SF 424 Grant Applicatioin Standard Form

Form Approved

OMB No. 4040-0002

Exp. Date XX/XX/20XX

ATTACHMENT A - APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY Version 01.1
1.a. Type of Submission: Application Plan Funding Request Other Other (specify)		* 1.b. Frequency: Annual Quarterly Other * Other (specify)				* 1.d. Version: Initial Resubmission		Revision Update
						* 2. Date Received:		STATE USE ONLY:
						3. Applicant Identifier:		5. Date Received by State:
								6. State Application Identifier:
						4a. Federal Entity Identifier:
						4b. Federal Award Identifier:
1.c. Consolidated Application/Plan/Funding		Request?
Yes No Explanation
7. APPLICANT INFORMATION:
* a. Legal Name:
* b. Employer/Taxpayer Identification Number (EIN/TIN):						* c. Organizational DUNS:
d. Address:
* Street1:						Street2:
* City:						County / Parish:
* State:						Province:
* Country:						* Zip / Postal Code:
e. Organizational Unit:
Department Name:						Division Name:
f. Name and contact information of person to be contacted on matters involving this submission:
Prefix:	* First Name:					Middle Name:
* Last Name:						Suffix:
Title:
Organizational Affiliation:
* Telephone Number:						Fax Number:
* Email:

Authorized for Local Reproduction

Standard Form 424 Mandatory

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY Version 01.1
* 8a. TYPE OF APPLICANT:
* Other (specify):
b. Additional Description:
* 9. Name of Federal Agency:
10. Catalog of Federal Domestic Assistance Number:
CFDA Title:
11. Descriptive Title of Applicant’s Project
12. Areas Affected by Funding:
13. 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
14. FUNDING PERIOD:
a. Start Date: b. End Date:
15. ESTIMATED FUNDING:
* a. Federal ($): b. Match ($):
* 16. IS SUBMISSION SUBJECT TO REVIEW BY STATE UNDER EXECUTIVE ORDER 12372 PROCESS?
a. This submission 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 State for review. c. Program is not covered by E.O. 12372.

Authorized for Local Reproduction

Standard Form 424 Mandatory

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY Version 01.1
* 17. Is The Applicant Delinquent On Any Federal Debt?
Yes No Explanation
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 218, Section 1001) ** I Agree ** This 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:
Organizational Affiliation:
* Telephone Number:
* Fax Number:
* Email:
* Signature of Authorized Representative:
* Date Signed:
Attach supporting documents as specified in agency instructions.
Add Attachments Delete Attachments View Attachments

Authorized for Local Reproduction

Standard Form 424 Mandatory

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY Version 01.1
* Consolidated Application/Plan/Funding Request Explanation:
Authorized for Local Reproduction Standard Form 424 Mandatory
APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY Version 01.1
* Applicant Federal Debt Delinquency Explanation:
Authorized for Local Reproduction Standard Form 424 Mandatory

ATTACHMENT A

INSTRUCTIONS FOR SF 424-M

Public reporting burden for this collection is estimated to average 1 hour 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 OMB), Paperwork Reduction Project (4040-0002), Washington, DC 20503. Please do not return your completed form to OMB.

This is a standard form (including the continuation sheet) required for use as a cover sheet for submission of applications, plans, and related

information under mandatory grant 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. In addition to the instructions provided below, applicants must consult agency instructions to determine agency-specific requirements.

Item:	Entry:		Item:	Entry:
1.	a. Select one Type of Submission in accordance with agency instructions. b. Select applicable frequency for the Type of Submission in 1.a. c. Indicate if the submission is a consolidated application/plan/funding request. d. Select the applicable version for the Type of Submission in 1.a.: Initial (first submission) Resubmission (repeating the submission without change due to problems with the initial submission) Revision (any change to a submission that has not yet been accepted or approved by the agency) Update (any change to an accepted or approved submission).		9.	Enter name of Federal agency from which assistance is being requested.
			10.	Enter the Catalog of Federal Domestic Assistance (CFDA) number and title of the program under which assistance is requested. Use the continuation sheet to enter multiple CFDA numbers and titles.
			11.	Enter a descriptive title of the project. For example, include in the description the primary purposes for which the funding shall be used; (e.g. community and economic development projects in the City of Chicago).
2.	Federal use only.		12.	List areas or entities affected using categories specified in agency instructions. This optional data element is intended for use only by programs for which the area(s) affected are likely to be different than the place(s) of performance reported on the Project/Performance Site Location form.
3.	Applicant use only.
4.	a. Enter Federal entity identifier, if any, as specified in agency instructions. b. Enter Federal award identifier assigned by agency (if applicable).
5.	State use only.		13.	a. Applicant – Enter the applicant’s congressional district. 13b. Program/Project – Enter all District(s) affected by the program or project. If all congressional districts are included for a State, use “all”, e.g., all congressional districts in Maryland would show as MD-all). This optional data element is intended for use only by programs for which the area(s) affected are likely to be different than the place(s) of performance reported on the Project/Performance Site Location attachment. Attach an additional list of Program /Project Congressional Districts, if necessary, in the block provided.
6.	State use only.
7.	Enter the following: a. Legal name of applicant, b. Employer/Taxpayer Identification Number (EIN/TIN) as assigned by the Internal Revenue Service. c. Organization’s DUNS number (received from Dun and Bradstreet) or the DUNS+4 number (if available), d. Complete address of the applicant. (A nine-digit zip code / postal code is required if the country is US.) e. Name of primary organizational unit (and department / division, if applicable), which will undertake the assistance activity, f. For the person to contact on matters related to this submission: name, organizational affiliation (if affiliated with an organization other than the applicant organization), e-mail address, phone number, and fax number.
			14.	a. Enter the start date of the funding period for this submission. b. Enter the end date of the funding period for this submission.
8.	a. Select the appropriate letter and enter in the space provided. Letters O, P, Q, R, S. T, U, V, and W are not applicable. A. State Government B. County Government C. City or Township Government D. Special District Government E. Regional Organization F. U.S. Territory or Possession G. Independent School District H. Public/State Controlled Institution of Higher Education I. Indian/Native American Tribal Government (Federally Recognized)	J. Indian/Native American Tribal Government (Other than Federally Recognized) K. Indian/Native American Tribally Designated Organization L. Public/Indian Housing Authority M. Nonprofit with 501C3 IRS Status (Other than Institution of Higher Education) N. Nonprofit without 501C3 IRS Status (Other than Institution of Higher Education) X. Other (specify in accordance with agency instructions) b. Enter secondary description of applicant type if required by the agency.	15.	a. Federal – Enter the amount requested from the Federal agency. If the agency has specified an amount, enter that amount. b. Match – Enter the amount of funds from all other sources.
			16.	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. Check appropriate box. If “a.” is selected, insert date application was submitted to the State.
			17.	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.
			18.	To be signed by the authorized representative of the applicant organization. Enter the name, title, phone number, e-mail address, and fax number of authorized representative.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 4040-0002. The time required to complete this information collection is estimated to average 1 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer