+-----------------------------------------------------------------------+
| ######  U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES                  |
|                                                                       |
| ####### PUBLIC HEALTH SERVICE                                         |
|                                                                       |
| ######## GRANT APPLICATION                                            |
|                                                                       |
| **For use by:**                                                       |
|                                                                       |
| ##### State and Local Government Applicants                           |
|                                                                       |
| ##### Nongovernmental Applicants for Health Services Projects         |
|                                                                       |
| ######### ![](media/image1.jpeg){width                                |
| ="3.1479166666666667in" height="3.0743055555555556in"}FORM PHS-5161-1 |
|                                                                       |
| **(Revised 7/00)**                                                    |
+-----------------------------------------------------------------------+

+-----------------------------------+---+----------------------------------+
| **GENERAL INFORMATION AND         |   |                                  |
| INSTRUCTIONS FOR GRANT            |   |                                  |
| APPLICATION**                     |   |                                  |
|                                   |   |                                  |
| **(FORM PHS-5161-1, Revised       |   |                                  |
| 7/00)**                           |   |                                  |
+-----------------------------------+---+----------------------------------+
| INTRODUCTION                      |   | > The seventh and last section   |
|                                   |   | > is the Checklist, which\       |
| This application form, the PHS    |   | > must be included with all      |
| 5161-1, is used for a\            |   | > applications.                  |
| variety of grant programs         |   | >                                |
| administered by the Public\       |   | > Before completing the          |
| Health Service (PHS). The basic   |   | > application, it is advisable   |
| format (Standard Form 424) is     |   | > to\                            |
| prescribed by OMB Circular A-102  |   | > refer to any relevant program  |
| for use by State and local        |   | > guidelines provided with\      |
| government applicants. The        |   | > the application kit. The kit   |
| PHS-5161-1\                       |   | > may also contain additional\   |
| is also intended for use by       |   | > supplementary instructions     |
| nongovernmental applicants\       |   | > pertaining to unique program   |
| seeking support for health        |   | > requirements set forth in      |
| services projects.                |   | > legislation or regulations.    |
|                                   |   | >                                |
| The application consists of this  |   | > For additional information     |
| section, General Information and  |   | > about, or copies of, material\ |
| Instructions, followed by six     |   | > referred to in this            |
| additional sections which         |   | > application, contact the       |
| comprise the standard             |   | > grants\                        |
| application.                      |   | > management office which        |
|                                   |   | > supplied the application kit.  |
| This section contains information |   | >                                |
| about PHS policies\               |   | > Comments concerning the        |
| and procedures.                   |   | > accuracy of the burden         |
|                                   |   | > estimates for the Program      |
| The second section, the SF-424,   |   | > Narrative and the Checklist    |
| is the face page of the\          |   | > and any suggestions for        |
| application which requests basic  |   | > reducing this burden should    |
| information about the\            |   | > be\                            |
| applicant and the project.        |   | > addressed to:                  |
|                                   |   | >                                |
| The third section, Budget         |   | > CDC Reports Clearance Officer\ |
| Information (nonconstruction\     |   | > 1600 Clifton Road\             |
| or construction) requests         |   | > MS-D-24\                       |
| information on the applicant's\   |   | > Atlanta, GA 30333\             |
| financial plan for carrying out   |   | > Attention: PRA (0920-0428)     |
| the project or program.\          |   | >                                |
| Both the Federal and non-Federal  |   | > ***NOTE:*** The grant          |
| shares are to be\                 |   | > application which you are\     |
| included in the financial plan.   |   | > submitting may be subject to   |
| The application kit contains      |   | > the reporting\                 |
| budget forms for both             |   | > requirements of the Public     |
| nonconstruction\                  |   | > Health System Impact\          |
| (SF-424A) and construction        |   | > Statement. Consult the Program |
| (SF-424C) projects or programs.   |   | > Announcement or\               |
| Please be sure that you use the   |   | > the Grants Management Officer  |
| correct form.                     |   | > for the program to\            |
|                                   |   | > which you are applying for     |
| The fourth section, Assurances    |   | > additional information.        |
| (nonconstruction or\              |   | >                                |
