**FORM APPROVED**

[**SOCIAL SECURITY ADMINISTRATION** **OMB NO. 0960‑0184**]{.underline}

**INSTRUCTIONS FOR COMPLETION OF**

**FEDERAL ASSISTANCE APPLICATION FORM SSA‑96**

**FOR**

**SOCIAL SECURITY ADMINISTRATION**

**RESEARCH AND DEMONSTRATION GRANT PROGRAMS**

Form SSA‑96 is used by applicant organizations requesting award
including the applicable Federal regulations. If the

Federal assistance support under all research and authorized official is
not available, an individual

demonstration grant programs administered by the Social authorized to
act on his/her behalf may sign as \"acting for\"

Security Administration (SSA). It is to be used to request the
designated official.

or to apply for new grants, supplemental funding for an

existing grant, continuation of an existing grant, and **PART
II---BUDGET INFORMATION**

changes to an existing grant. The application form is

comprised of four parts: PART I**---**FACE SHEET, SECTIONS A, B, C, and
D should include budget

PART II**---**BUDGET INFORMATION, PART III**---** estimates for the
first budget period (usually a year) and

PROGRAM NARRATIVE, and PART IV**---** SECTION E should present the need
for Federal assistance

ASSURANCES. in the subsequent budget period(s).

.

Please read and follow the instructions carefully to avoid **SECTION
A---BUDGET SUMMARY**

delays and misunderstandings. An application may be

considered incomplete and returned if it fails to follow the Grant
applicants requesting assistance to conduct activities

instructions or if the material presented is insufficient to under grant
programs administered by SSA are expected

permit an adequate review. to contribute towards the total cost of the
activity. These

costs must be reflected in the grant application. The budget

\--Type the application using standard‑size type. for the activity must
include funds requested from SSA

\--Type on one side only. and the applicant\'s share of allowable costs.

\--Reproduced copies should be single‑sided.

\--Do not bind or staple the applications. Secure them **Line 1, Columns
a and b**

with rubber bands or paper clips.

\--If continuation pages are required, please use In column a, enter
"SSA" and in column b, enter the

standard size (81/2 \" X 11\") white bond paper. Catalog of Federal
Domestic Assistance number.

\--All items on the forms must be completed. Enter

\"NONE\" or \"NA\" (not applicable) whenever appropriate. **Line 1,
Columns c through g**

All applicants *must* submit an original and 2 copies of the *For new
applications,* leave columns c and d blank. Enter

completed application. in column e the amount of Federal funds needed to

support the project for the first funding period (usually

**PART I---FACE SHEET** a year). Enter in column f the amount of the
cost of the

project to be borne by the applicant. Enter in column g

The FACE SHEET is a multipurpose standard form and the total of columns
e and f.

the standard instructions on the back of the form should

be followed for completing the form. The following F*or continuing grant
program applications,* enter in

supplementary information is provided for completing columns c and d the
estimated amount of funds that will

these sections for SSA research and demonstration grant remain
unobligated at the end of the current grant period.

applicants. Enter in columns e and f the amount of funds needed for

the upcoming period. The amount in column g should

**Item 6** equal the total of columns e and f.

Enter the IRS employer identification number.

F*or applications which request additional funds* for a

currently approved budget period and for other changes

to existing grants, do not use columns c and d. Enter in

columns e or f, as appropriate, the amount of the increase

or decrease of funds. In column g, enter the new total

**Item 11** budgeted amount which includes the total of the previous

Select a title that is both short and descriptive. authorized budgeted
amount plus or minus, as appropriate,

any amounts shown in column e or f. The amount in

**Item 18d** column g should not equal the total of the amount(s) in

To be valid and acceptable for review, an application must columns e
and/or f.

be properly executed by an individual authorized to act for

the applicant organization and to assume the obligations Lines 2 through
5, columns a through g of this section are

imposed by the requirements and conditions for any grant not to be
completed.

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Form **SSA‑96‑BK** (03-00) Page 1

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**SECTION B---BUDGET CATEGORIES**

**Line 6g\--***Construction*

SSA programs do not have construction authority but may

Use column 1 only. support limited alteration and renovation costs.
Amounts

Leave columns 2, 3, 4, and 5 blank. included under this category must be
fully explained under

SECTION F.

**Lines 6a\--h**

Show the estimated Federal costs for each object class **Line
6h\--***Other*

category in column 1. Use for all direct costs not clearly covered by
lines a

> through g. Examples are computer use charges, consultant

costs, and equipment rentals. Amounts entered under this

**Line 6a\--***Personnel* category must be itemized and fully explained
under

Show salaries and wages only. Fees and expenses for con- SECTION F
including the method used in computing the

sultants should be included on line h\--Other. In computing cost.

estimated salary changes, an individual\'s base salary

represents the total authorized annual compensation that **Line
6i\--***Total Direct Costs*

an applicant organization would be prepared to pay for Enter the total
of lines 6a through 6h.

a specified work period. The base salary excludes income

that an individual may be permitted to earn outside of full-

time duties to the applicant organization. **Line 6j\--***Indirect
Costs*

Applicants which are State and local governments, enter

**Line 6b\--***Fringe Benefits* the amount of indirect costs. List and
explain these costs

Fringe benefits may be requested as a direct cost to the under SECTION
F. Indicate if the costs are claimed in

extent that they are treated consistently by the applicant accordance
with an approved State cost allocation plan.

organization as a direct cost to all sponsors. As an

alternative, fringe benefits may be included in the Applicants other
than State and local governments, enter

calculation of the applicant organization\'s indirect costs. the amount
of indirect costs. If the costs are claimed in

If a fringe benefit rate has been negotiated with the accordance with an
approved indirect cost rate negotiated

Social Security Administration or another Federal with the Social
Security Administration or another

agency, indicate the agency and the applicable rate Federal agency,
include the name of the agency

under SECTION F. Otherwise, indicate the method used and the rate under
SECTION F. If a rate has not been

in computing the amount of fringe benefits claimed. negotiated, list and
explain the costs, including the method

of computation.

**Line 6c\--***Travel*

Include the cost of travel for employees only. Travel for **Line
6k\--***Totals*

consultants should be included on line 6h‑Other. Under Enter the total
of lines 6i and 6j.

SECTION F describe the purpose of any travel, number

of trips involved, destinations, individuals who will be **Line
7\--***Program Income*

traveling and the projected cost per trip, i.e., local Enter the
estimated amount of income, if any, expected

transportation, air travel, per diem, etc. Include the to be generated
from this project. Do not add or subtract

computations used in determining the cost. this amount from the total
project amount. Explain the

nature and source of income under SECTION F.

**Line 6d\--***Equipment*

Include only nonexpendable personal property which has **SECTION
C---NON-FEDERAL RESOURCES**

a useful life of more than 1 year and an acquisition cost of

\$5000 or more per unit. Under SECTION F, list and On line 8, column a,
enter SSA. In column b, enter the

explain the need for each item of equipment. amount of funds or the
value of in‑kind contributions to

be provided by the applicant. In column c, enter the

**Line 6e\--***Supplies* amount of State funds. In column d, enter the
amount of

Include all tangible personal property except that listed on funds or
the value of in‑kind contributions from other

line 6d. If the total exceeds \$500, list and explain the need sources.
Enter the totals in column e. Line 12 need not be

for the items under SECTION F. completed.

**Line 6f\--***Contractual* **SECTION D---FORECASTED CASH NEEDS**

Include all procurement contracts (except those which

belong on other lines such as equipment, supplies, **Line 13** ‑ Enter
the amount of Federal cash needed by

consultant, etc.). List each contract, the amount and quarter during the
first year.

purpose under SECTION F.

**Line 14 ‑** Enter the amount of cash from all other non-

Federal sources needed by quarter during the first year.

**Line 15 ‑** Enter the totals of amounts on lines 13 and 14.

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Form **SSA‑96‑BK** (03-00) Page 2

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**SECTION E‑BUDGET ESTIMATES OF FEDERAL** Enter in column 4 the total
amount required as computed

**FUNDS NEEDED FOR BALANCE OF THE PROJECT** from the information shown
in columns 1 through 3. Use

the following formula:

This section need not be completed for (1) noncompeting [No. of Months
(Col. 2)]{.underline}

continuation applications or (2) amendments, changes or Annual Salary
(Col. 1) X 12 X

supplements (augmentation) to funds for the current year

of existing grants. Percent of Effort (Col. 3) = Total Amount Required
(Col. 4)

*For new grant applications,* on line 16, enter SSA. In 2. *Fringe
Benefits*

columns b through e enter the amounts of Federal funds Enter in the
parenthesis the applicable fringe benefit rate(s).

which *will* be needed to complete the project over the In column 4,
enter the amount determined by applying the

succeeding funding periods (in years). rate to the total of the salaries
in column 4 to which the

rate(s) applies.

**SECTION** **F‑OTHER BUDGET INFORMATION**

3\. *Option for Salary Detail Submission*

**Line 21** ‑ Use this space to explain amounts for individual
Applicants may request that the salary rates and amounts

direct object‑class cost categories that may appear to be requested for
individuals not be made available to SSA

out of the ordinary or to explain the details as required reviewing
consultants. To do so, an additional copy of this

by the instructions. page must be submitted, complete in all respects,
except

that columns 1 and 4 may be left blank.

The information provided should include sufficient detail

to facilitate a determination as to allowability, relevance 4.
*Function/Task Description*

to the project, and cost/benefit. Attach a description of the function
or task to be

performed for all personnel listed.

**Line 22** ‑ Enter the type of indirect rate (provisional,

predetermined, final or fixed) that will be in effect during **PART
III‑PROGRAM NARRATIVE**

the funding period, the estimated amount of the base to

which the rate is applied, and the total indirect expense. The review of
grant applications is aided materially when

project descriptions are presented in a reasonably uniform

**Line 23** ‑ Provide any other explanations or comments pattern. For
this reason, the following guidelines should

deemed necessary. be used in completing the program narrative.

**SECTION G‑PERSONNEL** Continuation pages should be typed,
single‑spaced on one

side only of standard‑size white bond paper. Each page

An example for completion of this section is included on should be
numbered consecutively at the bottom beginning

the back of the form. with page III‑1.

1\. *Personnel* **NEW AND COMPETING CONTINUATION GRANTS**

List all personnel chargeable as a direct cost to the project

by title, salary and percentage of effort. Include names for The program
narrative should describe the major issues

key positions only. of concern, the research and demonstration
methodology

to be used in addressing these issues, and the potential for

Enter in column 1 the annual (12 months) salary rate for implementation
of the results. Review of the narrative will

each position which will be filled for all or any part of the
concentrate on the above and on the manageability of the

year by an incumbent working on the project. This rate design as
reflected in the work plan. Should the proposed

may not be more than that paid by the grantee to other project be
funded, the information provided in the

employees in comparable positions or, if the grantee has narrative will
form the basis for monitoring the project and

no comparable positions, the rate may not be more than evaluating
progress for future funding decisions as well as

that paid for such services elsewhere in the community. aiding SSA in
planning for required technical assistance

and for the implementation and dissemination of project

Enter in column 2 the number of months the position will findings.

be filled by an incumbent working on the project.

Enter in column 3 the percent of time or effort the

incumbent will devote to the project during the number

of months shown in column 2.

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The narrative should be organized under the following **III *. Research
and Demonstration Methodology***

major headings:

A. List the hypotheses to be tested and explain how

I . Project Title and Objectives they relate to the project objectives.

II . Background and Importance of Project

III . Research and Demonstration Methodology B. If experimental and
control groups are

IV . Evaluation Plan appropriate, discuss the experimental design of

V. Work Plan the project.

VI . Project Staff and Facilities

VII . Implementation Potential 1. Discuss how the control or comparison

VIII . Dissemination of Results groups will be formed. Specify how
subjects

will be selected (and who will do the

The program narrative should be completed as follows: selecting) for
both control and test

populations.

**I.** ***Project Title and Objectives*** 2. Indicate the intended
number of subjects to

be served (enrolled, surveyed, etc.).

A. Select a title that is both **short** and descriptive. 3. Specify how
the size of these groups will be

B. Specify the objectives of the project. or was determined based on the
hypotheses

to be tested.

**II *. Background and Importance of Project*** 4. Describe the process
of identifying and

acquiring \"eligible\" subjects.

A . Discuss the major areas the project will address 5. Describe any
incentives to encourage

and the national significance of these problem subjects to participate.

areas. Include factual comments on the number 6. Describe how dropouts
will be handled.

of individuals (recipients) affected and the 7. Comment on the
methodological problems

magnitude of the human, physical and fiscal that may arise and how they
will be treated.

resources involved.

C. Explain by what procedures the hypotheses will

B . Discuss the state‑of‑the‑art in resolving these be rejected or
accepted.

problems. Include approaches that have been or

are being taken in resolving the problems and

the outcomes of these approaches. Also include **IV . *Evaluation
Plan***

\(1\) the organizational structures which currently

deal with the problems, (2) the services The evaluation plan refers only
to the plan for

provided, and (3) the administrative methods evaluating the ultimate
success or failure of the

currently used. project and not the plan for evaluating the progress

of the project staff in accomplishing the project

C . Discuss the approaches proposed for resolving objectives. The latter
evaluation will be an ongoing

the problems included with this project and the effort of SSA research
and demonstration staff.

rationale supporting the proposed resolution.

D. If the performance of any of the project A. Discuss the criteria by
which the project will be

activities is to be transferred to a third party judged a success or
failure.

(e.g., evaluation of the project ‑ see IV. E.) B. List the data to be
collected and the normal

include the following information: (1) a variability associated with the
data.

description of the activities in question; (2) a C. Indicate by what
procedures the data are to be

justification for the performance by a third collected (survey, computer
tapes, interviews,

party; (3) estimated costs and time schedule; and etc.) and how often.

\(4\) a description of the kinds of organizations D. Discuss how the
data are to be analyzed to

or other parties to be selected and the method establish the success or
failure of the project.

of selection. E. Indicate who is to conduct the evaluation. If an

independent contractor, include the scope of

> work for the Request for Proposal (RFP).

E. Summarize important results obtained by others

> which bear on this project, citing publications
>
> where applicable. It should be apparent from
>
> the summary that existing literature has been **V *. Work Plan***
>
> critically reviewed and that related programs
>
> being carried on elsewhere are known to the A. List and describe each
> task (at least one
>
> applicant. paragraph per task) that must be completed to
>
> carry out the project. (Most projects should

F. Cite the most important publications of the have between 10 and 20
tasks.)

> Project Director on this or closely related work.
>
> If none, list the most important publications in
>
> other related fields over the last 5 years.

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>
> B. Specify the product(s) for each task that can B. Specify any
> special features of the target
>
> be provided to SSA on request as proof that group(s) and the
> operational environment in
>
> the task has been completed. which the project will operate that would
> vary
>
> C. Prepare a Gantt chart showing the start and in other locations,
> thus influencing utilization
>
> end dates for each task. Include milestones potential, e.g., rural
> population, minority
>
> such as: composition, political climate, governmental
>
> \--onsite acquisition of staff; centralization or decentralization,
> etc.
>
> \--physical acquisition of facilities and C. Specify how final
> products will be oriented
>
> equipment; toward facilitating implementation in other
>
> \--pretest of measurement devices; locations.
>
> \--establishment of linkages with ongoing D. Discuss commitments made
> by Federal, State
>
> programs; or local governments and other organizations
>
> \--acquisition of subjects for testing; to continue the project or
> implement its
>
> \--signing of agreements and contracts; findings after completion.
>
> \--arrangements with public and private
>
> agencies to provide services, data or other **VIII . *Dissemination*
> of *Results***
>
> support;
>
> \--steps to involve potential users; and A. Specify the means to
> disseminate the results
>
> \--completion and dissemination of final report. and promote
> utilization of these results by

D. Show the level of effort in man‑months (by others in the field.

project personnel, if possible) required to B. Describe the training
methods and content to

complete each task. be packaged for dissemination and use for

E. Indicate the formats for the interim and final others. Note any
restrictions or limitations

> Progress reports to be submitted to SSA. (patent, copyright,
> proprietary interest, etc.)
>
> on its use by SSA.
>
> **VI . *Project Staff and Facilities*** **NONCOMPETING CONTINUATION
> GRANTS**
>
> A. Include a project staff organization chart and, In the narrative
> for noncompeting continuation
>
> if applicable, show the linkages with applications, include changes or
> additions to the original
>
> State/county organization charts. Note that proposal that are required
> to make it an up‑to‑date
>
> the Project Director should be full‑time, if representation of the
> project. Include changes or
>
> possible. modifications in the project objectives, work plan, and
>
> B. Staff Qualifications‑Include a biographical evaluation design and
> the reasons for the changes.
>
> sketch of the proposed Project Director and
>
> other key project staff, highlighting special 1. Discuss progress
> towards meeting the project\'s
>
> qualifications that relate to the accomplish‑ objectives covering the
> following points:
>
> ment of project objectives, such as education (a) Accomplishments,
> findings, and products to
>
> and experience. For each of the key staff not date. List in
> chronological order the sequence of
>
> identified at the time of application, provide significant events and
> accomplishments. Explain
>
> (in lieu of a biographical sketch) a job any time lags in completing
> tasks and adhering
>
> description, qualifications sought and a to the work plan and time
> schedule originally
>
> projection of how long after notification of approved.
>
> grant award the recruitment of these staff will take. (b) Problems
> encountered, particularly with respect
>
> C. Discuss other qualifications of staff or of to methodology,
> sampling and control group
>
> organizations affiliated with the project that identification.
>
> enhance its potential success. 2. Discuss changes in project personnel
> and provide
>
> D. Include copies of endorsements or letters of biographical
> information for new key personnel.
>
> agreement from State administrators, private
>
> service providers and other potential users. **PART IV‑ASSURANCES**
>
> E. Describe the facilities where the activity will
>
> be conducted and the location. This form must be executed by an
> authorized official of
>
> the applicant organization or agency and submitted with
>
> **VII *. Implementation Potential*** the grant application.
>
> A. Estimate the costs and the benefits that might
>
> accrue from replication or installation on a
>
> statewide basis, specifying the assumptions
>
> and logic used in making the estimate.

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Form **SSA‑96‑BK** (03-00) **⋆ U.S. Government Printing Office: 1994
300-945/00013** Page 5

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OMB Approval No. 0348-0043

+--------+---+----+------+---+------+--------+------------+------------+
| *      |   |    |      | 2 |      |        | Applicant  |            |
| *APPLI |   |    |      | \ |      |        | Identifier |            |
| CATION |   |    |      | . |      |        |            |            |
| FOR**  |   |    |      | D |      |        |            |            |
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+--------+---+----+------+---+------+--------+------------+------------+
| **F    |   |    |      |   |      |        |            |            |
| EDERAL |   |    |      |   |      |        |            |            |
| ASSIST |   |    |      |   |      |        |            |            |
| ANCE** |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| 1\.    |   |    |      | 3 |      |        | State      |            |
| TYPE   |   |    |      | \ |      |        | A          |            |
| OF     |   |    |      | . |      |        | pplication |            |
| SUBMI  |   |    |      | D |      |        | Identifier |            |
| SSION: |   |    |      | A |      |        |            |            |
|        |   |    |      | T |      |        |            |            |
|        |   |    |      | E |      |        |            |            |
|        |   |    |      | R |      |        |            |            |
|        |   |    |      | E |      |        |            |            |
|        |   |    |      | C |      |        |            |            |
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+--------+---+----+------+---+------+--------+------------+------------+
| *Appli |   |    |      |   |      |        |            |            |
| cation |   |    |      |   |      |        |            |            |
| Pre    |   |    |      |   |      |        |            |            |
| applic |   |    |      |   |      |        |            |            |
| ation* |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
|       |   |    |      | 4 |      |        | Federal    |            |
| Constr |   |    |      | \ |      |        | Identifier |            |
| uction |   |    |      | . |      |        |            |            |
| Constr |   |    |      | D |      |        |            |            |
| uction |   |    |      | A |      |        |            |            |
|        |   |    |      | T |      |        |            |            |
|        |   |    |      | E |      |        |            |            |
|        |   |    |      | R |      |        |            |            |
|        |   |    |      | E |      |        |            |            |
|        |   |    |      | C |      |        |            |            |
|        |   |    |      | E |      |        |            |            |
|        |   |    |      | I |      |        |            |            |
|        |   |    |      | V |      |        |            |            |
|        |   |    |      | E |      |        |            |            |
|        |   |    |      | D |      |        |            |            |
|        |   |    |      | B |      |        |            |            |
|        |   |    |      | Y |      |        |            |            |
|        |   |    |      | F |      |        |            |            |
|        |   |    |      | E |      |        |            |            |
|        |   |    |      | D |      |        |            |            |
|        |   |    |      | E |      |        |            |            |
|        |   |    |      | R |      |        |            |            |
|        |   |    |      | A |      |        |            |            |
|        |   |    |      | L |      |        |            |            |
|        |   |    |      | A |      |        |            |            |
|        |   |    |      | G |      |        |            |            |
|        |   |    |      | E |      |        |            |            |
|        |   |    |      | N |      |        |            |            |
|        |   |    |      | C |      |        |            |            |
|        |   |    |      | Y |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
|        |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| Non-   |   |    |      |   |      |        |            |            |
| Constr |   |    |      |   |      |        |            |            |
| uction |   |    |      |   |      |        |            |            |
| Non-   |   |    |      |   |      |        |            |            |
| Constr |   |    |      |   |      |        |            |            |
| uction |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| 5\.    |   |    |      |   |      |        |            |            |
| APP    |   |    |      |   |      |        |            |            |
| LICANT |   |    |      |   |      |        |            |            |
| INFOR  |   |    |      |   |      |        |            |            |
| MATION |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| Legal  |   |    |      |   |      | Or     |            |            |
| Name:  |   |    |      |   |      | ganiza |            |            |
|        |   |    |      |   |      | tional |            |            |
|        |   |    |      |   |      | Unit:  |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| A      |   |    |      |   |      | Name   |            |            |
| ddress |   |    |      |   |      | and    |            |            |
| (give  |   |    |      |   |      | tel    |            |            |
| city,  |   |    |      |   |      | ephone |            |            |
| c      |   |    |      |   |      | number |            |            |
| ounty, |   |    |      |   |      | of the |            |            |
| state, |   |    |      |   |      | person |            |            |
| and    |   |    |      |   |      | to be  |            |            |
| zip    |   |    |      |   |      | con    |            |            |
| code): |   |    |      |   |      | tacted |            |            |
|        |   |    |      |   |      | on     |            |            |
|        |   |    |      |   |      | m      |            |            |
|        |   |    |      |   |      | atters |            |            |
|        |   |    |      |   |      | inv    |            |            |
|        |   |    |      |   |      | olving |            |            |
|        |   |    |      |   |      | this   |            |            |
|        |   |    |      |   |      | appli  |            |            |
|        |   |    |      |   |      | cation |            |            |
|        |   |    |      |   |      | (give  |            |            |
|        |   |    |      |   |      | area   |            |            |
|        |   |    |      |   |      | code)  |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
|        |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| 6\.    |   |    |      |   |      | 7\.    |            |            |
| EM     |   |    |      |   |      | TYPE   |            |            |
| PLOYER |   |    |      |   |      | OF     |            |            |
| ID     |   |    |      |   |      | APPL   |            |            |
| ENTIFI |   |    |      |   |      | ICANT: |            |            |
| CATION |   |    |      |   |      | (enter |            |            |
| NUMBER |   |    |      |   |      | appro  |            |            |
| (EIN): |   |    |      |   |      | priate |            |            |
|        |   |    |      |   |      | letter |            |            |
|        |   |    |      |   |      | in     |            |            |
|        |   |    |      |   |      | box) ⋆ |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| \-\--  |   |    |      |   |      | A.     |            |            |
|        |   |    |      |   |      | State  |            |            |
|        |   |    |      |   |      | H.     |            |            |
|        |   |    |      |   |      | Indep  |            |            |
|        |   |    |      |   |      | endent |            |            |
|        |   |    |      |   |      | School |            |            |
|        |   |    |      |   |      | Dist.  |            |            |
|        |   |    |      |   |      |        |            |            |
|        |   |    |      |   |      | B.     |            |            |
|        |   |    |      |   |      | County |            |            |
|        |   |    |      |   |      | I.     |            |            |
|        |   |    |      |   |      | State  |            |            |
|        |   |    |      |   |      | Cont   |            |            |
|        |   |    |      |   |      | rolled |            |            |
|        |   |    |      |   |      | Insti  |            |            |
|        |   |    |      |   |      | tution |            |            |
|        |   |    |      |   |      | of     |            |            |
|        |   |    |      |   |      | Higher |            |            |
|        |   |    |      |   |      | Le     |            |            |
|        |   |    |      |   |      | arning |            |            |
|        |   |    |      |   |      |        |            |            |
|        |   |    |      |   |      | C.     |            |            |
|        |   |    |      |   |      | Mun    |            |            |
|        |   |    |      |   |      | icipal |            |            |
|        |   |    |      |   |      | J.     |            |            |
|        |   |    |      |   |      | P      |            |            |
|        |   |    |      |   |      | rivate |            |            |
|        |   |    |      |   |      | Univ   |            |            |
|        |   |    |      |   |      | ersity |            |            |
|        |   |    |      |   |      |        |            |            |
|        |   |    |      |   |      | D.     |            |            |
|        |   |    |      |   |      | To     |            |            |
|        |   |    |      |   |      | wnship |            |            |
|        |   |    |      |   |      | K.     |            |            |
|        |   |    |      |   |      | Indian |            |            |
|        |   |    |      |   |      | Tribe  |            |            |
|        |   |    |      |   |      |        |            |            |
|        |   |    |      |   |      | E.     |            |            |
|        |   |    |      |   |      | Inte   |            |            |
|        |   |    |      |   |      | rstate |            |            |
|        |   |    |      |   |      | L.     |            |            |
|        |   |    |      |   |      | Indi   |            |            |
|        |   |    |      |   |      | vidual |            |            |
|        |   |    |      |   |      |        |            |            |
|        |   |    |      |   |      | F.     |            |            |
|        |   |    |      |   |      | In     |            |            |
