required) 16a. Enter the
applicant’s Congressional District, and 16b. Enter all
District(s) affected by the program or project. Enter in the
format: 2 characters State Abbreviation – 3 characters
District Number, e.g., CA-005 for California 5th district, CA012 for California 12th district, NC-103 for North Carolina’s
103rd district. • If all congressional districts in a state are
affected, enter “all” for the district number, e.g., MD-all for all
congressional districts in Maryland. • If nationwide, i.e. all
districts within all states are affected, enter US-all. • If the
program/project is outside the US, enter 00-000.

17.

Proposed Project Start and End Dates: (Required) Enter
the proposed start date and end date of the project.

18.

Estimated Funding: (Required) Enter the amount
requested or to be contributed during the first funding/budget
period by each contributor. Value of in-kind contributions
should be included on appropriate lines, as applicable. If the
action will result in a dollar change to an existing award,
indicate only the amount of the change. For decreases,
enclose the amounts in parentheses.

c. Organizational DUNS: (Required) Enter the organization’s DUNS or
DUNS+4 number received from Dun and Bradstreet. Information on obtaining
a DUNS number may be obtained by visiting the Grants.gov website.

19.

d. Address: Enter the complete address as follows: Street address (Line 1
required), City (Required), County, State (Required, if country is US),
Province, Country (Required), Zip/Postal Code (Required, if country is US).

20.

e. Organizational Unit: Enter the name of the primary organizational unit
(and department or division, (if applicable) that will undertake the assistance
activity, if applicable.

21.

f. Name and contact information of person to be contacted on matters
involving this applicat required), organizational affiliation (if affiliated with an
organization other on: Enter the name (First and last name than the applicant
organization), telephone number (Required), fax number, and email address
(Required) of the person to contact on matters related to this application.

9.

Type of Applicant: (Required) Select up to three applicant type(s) in
accordance with agency instructions.
A. State Government
M. Nonprofit
B. County Government
N. Nonprofit
C. City or Township
O. Private Institution of
Government
Higher Education
D. Special District Government
P. Individual
E. Regional Organization
Q. For-Profit Organization
F. U.S. Territory or Possession
(Other than Small
G. Independent School District
Business)
H. Public/State Controlled
R. Small Business
Institution of Higher
S. Hispanic-serving
Education
Institution
I.
Indian/Native American
T. Historically Black
Tribal Government
Colleges and
(Federally Recognized)
Universities (HBCUs)
J. Indian/Native American
U. Tribally Controlled
Tribal Government (Other
Colleges and
than Federally Recognized)
Universities (TCCUs)
K. Indian/Native American
V. Alaska Native and
Tribally Designated
Native Hawaiian Serving
Organization
Institutions
L. Public/Indian Housing
W. Non-domestic (non-US)
Authority
Entity
X. Other (specify)

Is Application Subject to Review by State Under
Executive Order 12372 Process? Applicants should
contact the State Single Point of Contact (SPOC) for Federal
Executive Order 12372 to determine whether the application
is subject to the State intergovernmental review process.
Select the appropriate box. If “a.” is selected, enter the date
the application was submitted to the State.
Is the Applicant Delinquent on any Federal Debt?
(Required) Select the appropriate box. This question applies
to 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.
Authorized Representative: (Required) To be signed and
dated by the authorized representative of the applicant
organization. Enter the name (First and last name required)
title (Required), telephone number (Required), fax number,
and email address (Required) of the person authorized to
sign for the applicant. A copy of the governing body’s
authorization for you to sign this application as the official
representative must be on file in the applicant’s office.
(Certain Federal agencies may require that this
authorization be submitted as part of the application.)