| construction) sets forth certain  |   | > **TYPES OF APPLICATIONS**      |
| requirements with which\          |   | >                                |
| applicants must certify that they |   | > The Form PHS-5161-1 may be     |
| will comply if a grant\           |   | > used for any of the\           |
| is awarded. The application kit   |   | > following types of             |
| includes assurances for\          |   | > applications:                  |
| both nonconstruction (SF-424B)    |   | >                                |
| and construction\                 |   | > **1. New** - A new application |
| (SF-424D) projects or programs.   |   | > is a request for financial\    |
| Please be sure that you\          |   | > assistance for a project or    |
| submit the correct assurance form |   | > program not currently\         |
| and that the back of\             |   | > receiving PHS support. If      |
| the form is signed by a duly      |   | > recommended for\               |
| authorized official of the\       |   | > approval it must compete with  |
| applicant organization.           |   | > other new applications,        |
|                                   |   | > competing continuation         |
| The fifth section,                |   | > applications, and competing    |
| Certifications, sets forth        |   | > supplemental applications for  |
| certain\                          |   | > any\                           |
| requirements for grantees which   |   | > available funds in accordance  |
| have been legislatively\          |   | > with Federal\                  |
| implemented since the SF-424      |   | > awarding office funding        |
| assurances pages were\            |   | > priorities. A complete\        |
| last revised. This form must also |   | > submission of all information  |
| be signed by a duly\              |   | > requested, including\          |
| authorized official of the        |   | > budget justification, is       |
| applicant organization and\       |   | > required for all new\          |
| submitted.                        |   | > applications.                  |
|                                   |   |                                  |
| The sixth section, Program        |   |                                  |
| Narrative, requests the\          |   |                                  |
| applicant to describe the         |   |                                  |
| objectives of the program and\    |   |                                  |
| to relate how those objectives    |   |                                  |
| will be attained. For\            |   |                                  |
| projects funded beyond the first  |   |                                  |
| year, this section is\            |   |                                  |
| used to describe the objectives   |   |                                  |
| and activities to be undertaken   |   |                                  |
| during the next period of support |   |                                  |
| and also as a progress or         |   |                                  |
| performance report for activities |   |                                  |
| previously undertaken.            |   |                                  |
+-----------------------------------+---+----------------------------------+
| **2. Noncompeting                 | > |                                  |
| Continuation** - A noncompeting\  |   |                                  |
| continuation application is a     | n |                                  |
| request for support\              | o |                                  |
| beyond the initial budget         | n |                                  |
| period^1^ within a previously     | c |                                  |
| approved project period^2^. These | o |                                  |
| appli-cations do not compete with | m |                                  |
| other applications, and the level | p |                                  |
| of support is determined by the   | e |                                  |
| awarding office after considering | t |                                  |
| the previously recom-mended level | i |                                  |
| of support and the progress       | n |                                  |
| achieved on the project.          | g |                                  |
|                                   | , |                                  |
| A complete resubmission of the    | > |                                  |
| material contained\               |   |                                  |
| in the initially approved         | b |                                  |
| application is not\               | u |                                  |
| necessary, but the continuation   | t |                                  |
| application should\               | > |                                  |
| include: a detailed               |   |                                  |
| justification, as necessary;\     | a |                                  |
| information on the qualifying     | r |                                  |
| experience of key\                | e |                                  |
| personnel added since the         | > |                                  |
| previous application; a\          |   |                                  |
| report of progress relative to    | s |                                  |
| approved objectives;\             | u |                                  |
| and a narrative discussing any    | b |                                  |
| significant changes\              | j |                                  |
| to the originally approved        | e |                                  |
| project plan. Refer to\           | c |                                  |
| Item 6(b) in the Program          | t |                                  |