|        |   |    |      |   |      | termun |            |            |
|        |   |    |      |   |      | icipal |            |            |
|        |   |    |      |   |      | M.     |            |            |
|        |   |    |      |   |      | Profit |            |            |
|        |   |    |      |   |      | Organi |            |            |
|        |   |    |      |   |      | zation |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
|        |   |    |      |   |      | G.     |            |            |
|        |   |    |      |   |      | S      |            |            |
|        |   |    |      |   |      | pecial |            |            |
|        |   |    |      |   |      | Di     |            |            |
|        |   |    |      |   |      | strict |            |            |
|        |   |    |      |   |      | N.     |            |            |
|        |   |    |      |   |      | Other  |            |            |
|        |   |    |      |   |      | (Spe   |            |            |
|        |   |    |      |   |      | cify): |            |            |
|        |   |    |      |   |      | \_     |            |            |
|        |   |    |      |   |      | \_\_\_ |            |            |
|        |   |    |      |   |      | \_\_\_ |            |            |
|        |   |    |      |   |      | \_\_\_ |            |            |
|        |   |    |      |   |      | \_\_\_ |            |            |
|        |   |    |      |   |      | \_\_\_ |            |            |
|        |   |    |      |   |      | \_\_\_ |            |            |
|        |   |    |      |   |      | \_\_\_ |            |            |
|        |   |    |      |   |      | \_\_\_ |            |            |
|        |   |    |      |   |      | N.     |            |            |
|        |   |    |      |   |      | Other  |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| 8\.    |   |    |      |   |      |        |            |            |
| TYPE   |   |    |      |   |      |        |            |            |
| OF     |   |    |      |   |      |        |            |            |
| APPLIC |   |    |      |   |      |        |            |            |
| ATION: |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| New    |   |    |      |   |      |        |            |            |
| Contin |   |    |      |   |      |        |            |            |
| uation |   |    |      |   |      |        |            |            |
| Re     |   |    |      |   |      |        |            |            |
| vision |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
|        |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| If     |   |    |      |   |      |        |            |            |
| Rev    |   |    |      |   |      |        |            |            |
| ision, |   |    |      |   |      |        |            |            |
| enter  |   |    |      |   |      |        |            |            |
| appro  |   |    |      |   |      |        |            |            |
| priate |   |    |      |   |      |        |            |            |
| let    |   |    |      |   |      |        |            |            |
| ter(s) |   |    |      |   |      |        |            |            |
| in     |   |    |      |   |      |        |            |            |
| bo     |   |    |      |   |      |        |            |            |
| x(es): |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| A.     |   |    |      |   |      |        |            |            |
| In     |   |    |      |   |      |        |            |            |
| crease |   |    |      |   |      |        |            |            |
| Award  |   |    |      |   |      |        |            |            |
| B.     |   |    |      |   |      |        |            |            |
| De     |   |    |      |   |      |        |            |            |
| crease |   |    |      |   |      |        |            |            |
| Award  |   |    |      |   |      |        |            |            |
| C.     |   |    |      |   |      |        |            |            |
| In     |   |    |      |   |      |        |            |            |
| crease |   |    |      |   |      |        |            |            |
| Du     |   |    |      |   |      |        |            |            |
| ration |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| D.     |   |    |      |   |      | 9\.    |            |            |
| De     |   |    |      |   |      | NAME   |            |            |
| crease |   |    |      |   |      | OF     |            |            |
| Du     |   |    |      |   |      | F      |            |            |
| ration |   |    |      |   |      | EDERAL |            |            |
| Other  |   |    |      |   |      | A      |            |            |
| (spe   |   |    |      |   |      | GENCY: |            |            |
| cify): |   |    |      |   |      |        |            |            |
|        |   |    |      |   |      |        |            |            |
| \_     |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
| \_\_\_ |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| 10\.   |   |    |      |   |      | 11\.   |            |            |
| C      |   |    |      |   |      | DESCR  |            |            |
| ATALOG |   |    |      |   |      | IPTIVE |            |            |
| OF     |   |    |      |   |      | TITLE  |            |            |
| F      |   |    |      |   |      | OF     |            |            |
| EDERAL |   |    |      |   |      | APPLI  |            |            |
| DO     |   |    |      |   |      | CANT'S |            |            |
| MESTIC |   |    |      |   |      | PR     |            |            |
|        |   |    |      |   |      | OJECT: |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| ASS    |   |    |      |   |      |        |            |            |
| ISTANT |   |    |      |   |      |        |            |            |
| N      |   |    |      |   |      |        |            |            |
| UMBER: |   |    |      |   |      |        |            |            |
| \-\--  |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| TITLE: |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| 12\.   |   |    |      |   |      |        |            |            |
| AREAS  |   |    |      |   |      |        |            |            |
| AF     |   |    |      |   |      |        |            |            |
| FECTED |   |    |      |   |      |        |            |            |
| BY     |   |    |      |   |      |        |            |            |
| P      |   |    |      |   |      |        |            |            |
| ROJECT |   |    |      |   |      |        |            |            |
| (c     |   |    |      |   |      |        |            |            |
| ities, |   |    |      |   |      |        |            |            |
| cou    |   |    |      |   |      |        |            |            |
| nties, |   |    |      |   |      |        |            |            |
| s      |   |    |      |   |      |        |            |            |
| tates, |   |    |      |   |      |        |            |            |
| etc.): |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| 13\.   |   |    | 14\. |   |      |        |            |            |
| PR     |   |    | C    |   |      |        |            |            |
| OPOSED |   |    | ONGR |   |      |        |            |            |
| PR     |   |    | ESSI |   |      |        |            |            |
| OJECT: |   |    | ONAL |   |      |        |            |            |
|        |   |    | D    |   |      |        |            |            |
|        |   |    | ISTR |   |      |        |            |            |
|        |   |    | ICTS |   |      |        |            |            |
|        |   |    | OF:  |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| Start  | E |    | a\.  |   |      |        | b\.        |            |
| Date   | n |    | A    |   |      |        | Project    |            |
|        | d |    | ppli |   |      |        |            |            |
|        | i |    | cant |   |      |        |            |            |
|        | n |    |      |   |      |        |            |            |
|        | g |    |      |   |      |        |            |            |
|        | D |    |      |   |      |        |            |            |
|        | a |    |      |   |      |        |            |            |
|        | t |    |      |   |      |        |            |            |
|        | e |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| 15\.   |   |    |      |   | 16\. |        |            |            |
| EST    |   |    |      |   | IS   |        |            |            |
| IMATED |   |    |      |   | APP  |        |            |            |
| FU     |   |    |      |   | LICA |        |            |            |
| NDING: |   |    |      |   | TION |        |            |            |
|        |   |    |      |   | SUB  |        |            |            |
|        |   |    |      |   | JECT |        |            |            |
|        |   |    |      |   | TO   |        |            |            |
|        |   |    |      |   | RE   |        |            |            |
|        |   |    |      |   | VIEW |        |            |            |
|        |   |    |      |   | BY   |        |            |            |
|        |   |    |      |   | S    |        |            |            |
|        |   |    |      |   | TATE |        |            |            |
|        |   |    |      |   | E    |        |            |            |
|        |   |    |      |   | XECU |        |            |            |
|        |   |    |      |   | TIVE |        |            |            |
|        |   |    |      |   | O    |        |            |            |
|        |   |    |      |   | RDER |        |            |            |
|        |   |    |      |   | 1    |        |            |            |
|        |   |    |      |   | 2372 |        |            |            |
|        |   |    |      |   | PROC |        |            |            |
|        |   |    |      |   | ESS? |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| a\.    |   | \$ |      | . | a\.  |        |            |            |
| F      |   |    |      | 0 | YES. |        |            |            |
| ederal |   |    |      | 0 | THIS |        |            |            |
|        |   |    |      |   | PR   |        |            |            |
|        |   |    |      |   | EAPP |        |            |            |
|        |   |    |      |   | LICA |        |            |            |
|        |   |    |      |   | TION |        |            |            |
|        |   |    |      |   | /APP |        |            |            |
|        |   |    |      |   | LICA |        |            |            |
|        |   |    |      |   | TION |        |            |            |
|        |   |    |      |   | WAS  |        |            |            |
|        |   |    |      |   | MADE |        |            |            |
|        |   |    |      |   | A    |        |            |            |
|        |   |    |      |   | VAIL |        |            |            |