| Narrative instructions, and to    | > |                                  |
| program guidelines for additional |   |                                  |
| guidance on preparing the         | t |                                  |
| progress report.                  | o |                                  |
|                                   | > |                                  |
| **3. Competing Continuation** - A |   |                                  |
| competing continua-tion           | t |                                  |
| application is a request for the  | h |                                  |
| extension of support for one or   | e |                                  |
| more budget periods of a project\ | > |                                  |
| which would otherwise expire.     |   |                                  |
| These applications\               | a |                                  |
| are subject to the same review    | p |                                  |
| and analysis as new\              | p |                                  |
| applications and they compete for | r |                                  |
| available funds\                  | o |                                  |
| with other competing continuation | v |                                  |
| applications,\                    | a |                                  |
| new applications, and competing   | l |                                  |
| supplemental\                     | > |                                  |
| applications. The information     |   |                                  |
| requirements ap-plicable to       | o |                                  |
| competing continuation            | f |                                  |
| applications are\                 | > |                                  |
| the same as those that apply to   |   |                                  |
| new applications\                 | t |                                  |
| except that competing             | h |                                  |
| continuation applications\        | e |                                  |
| must also include a progress      | \ |                                  |
| report as described\              | > |                                  |
| under Item 6(b) of the Program    |   |                                  |
| Narrative section.                | a |                                  |
|                                   | w |                                  |
| **4. Supplemental** - A           | a |                                  |
| supplemental application is a\    | r |                                  |
| request for additional funding    | d |                                  |
| within an approved\               | i |                                  |
| budget period for program         | n |                                  |
| expansion or\                     | g |                                  |
| administrative increases.         | > |                                  |
| Applications for funds to\        |   |                                  |
| expand the scope of the project   | o |                                  |
| are subject to the\               | f |                                  |
| same review procedures as new or  | f |                                  |
| competing\                        | i |                                  |
| continuation applications.        | c |                                  |
| Applications for funds to\        | e |                                  |
| meet increases in costs incurred  | > |                                  |
| during a current\                 |   |                                  |
| budget period (such as increases  | a |                                  |
| in fringe\                        | n |                                  |
| benefits, salaries, or other      | d |                                  |
| project costs not included\       | > |                                  |
| in the previous application) are  |   |                                  |
| generally                         | t |                                  |
|                                   | h |                                  |
| **^1^Budget Period** - The        | e |                                  |
| interval of the time (usually 12  | > |                                  |
| months) into which the project    |   |                                  |
|                                   | a |                                  |
| period is divided for funding and | v |                                  |
| reporting purposes.               | a |                                  |
|                                   | i |                                  |
| **^2^Project Period** - The total | l |                                  |
| time for which support of a       | a |                                  |
| project has been programmati-\    | b |                                  |
| cally approved. A project period  | i |                                  |
| may consist of one or more budget | l |                                  |
| periods                           | i |                                  |
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|                                   | . |                                  |
+-----------------------------------+---+----------------------------------+

+-----------------------------------+----------------------------------+
| ASSEMBLING AND MAILING            | > **NONCONFORMING APPLICATIONS** |
|                                   |                                  |
| To facilitate review and          | Applications which are           |
| processing of the application by\ | determined to be non-conforming  |
| the awarding office, all pages    | shall not be accepted for        |
| should be numbered and\           | processing and\                  |
| preceded by a table of contents.  | shall be returned to the         |
| Assemble the\                     | applicant. A grant application\  |
| application with a cover letter   | may be classified as             |
| on top indicating the\            | nonconforming if it does not     |
| specific program for which you    | meet\                            |
| are applying, followed\           | the requirements of the program  |
| by a table of contents, the       | announcement to\                 |
| printed forms, the program\       | which it is responding.          |
| narrative, biographical sketches, |                                  |
| and any remaining\                | > **APPLICATION REVIEW**         |
| documents. Completed applications |                                  |
| should be signed in\              | Applications will be evaluated   |
| ink by an authorized official of  | and rated according to\          |
| the applicant organization and    | criteria and priorities which    |
| duplicated in accord with         | are established for the\         |
| applicable\                       | particular grant program         |
| requirements. Mail completed      | involved and which are\          |
| applications to the\              | described in program             |
| appropriate grants management     | announcements and program\       |
| office (unless other\             | guidelines.                      |
| instructions have been provided)  |                                  |
| in time to meet the\              | > **UNSUCCESSFUL APPLICANTS**    |
| deadline date for receipt         |                                  |
| established by the awarding\      | After a decision has been        |
| office.                           | reached either to disapprove\    |
|                                   | or not fund a grant application  |
| ACKNOWLEDGMENT                    | during a given review\           |
|                                   | cycle, a written notice shall be |
| Applicants will be sent a written | sent to the unsuccessful\        |
| acknowledgment of\                | applicant within 30 days after   |
| receipt by PHS administering      | that decision.                   |
| offices.                          |                                  |
|                                   | > **PRIVACY ACT**                |
| LATE APPLICATIONS                 | >                                |
|                                   | > The Privacy Act of 1974 (5     |
| **New/Competing Continuation**    | > U.S.C. § 552a) gives\          |
|                                   | > individuals the right of       |
| Applications will be considered   | > access to information          |
| to be \"on time\" if they\        | > concerning\                    |
| are (1) received on or before the | > themselves and provides a      |
| established deadline\             | > mechanism for\                 |
| date or (2) sent on or before the | > correction or amendment of     |
| established deadline\             | > such records. The Privacy\     |
| date and received in time for     | > Act also provides for          |
| orderly processing.\              | > protection of information\     |
| Applicants should request a       | > pertaining to an individual,   |
| legibly dated U.S. Postal\        | > but it does not prevent\       |
| Service postmark or obtain a      | > disclosure of such information |
| legibly dated receipt from\       | > if its release is required\    |
| a commercial carrier or the U.S.  | > under the Freedom of           |
| Postal Service. Private\          | > Information Act. The Privacy   |
| metered postmarks shall not be    | > Act\                           |
| acceptable as proof of\           | > requires that a Federal agency |
| timely mailing. Late competing    | > must advise each\              |
| applications not\                 | > individual whom it asks to     |
| accepted for processing may       | > supply the information (1) of\ |
| either be returned to the\        | > the authority which authorizes |
| applicant or held for the next    | > the solicitation, (2)\         |
| regularly scheduled\              | > whether disclosure is          |
| review cycle.                     | > voluntary or mandatory, (3)    |
|                                   | > the\                           |
| **Noncompeting Continuation**     | > principal purpose or purposes  |
|                                   | > for which the information\     |
| Applications which are not        | > is to be used, (4) the use     |
| received in time to permit\       | > outside the agency\            |
| orderly review, processing, and   | > which may be made of the       |
| award issuance on or\             | > information, and (5) the\      |
| before the beginning date of the  | > effects on the individual, if  |
| continuation budget\              | > any, of not providing all or\  |
| period, may result in: (1) an     | > any part of the requested      |
| extension of the current\         | > information.                   |
| budget period *without additional | >                                |
| Federal funds,* and (2)\          | > PHS is requesting the          |
| a delay in the beginning date of  | > information called for in      |
| the new budget period.            | > this\                          |
|                                   | > application pursuant to its    |
|                                   | > statutory authority to award\  |
|                                   | > grants. Provision 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 PHS\             |
|                                   | > programs. Insufficient         |
|                                   | > information may hinder PHS\    |
|                                   | > ability to review              |