|        |   |    |      |   | ABLE |        |            |            |
|        |   |    |      |   | TO   |        |            |            |
|        |   |    |      |   | THE  |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
|        |   |    |      |   | S    |        |            |            |
|        |   |    |      |   | TATE |        |            |            |
|        |   |    |      |   | E    |        |            |            |
|        |   |    |      |   | XECU |        |            |            |
|        |   |    |      |   | TIVE |        |            |            |
|        |   |    |      |   | O    |        |            |            |
|        |   |    |      |   | RDER |        |            |            |
|        |   |    |      |   | 1    |        |            |            |
|        |   |    |      |   | 2372 |        |            |            |
|        |   |    |      |   | PRO  |        |            |            |
|        |   |    |      |   | CESS |        |            |            |
|        |   |    |      |   | FOR  |        |            |            |
|        |   |    |      |   | RE   |        |            |            |
|        |   |    |      |   | VIEW |        |            |            |
|        |   |    |      |   | ON:  |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| b\.    |   | \$ |      | . |      |        |            |            |
| App    |   |    |      | 0 |      |        |            |            |
| licant |   |    |      | 0 |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
|        |   |    |      |   | DA   |        |            |            |
|        |   |    |      |   | TE\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
|        |   |    |      |   | \_\_ |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| c\.    |   | S  |      | . | b\.  |        |            |            |
| State  |   |    |      | 0 | NO.  |        |            |            |
|        |   |    |      | 0 | PRO  |        |            |            |
|        |   |    |      |   | GRAM |        |            |            |
|        |   |    |      |   | IS   |        |            |            |
|        |   |    |      |   | NOT  |        |            |            |
|        |   |    |      |   | COV  |        |            |            |
|        |   |    |      |   | ERED |        |            |            |
|        |   |    |      |   | BY   |        |            |            |
|        |   |    |      |   | E.O. |        |            |            |
|        |   |    |      |   | 1    |        |            |            |
|        |   |    |      |   | 2372 |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| d\.    |   | \$ |      | . | OR   |        |            |            |
| Local  |   |    |      | 0 | PRO  |        |            |            |
|        |   |    |      | 0 | GRAM |        |            |            |
|        |   |    |      |   | HAS  |        |            |            |
|        |   |    |      |   | NOT  |        |            |            |
|        |   |    |      |   | BEEN |        |            |            |
|        |   |    |      |   | SELE |        |            |            |
|        |   |    |      |   | CTED |        |            |            |
|        |   |    |      |   | BY   |        |            |            |
|        |   |    |      |   | S    |        |            |            |
|        |   |    |      |   | TATE |        |            |            |
|        |   |    |      |   | FOR  |        |            |            |
|        |   |    |      |   | RE   |        |            |            |
|        |   |    |      |   | VIEW |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| e\.    |   | \$ |      | . |      |        |            |            |
| Other  |   |    |      | 0 |      |        |            |            |
|        |   |    |      | 0 |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| f\.    |   | \$ |      | . | 17\. |        |            |            |
| P      |   |    |      | 0 | IS   |        |            |            |
| rogram |   |    |      | 0 | THE  |        |            |            |
| Income |   |    |      |   | A    |        |            |            |
|        |   |    |      |   | PPLI |        |            |            |
|        |   |    |      |   | CANT |        |            |            |
|        |   |    |      |   | DE   |        |            |            |
|        |   |    |      |   | LINQ |        |            |            |
|        |   |    |      |   | UENT |        |            |            |
|        |   |    |      |   | ON   |        |            |            |
|        |   |    |      |   | ANY  |        |            |            |
|        |   |    |      |   | FED  |        |            |            |
|        |   |    |      |   | ERAL |        |            |            |
|        |   |    |      |   | D    |        |            |            |
|        |   |    |      |   | EBT? |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
|        |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| g\.    |   | \$ |      | . | Yes  |        |            |            |
| TOTAL  |   |    |      | 0 | If   |        |            |            |
|        |   |    |      | 0 | "Y   |        |            |            |
|        |   |    |      |   | es," |        |            |            |
|        |   |    |      |   | at   |        |            |            |
|        |   |    |      |   | tach |        |            |            |
|        |   |    |      |   | an   |        |            |            |
|        |   |    |      |   | expl |        |            |            |
|        |   |    |      |   | anat |        |            |            |
|        |   |    |      |   | ion. |        |            |            |
|        |   |    |      |   | No   |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| 18\.   |   |    |      |   |      |        |            |            |
| TO THE |   |    |      |   |      |        |            |            |
| BEST   |   |    |      |   |      |        |            |            |
| OF MY  |   |    |      |   |      |        |            |            |
| KNO    |   |    |      |   |      |        |            |            |
| WLEDGE |   |    |      |   |      |        |            |            |
| AND    |   |    |      |   |      |        |            |            |
| B      |   |    |      |   |      |        |            |            |
| ELIEF, |   |    |      |   |      |        |            |            |
| ALL    |   |    |      |   |      |        |            |            |
| DATA   |   |    |      |   |      |        |            |            |
| IN     |   |    |      |   |      |        |            |            |
| THIS   |   |    |      |   |      |        |            |            |
| AP     |   |    |      |   |      |        |            |            |
| PLICAT |   |    |      |   |      |        |            |            |
| ION/PR |   |    |      |   |      |        |            |            |
| EAPPLI |   |    |      |   |      |        |            |            |
| CATION |   |    |      |   |      |        |            |            |
| ARE    |   |    |      |   |      |        |            |            |
| TRUE   |   |    |      |   |      |        |            |            |
| AND    |   |    |      |   |      |        |            |            |
| CO     |   |    |      |   |      |        |            |            |
| RRECT. |   |    |      |   |      |        |            |            |
| THE    |   |    |      |   |      |        |            |            |
| DO     |   |    |      |   |      |        |            |            |
| CUMENT |   |    |      |   |      |        |            |            |
| HAS    |   |    |      |   |      |        |            |            |
| BEEN   |   |    |      |   |      |        |            |            |
| DULY   |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| AUTH   |   |    |      |   |      |        |            |            |
| ORIZED |   |    |      |   |      |        |            |            |
| BY THE |   |    |      |   |      |        |            |            |
| GOV    |   |    |      |   |      |        |            |            |
| ERNING |   |    |      |   |      |        |            |            |
| BODY   |   |    |      |   |      |        |            |            |
| OF THE |   |    |      |   |      |        |            |            |
| APP    |   |    |      |   |      |        |            |            |
| LICANT |   |    |      |   |      |        |            |            |
| AND    |   |    |      |   |      |        |            |            |
| THE    |   |    |      |   |      |        |            |            |
| APP    |   |    |      |   |      |        |            |            |
| LICANT |   |    |      |   |      |        |            |            |
| WILL   |   |    |      |   |      |        |            |            |
| COMPLY |   |    |      |   |      |        |            |            |
| WITH   |   |    |      |   |      |        |            |            |
| THE    |   |    |      |   |      |        |            |            |
| AT     |   |    |      |   |      |        |            |            |
| TACHED |   |    |      |   |      |        |            |            |
| ASSU   |   |    |      |   |      |        |            |            |
| RANCES |   |    |      |   |      |        |            |            |
| IF THE |   |    |      |   |      |        |            |            |
| ASSI   |   |    |      |   |      |        |            |            |
| STANCE |   |    |      |   |      |        |            |            |
| IS     |   |    |      |   |      |        |            |            |
| A      |   |    |      |   |      |        |            |            |
| WARDED |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| a      |   |    |      |   |      | b\.    |            | c\.        |
| Typed  |   |    |      |   |      | Title  |            | Telephone  |
| Name   |   |    |      |   |      |        |            | number     |
| of     |   |    |      |   |      |        |            |            |
| Auth   |   |    |      |   |      |        |            |            |
| orized |   |    |      |   |      |        |            |            |
| Re     |   |    |      |   |      |        |            |            |
| presen |   |    |      |   |      |        |            |            |
| tative |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+
| d\.    |   |    |      |   |      |        |            | e\. Date   |
| Sig    |   |    |      |   |      |        |            | Signed     |
| nature |   |    |      |   |      |        |            |            |
| of     |   |    |      |   |      |        |            |            |
| Auth   |   |    |      |   |      |        |            |            |
| orized |   |    |      |   |      |        |            |            |
| Re     |   |    |      |   |      |        |            |            |
| presen |   |    |      |   |      |        |            |            |
| tative |   |    |      |   |      |        |            |            |
+--------+---+----+------+---+------+--------+------------+------------+

Previous Editions Not Usable Standard Form 424 (REV4‑88)

Page I Prescribed by OMB Circular A‑102

> **INSTRUCTIONS FOR THE SF 424**

This is a standard form used by applicants as a required facesheet for
preapplications and applications submitted

for Federal assistance. It will be used by Federal agencies to obtain
applicant certification that States which have

established a review and comment procedure in response to Executive
Order 12372 and have selected the

program to be included in their process, have been given an opportunity
to review the applicant\'s submission.

Item: Entry: Item: Entry:

1\. Self‑explanatory. append an explanation on a separate sheet. If

appropriate (e.g., construction or real property

2\. Date application submitted to Federal agency projects), attach a map
showing project location.

(or State if applicable) & applicant\'s control For preapplications, use
a separate sheet to

number (if applicable). provide a summary description of this project.

3\. State use only (if applicable). 12. List only the largest political
entities affected

(e. g., State, counties, cities).

4\. If this application is to continue or revise an

existing award, enter present Federal identifier 13. Self‑explanatory.

number. If for a new project, leave blank.

14\. List the applicant\'s Congressional District and

5\. Legal name of applicant organization, name of any District(s)
affected by the program or

primary organizational unit which will under‑ project.

take the assistance activity, complete address of

the applicant, and name and telephone number 15. Amount requested or to
be contributed during

of the person to contact on matters related to this the first
funding/budget period by each contrib-

application. utor. Value of in‑kind contributions should be

included on appropriate lines as applicable. If

6\. Enter Employer Identification Number (EIN) as the action will result
in a dollar change to an

assigned by the Internal Revenue Service. existing award, indicate
*[on1y]{.underline}* the amount of the

change. For decreases, enclose the amounts in

7\. Enter the appropriate letter in the space pro‑ parentheses. If both
basic and supplemental

vided. amounts are included, show breakdown on an

attached sheet. For multiple program funding,

8\. Check appropriate box and enter appropriate let‑ use totals and show
breakdown using same

ter(s) in the space(s) provided: categories as item 15.

> \--\"New\" means a new assistance award. 16. Applicants should contact
> the State Single Point
>
> of Contact (SPOC) for Federal Executive Order
>
> \--\"Continuation\" means an extension for an 12372 to determine
> whether the application is
>
> additional funding/budget period for a subject to the State
> intergovernmental review
>
> project with a projected completion date. process.
>
> \--\"Revision\" means any change in the 17. This question applies to
> the applicant organiza-
>
> Federal Government\'s financial obligation tion, not the person who
> signs as the authorized
>
> or contingent liability from an existing representative. Categories of
> debt include delin-
>
> obligation. quent audit disallowances, loans and taxes.
>
> 9\. Name of Federal agency from which assistance 18. To be signed by
> the authorized representative of
>
> is being requested with this application. the applicant. A copy of the
> governing body\'s
>
> authorization for you to sign this application as
>
> 10\. Use the Catalog of Federal Domestic Assistance official
> representative must be on file in the
>
> number and title of the program under which applicant\'s office.
> (Certain Federal agencies
>
> assistance is requested. may require that this authorization be
> submitted
>
> as part of the application.)
>
> 11\. Enter a brief descriptive title of the project. If
>
> more than one program is involved, you should

Page I.A. SF 424 (REV 4‑88) Back

<table>
<colgroup>
<col style="width: 1%" />
<col style="width: 16%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 4%" />
<col style="width: 10%" />
<col style="width: 2%" />
<col style="width: 11%" />
<col style="width: 2%" />
<col style="width: 12%" />
<col style="width: 3%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="2">(Round to nearest dollar)</td>
<td colspan="2"></td>
<td colspan="5"><strong>PART II - BUDGET INFORMATION</strong></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"><strong>SECTION A - BUDGET SUMMARY</strong></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td>Grant Program,</td>
<td></td>
<td colspan="2">Federal</td>
<td colspan="4">Estimated Unobligated Funds</td>
<td></td>
<td colspan="3">New or Revised Budget</td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td><p>Function</p>
<p>or Activity</p>
<p>(a)</p></td>
<td></td>
<td colspan="2"><p>Catalog No.</p>
<p>(b)</p></td>
<td colspan="2"><p>Federal</p>
<p>(c)</p></td>
<td colspan="2"><p>Non-Federal</p>
<p>(d)</p></td>
<td><p>Federal</p>
<p>(e)</p></td>
<td></td>
<td><p>Non-Federal</p>
<p>(f)</p></td>
<td></td>
<td><p>Total</p>
<p>(g)</p></td>
</tr>
<tr class="odd">
<td>1.</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2">$</td>
<td colspan="2">$</td>
<td>$</td>
<td></td>
<td>$</td>
<td>$</td>
<td></td>
</tr>
<tr class="even">
<td>2.</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>3.</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4.</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>5.</td>
<td colspan="2">TOTALS</td>
<td colspan="2"></td>
<td colspan="2">$</td>
<td colspan="2">$</td>
<td>$</td>
<td></td>
<td>$</td>
<td>$</td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"><strong>SECTION B - BUDGET CATEGORIES</strong></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="5">Grant Program, Function or Activity</td>
<td colspan="2"></td>
<td></td>
<td>Total</td>
</tr>
<tr class="even">
<td>6.</td>
<td colspan="2">Object Class Categories</td>
<td></td>
<td>(1)</td>
<td></td>
<td colspan="2">(2)</td>
<td colspan="2">(3)</td>
<td colspan="2">(4)</td>
<td></td>
<td>(5)</td>
</tr>
<tr class="odd">
<td>a.</td>
<td colspan="2">Personnel</td>
<td></td>
<td>$</td>
<td></td>
<td colspan="2">$</td>
<td colspan="2">$</td>
<td colspan="2">$</td>
<td>$</td>
<td></td>
</tr>
<tr class="even">
<td>b.</td>
<td colspan="2">Fringe Benefits</td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>c.</td>
<td colspan="2">Travel</td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>d.</td>
<td colspan="2">Equipment</td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>e.</td>
<td colspan="2">Supplies</td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>f.</td>
<td colspan="2">Contractual</td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>g.</td>
<td colspan="2">Construction</td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>h.</td>
<td colspan="2">Other</td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>i.</td>
<td colspan="2">Total Direct Costs</td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>j.</td>
<td colspan="2">Indirect Costs</td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>k.</td>
<td colspan="2">TOTALS</td>
<td></td>
<td>$</td>
<td></td>
<td colspan="2">$</td>
<td colspan="2">$</td>
<td colspan="2">$</td>
<td>$</td>
<td></td>
</tr>
<tr class="even">
<td>7.</td>
<td colspan="2">Program Income</td>
<td></td>
<td>$</td>
<td></td>
<td colspan="2">$</td>
<td colspan="2">$</td>
<td colspan="2">$</td>
<td>$</td>
<td></td>
</tr>
</tbody>
</table>

FORM **SSA‑96‑BK** (03-00) Page II

Destroy Prior Editions

[Part II (continued)]{.underline}

+--------------+-------+--------+--------+--------+--------+---+-------+
| **SECTION    |       |        |        |        |        |   |       |
| C -          |       |        |        |        |        |   |       |
| NON-FEDERAL  |       |        |        |        |        |   |       |
| RESOURCES**  |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| \(a\) Grant  |       | \(b\)  | \(c\)  | \(d\)  | \(a\)  |   |       |
| Program      |       | App    | State  | Other  | TOTALS |   |       |
|              |       | licant |        | S      |        |   |       |
|              |       |        |        | ources |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 8\.          |       | \$     | \$     | \$     | \$     |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 9\.          |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 10\.         |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 11\.         |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 12\. TOTALS  |       | \$     | \$     | \$     | \$     |   |       |
| (sum of      |       |        |        |        |        |   |       |
| lines 8 -    |       |        |        |        |        |   |       |
| 11)          |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| **SECTION    |       |        |        |        |        |   |       |
| D -          |       |        |        |        |        |   |       |
| FORECASTED   |       |        |        |        |        |   |       |
| CASH NEEDS** |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
|              | Total | 1st    | 2nd    | 3rd    | 4th    |   |       |
|              | for   | Q      | Q      | Q      | Q      |   |       |
|              | 1st   | uarter | uarter | uarter | uarter |   |       |
|              | Year  |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 13\. Federal | \$    | \$     | \$     | \$     | \$     |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 14\.         |       |        |        |        |        |   |       |
| Non-Federal  |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 15\. TOTALS  | \$    | \$     | \$     | \$     | \$     |   |       |
| (sum of      |       |        |        |        |        |   |       |
| lines 13 and |       |        |        |        |        |   |       |
| 14)          |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| **SECTION    |       |        |        |        |        |   |       |
| E - BUDGET   |       |        |        |        |        |   |       |
| ESTIMATES OF |       |        |        |        |        |   |       |
| FEDERAL      |       |        |        |        |        |   |       |
| FUNDS NEEDED |       |        |        |        |        |   |       |
| FOR BALANCE  |       |        |        |        |        |   |       |
| OF THE       |       |        |        |        |        |   |       |
| PROJECT**    |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
|              |       | FUTURE |        |        |        |   |       |
|              |       | F      |        |        |        |   |       |
|              |       | UNDING |        |        |        |   |       |
|              |       | P      |        |        |        |   |       |
|              |       | ERIODS |        |        |        |   |       |
|              |       | (      |        |        |        |   |       |
|              |       | Years) |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| \(a\) Grant  |       | \(b\)  | \(c\)  | \(d\)  | \(e\)  |   |       |
| Program      |       | Second | Third  | Fourth | Fifth  |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 16\.         |       | \$     | \$     | \$     | \$     |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 17\.         |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 18\.         |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 19\.         |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 20\. TOTALS  |       | \$     | \$     | \$     | \$     |   |       |
| (sum of      |       |        |        |        |        |   |       |
| lines 16-19) |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| **SECTION    |       |        |        |        |        |   |       |
| F - OTHER    |       |        |        |        |        |   |       |
| BUDGET       |       |        |        |        |        |   |       |
| I            |       |        |        |        |        |   |       |
| NFORMATION** |       |        |        |        |        |   |       |
|              |       |        |        |        |        |   |       |
| (Attach      |       |        |        |        |        |   |       |
| additional   |       |        |        |        |        |   |       |
| Sheets if    |       |        |        |        |        |   |       |
| Necessary)   |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 21\. Direct  |       |        | 22\.   |        |        |   |       |
| Charges:     |       |        | In     |        |        |   |       |
|              |       |        | direct |        |        |   |       |
|              |       |        | Ch     |        |        |   |       |
|              |       |        | arges: |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+
| 23\.         |       |        |        |        |        |   |       |
| Remarks:     |       |        |        |        |        |   |       |
+--------------+-------+--------+--------+--------+--------+---+-------+

FORM **SSA‑96‑BK** (03-00) Page II.A

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Part II (Continued) **SECTION G ‑ PERSONNEL**

  -------------------------------------------------------------------- ------------ ----------- --------- ------------------------------------------ ----
                                                                       **Annual**   **No.**               **Total**                                  

  **Name and**                                                         **Salary**   **Mos.**    **%       **Amount**                                 
                                                                                                Time**                                               

  **Position Title**                                                   **Rate**     **Budg.**             **Required**                               

                                                                       **(1)**      **(2)**     **(3)**   **(4)**                                    

                                                                       Total                                                                         
                                                                       Salaries and                                                                  

                                                                       Wages                              \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   

                                                                       Total Fringe                       \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   
                                                                       Benefits                                                                      

  Fringe Benefits                                                                   .                                                                
  (Rate\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)                                                                                 

                                                                       **TOTAL**                          \$                                         
  -------------------------------------------------------------------- ------------ ----------- --------- ------------------------------------------ ----

FORM **SSA‑96‑BK** (03-00) Page II.B.

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Part II (Continued)

+--------------------------------+------------+----+----+------------+
| **EXAMPLES**                   | **(1) (2)  |    |    |            |
|                                | (3) (4)**  |    |    |            |
+--------------------------------+------------+----+----+------------+
| NAME                           | Annual     | N  | \% | Total      |
|                                | Salary     | o. |    | Amount     |
|                                |            |    | Ti |            |
|                                | Rate       | Mo | me | Required   |
|                                |            | s. |    |            |
|                                |            |    |    |            |
|                                |            | B  |    |            |
|                                |            | ud |    |            |
|                                |            | g. |    |            |
+--------------------------------+------------+----+----+------------+
| John Doe, Project Director     | 24,000     | [1 | 1  | 24,000     |
| [1]{.underline}/               |            | 2] | 00 |            |
|                                |            | {. |    |            |
|                                |            | un |    |            |
|                                |            | de |    |            |
|                                |            | rl |    |            |
|                                |            | in |    |            |
|                                |            | e} |    |            |
|                                |            |    |    |            |
|                                |            | 12 |    |            |
+--------------------------------+------------+----+----+------------+
|                                |            |    |    |            |
+--------------------------------+------------+----+----+------------+
| Jane Smith, Asst. Dir          | 18,500     | [1 | 1  | 15,417     |
| [1]{.underline}/               |            | 0] | 00 |            |
|                                |            | {. |    |            |
|                                |            | un |    |            |
|                                |            | de |    |            |
|                                |            | rl |    |            |
|                                |            | in |    |            |
|                                |            | e} |    |            |
|                                |            |    |    |            |
|                                |            | 12 |    |            |
+--------------------------------+------------+----+----+------------+
|                                |            |    |    |            |
+--------------------------------+------------+----+----+------------+
| Senior Counselor               | 19,750     | [1 | 60 | 11,850     |
| [2/]{.underline}               |            | 2] |    |            |
|                                |            | {. |    |            |
|                                |            | un |    |            |
|                                |            | de |    |            |
|                                |            | rl |    |            |
|                                |            | in |    |            |
|                                |            | e} |    |            |
|                                |            |    |    |            |
|                                |            | 12 |    |            |
+--------------------------------+------------+----+----+------------+
|                                |            |    |    |            |
+--------------------------------+------------+----+----+------------+
| Secretary [2/]{.underline}     | 11,500     | [  | 75 | 6,469      |
|                                |            | 9] |    |            |
|                                |            | {. |    |            |
|                                |            | un |    |            |
|                                |            | de |    |            |
|                                |            | rl |    |            |
|                                |            | in |    |            |
|                                |            | e} |    |            |
|                                |            |    |    |            |
|                                |            | 12 |    |            |
+--------------------------------+------------+----+----+------------+
|                                | Total      |    |    | 57,736     |
|                                | Salaries   |    |    |            |
|                                | and Wages  |    |    |            |
+--------------------------------+------------+----+----+------------+
| Fringe Benefits (Rate:         | Total      |    |    | 8,278      |
| [1]{.underline}/ - 21%         | Fringe     |    |    |            |
|                                | Benefits   |    |    | 2,748      |
| [2/]{.underline} - 15%)        |            |    |    |            |
+--------------------------------+------------+----+----+------------+
| CATEGORY TOTAL: 68,762         |            |    |    |            |
+--------------------------------+------------+----+----+------------+

FORM **SSA‑96‑BK** (03-00) Page II.C.

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> **PART IV ASSURANCES**
>
> **OMB Approval No. 0348‑0040**

Note: Certain of these assurances may not be applicable to your project
or program. If you have questions, please contact the awarding agency.
Further, certain Federal awarding agencies may require applicants to
certify to additional assurances. If such is the case, you will be
notified.

As the duly authorized representative of the applicant I certify that
the applicant:

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

> 1\. Has the legal authority to apply for Federal assistance, (e) the
> Drug Abuse Office and Treatment Act of 1972
>
> and the institutional, managerial and financial capabil‑ (P.L.
> 92‑255), as amended, relating to nondiscrimina-
>
> ity (including funds sufficient to pay the non‑Federal tion on the
> basis of drug abuse; (f) the Comprehensive
>
> share of project costs) to ensure proper planning, man‑ Alcohol Abuse
> and Alcoholism Prevention, Treatment
>
> agement and completion of the project described in this and
> Rehabilitation Act of 1970 (P.L. 91‑616), as
>
> application. amended, relating to nondiscrimination on the basis of
>
> alcohol abuse or alcoholism; (g) §§ 523 and 527 of the
>
> 2\. Will give the awarding agency, the Comptroller Gen‑ Public Health
> Service Act of 1912 (42 U.S.C. 290 dd-3
>
> eral of the United States, and if appropriate, the State, and 290
> ee-3), as amended, relating to confidentiality
>
> through any authorized representative, access to and the of alcohol
> and drug abuse patient records; (h) Title VIII
>
> right to examine all records, books, papers, or docu‑ of the Civil
> Rights Act of 1968 (42 U.S.C. § 3601 et
>
> ments related to the award; and will establish a proper seq.), as
> amended, relating to nondiscrimination in the
>
> accounting system in accordance with generally ac‑ sale, rental or
> financing of housing; (i) any other
>
> cepted accounting standards or agency directives. nondiscrimination
> provisions in the specific statute(s)
>
> under which application for Federal assistance is being
>
> 3\. Will establish safeguards to prohibit employees from made; and (j)
> the requirements of any other nondiscrim-
>
> using their positions for a purpose that constitutes or ination
> statute(s) which may apply to the application.
>
> presents the appearance of personal or organizational
>
> conflict of interest, or personal gain. 7. Will comply, or has already
> complied, with the require-
>
> ments of Titles II and III of the Uniform Relocation
>
> 4\. Will initiate and complete the work within the applica‑ Assistance
> and Real Property Acquisition Policies Act
>
> ble time frame after receipt of approval of the awarding of 1970 (P.L.
> 91‑646) which provide for fair and equi-
>
> agency. table treatment of persons displaced or whose property
>
> is acquired as a result of Federal or federally assisted
>
> 5\. Will comply with the Intergovernmental Personnel Act programs.
> These requirements apply to all interests in
>
> of 1970 (42 U.S.C. §§ 4728‑4763) relating to pre‑ real property
> acquired for project purposes regardless of
>
> scribed standards for merit systems for programs Federal participation
> in purchases.
>
> funded under one of the nineteen statutes or regulations
>
> specified in Appendix A of OPM\'s Standards for a
>
> Merit System of Personnel Administration (5 C.F.R. 8. Will comply with
> the provisions of the Hatch Act (5
>
> 900, Subpart F). U.S.C. §§ 1501‑1508 and 7324‑7328) which limit the
>
> political activities of employees whose principal em-
>
> 6\. Will comply with all Federal statutes relating to nondis‑ ployment
> activities are funded in whole or in part with
>
> crimination. These include but are not limited to: (a) Federal funds.
>
> Title VI of the Civil Rights Act of 1964 (P.L. 88‑352)
>
> which prohibits discrimination on the basis of race,
>
> color or national origin; (b) Title IX of the Education 9. Will
> comply, as applicable, with the provisions of the
>
> Amendments of 1972, as amended (20 U.S.C. §§ Davis‑Bacon Act (40
> U.S.C. §§ 276a to 276a-7), the
>
> 1681‑1683, and 1685‑1686), which prohibits discrimi‑ Copeland Act (40
> U.S.C. § 276c and 18 U.S.C. §§
>
> nation on the basis of sex; (c) Section 504 of the Reha‑ 874), and the
> Contract Work Hours and Safety Stand-
>
> bilitation Act of 1973, as amended (29 U.S.C. § 794), ards Act (40
> U.S.C. §§ 327‑333), regarding labor
>
> which prohibits discrimination on the basis of handi‑ standards for
> federally assisted construction subagree-
>
> caps; (d) the Age Discrimination Act of 1975, as ments.
>
> amended (42 U.S.C. §§ 6101‑6107), which prohibits
>
> discrimination on the basis of age;

FORM **SSA‑96‑BK** (03-00) Page IV

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10\. Will comply, if applicable, with flood insurance 13. Will assist
the awarding agency in assuring compliance

> purchase requirements of Section 102(a) of the Flood with Section 106
> of the National Historic Preservation
>
> Disaster Protection‑Act of 1973 (P.L. 93‑234) which Act of 1966, as
> amended (16 U.S.C. 470), EO 11593
>
> requires recipients in a special flood hazard area to (identification
> and protection of historic properties),
>
> participate in the program and to purchase flood and the
> Archaeological and Historic Preservation Act of
>
> insurance if the total cost of insurable construction 1974 (16 U.S.C.
> 469a‑1 et seq.).
>
> and acquisition is \$10,000 or more.
>
> 14\. Will comply with P.L. 93‑348 regarding the protection

11\. Will comply with environmental standards which may of human
subjects involved in research, development,

be prescribed pursuant to the following: (a) institution and related
activities supported by this award of assis-

of environmental quality control measures under the tance.

National Environmental Policy Act of 1969 (P.L. 91-

190\) and Executive Order (EO) 11514; (b) notification 15. Will comply
with the Laboratory Animal Welfare Act

of violating facilities pursuant to EO 11738; (c) protec‑ of 1966 (P.L.
89‑544, as amended, 7 U.S.C. 2131 et

tion of wetlands pursuant to EO 11990; (d) evaluation seq.) pertaining
to the care, handling, and treatment of

of flood hazards in floodplains in accordance with EO warm blooded
animals held for research, teaching, or

11988; (e) assurance of project consistency with the other activities
supported by this award of assistance.

approved State management program developed under

> the Coastal Zone Management Act of 1972 (16 U.S.C. 16. Will comply
> with the Lead‑Based Paint Poisoning
>
> §§ 1451 et seq.); (f) conformity of Federal actions to Prevention Act
> (42 U.S.C**.** §§ 4801 et seq.) which
>
> State (Clear Air) Implementation Plans under Section prohibits the use
> of lead based paint in construction or
>
> 176(c) of the Clear Air Act of 1955, as amended (42 rehabilitation of
> residence structures.
>
> U.S.C. § 7401 et seq.); (g) protection of underground

sources of drinking water under the Safe Drinking 17. Will cause to be
performed the required financial and

Water Act of 1974, as amended, (P.L. 93‑523); and (h) compliance audits
in accordance with the Single Audit

protection of endangered species under the Endangered Act of 1984.

Species Act of 1973, as amended, (P.L. 93‑205).

18\. Will comply with all applicable requirements of all

12\. Will comply with the Wild and Scenic Rivers Act of other Federal
laws, executive orders, regulations and

1968 (16 U.S.C. §§ 1271 et seq.) related to protecting policies
governing this program.

components or potential components of the national

wild and scenic rivers system.

  ------------------------- ----------- -----------------------------------
  **SIGNATURE OF AUTHORIZED **TITLE**   
  CERTIFYING OFFICIAL**                 

  **APPLICANT                           **DATE SUBMITTED**
  ORGANIZATION**                        
  ------------------------- ----------- -----------------------------------

FORM **SSA‑96‑BK** (03-00) Page IV.A.

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> **PART IV**
>
> **ASSURANCES (Continued)**

**PRIVACY ACT** 5. To a Federal agency, in response to its request, in
connection

with the letting of a contract, or the issuance of a

The Privacy Act of 1974 (5 U.S.C. 552a) gives individuals the license,
grant, or other benefit by the requesting agency, to

right of access to information concerning themselves and provides the
extent that the record is relevant and necessary to the

a mechanism for correction or amendment of the records. The requesting
agency\'s decision on the matter.

Privacy Act also provides for protection of information pertaining

to an individual, but it does not prevent disclosure of such infor- 6.
To individuals and organizations deemed qualified by SSA

mation if required to be released under the Freedom of Informa- to carry
out specific research related to the review and award

tion Act. The Privacy Act requires that a Federal agency, advise
processes of SSA.

each individual whom it asks to supply information of the authority

which authorizes the solicitation, whether disclosure is voluntary 7. To
organizations in the private sector with whom SSA has

or mandatory, the principal purpose or purposes for which the contracted
for the purpose of collating, analyzing, aggregating ,

information is intended to be used, the use outside the agency or
otherwise refining records in a system. Relevant

which may be made of the information, and the effects on the records
will be disclosed to such a contractor. The contractor

individual, if any, of not providing all or any part of the requested
shall be required to maintain Privacy Act safeguards with

information. respect to such records.

SSA is requesting the information called for in this application 8. To
the grantee institution relative to performance or admini-

pursuant to its statutory authority for awarding grants. Provision
stration under the terms and conditions of the award.

of the information requested is entirely voluntary. The collection

of this information is for the purpose of aiding in the review of

applications prior to grant award decisions and for management of
**FREEDOM OF INFORMATION ACT**

SSA programs. A lack of sufficient information may hinder SSA\'s

ability to review applications, monitor grantee performance, or The
Freedom of Information Act and the associated Public Infor-

perform overall management of grant programs. mation Regulations (20 CFR
Part 402) of the Social Security

Administration require the release of certain information

This information will be used within the Social Security Admini-
regarding grants requested by any member of the public. The

stration (Agency), and may also be disclosed outside the Agency intended
use of the information will not be a criterion for release.

as permitted by the Privacy Act, including disclosures to the Grant
applications and grant related reports are generally available

public as required by the Freedom of Information Act, to the for
inspection and copying except that information considered to

Congress, the National Archives, the Bureau of the Census, law be an
unwarranted invasion of personal privacy will not be dis-

enforcement agencies upon their request, the General Accounting closed.
For specific guidance on the availability of information,

Office, and pursuant to court order. It may also be disclosed refer to
20 CFR Part 402.

outside the Agency, if necessary, for the following purposes:

**PUBLIC REPORTING BURDEN**

1\. To the cognizant audit agency for auditing.

Public reporting burden for this collection of information is esti-

2\. To the Department of Justice as required for litigation. mated to
average 14 hours per response, including the time for

reviewing instructions, searching existing data sources, gathering

3\. To a congressional office from the record of an individual in and
maintaining the data needed, and completing and reviewing

the response to an inquiry from the congressional office the collection
of information. Send comments regarding this bur-

made at the request of that individual. den estimate or any other aspect
of this collection of information,

including suggestions for reducing this burden to the Social Secu-

4\. To qualified experts not within the definition of Agency rity
Administration ATTN: Reports Clearance Officer 1‑A‑21

employees as prescribed in the Agency regulations Operations Bldg.,
Baltimore, MD 21235 and to the Office of

(20 CFR, Part 401.10) for opinions as a part of the Information and
Regulatory Affairs, Office of Management and

application review process. Budget, Washington, DC 20503.

FORM **SSA‑96‑BK** (03-00) Page IV.B.

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