|                                   | > applications, monitor grantee\ |
|                                   | > performance, or perform        |
|                                   | > overall management of grant\   |
|                                   | > programs.                      |
+-----------------------------------+----------------------------------+

+-----------------------------------+----------------------------------+
| This information will be used     | > 6\. To individuals and         |
| within the Department of\         | > organizations deemed qualified |
| Health and Human Services, and    | > by PHS to carry out specific   |
| may also be disclosed\            | > research related to the review |
| outside the Department as         | > and award processes of PHS.    |
| permitted by the Privacy Act,\    | >                                |
| including disclosures to the      | > 7\. To organizations in the    |
| public as required by the\        | > private sector with whom\      |
| Freedom of Information Act, to    | > PHS has contracted for the     |
| the Congress, the\                | > purpose of collating,\         |
| National Archives, the Bureau of  | > analyzing, aggregating, or     |
| the Census, law\                  | > otherwise refining\            |
| enforcement agencies upon their   | > records in a system. Relevant  |
| request, the General\             | > records will be\               |
| Accounting Office, and pursuant   | > disclosed to such a            |
| to court order. It may\           | > contractor. The contractor\    |
| also be disclosed outside the     | > shall be required to maintain  |
| Department, if necessary,\        | > Privacy Act\                   |
| for the following purposes:       | > safeguards with respect to     |
|                                   | > such records.                  |
| > 1\. To the cognizant audit      | >                                |
| > agency for auditing.            | > 8\. To the grantee institution |
| >                                 | > relative to performance\       |
| > 2\. To the Department of        | > or administration under the    |
| > Justice as required for\        | > terms and conditions\          |
| > litigation.                     | > of the award.                  |
| >                                 | >                                |
| > 3\. To a congressional office   | > **FREEDOM OF INFORMATION ACT** |
| > from the record of an\          | >                                |
| > individual in response to an    | > The Freedom of Information Act |
| > inquiry from the\               | > and the associated\            |
| > congressional office made at    | > Public Information Regulations |
| > the request of that\            | > (45 CFR Part 5) of the\        |
| > individual.                     | > Department of Health and Human |
| >                                 | > Services require the\          |
| > 4\. To qualified experts not    | > release of certain information |
| > within the definition of\       | > regarding grants\              |
| > Department employees as         | > requested by any member of the |
| > prescribed in the\              | > public. The intended\          |
| > Department's regulations \[45   | > use of the information will    |
| > CFR Part 5(b)(2)\]\             | > not be a criterion for         |
| > for their opinions, as part of  | > release.\                      |
| > the application\                | > Grant applications and grant   |
| > review process.                 | > related reports are\           |
| >                                 | > generally available for        |
| > 5\. To a Federal agency in      | > inspection and copying except\ |
| > response to its request, in\    | > that information considered to |
| > connection with the letting of  | > be an unwarranted\             |
| > a contract, or the\             | > invasion of personal privacy   |
| > issuance of a license, grant,   | > will not be disclosed. For\    |
| > or other benefit by the\        | > specific guidance on the       |
| > requesting agency, to the       | > availability of information,\  |
| > extent that the record is\      | > refer to 45 CFR Part 5.        |
| > relevant and necessary to the   |                                  |
| > requesting agency's\            |                                  |
| > decision on the matter.         |                                  |
+-----------------------------------+----------------------------------+

<table>
<colgroup>
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</colgroup>
<tbody>
<tr class="odd">
<td colspan="47">Version 7/03</td>
</tr>
<tr class="even">
<td colspan="25" rowspan="2"><p><strong>APPLICATION FOR</strong></p>
<p><strong>FEDERAL ASSISTANCE</strong></p></td>
<td colspan="15"><strong>2. DATE SUBMITTED</strong></td>
<td colspan="7">Applicant Identifier</td>
</tr>
<tr class="odd">
<td colspan="15">     </td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="10"><strong>1. TYPE OF SUBMISSION:</strong></td>
<td colspan="15"></td>
<td colspan="15"><strong>3. DATE RECEIVED BY STATE</strong></td>
<td colspan="7">State Application Identifier</td>
</tr>
<tr class="odd">
<td colspan="10" rowspan="3"><p>Application</p>
<blockquote>
<p> Construction</p>
<p> Non-Construction</p>
</blockquote></td>
<td colspan="15" rowspan="3"><p>Preapplication</p>
<p> Construction</p>
<p> Non-Construction</p></td>
<td colspan="15">     </td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="15"><strong>4. DATE RECEIVED BY FEDERAL
AGENCY</strong></td>
<td colspan="7">Federal Identifier</td>
</tr>
<tr class="odd">
<td colspan="15">     </td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="47"><strong>5. APPLICANT INFORMATION</strong></td>
</tr>
<tr class="odd">
<td colspan="38">Legal Name:</td>
<td colspan="9">Organizational Unit:</td>
</tr>
<tr class="even">
<td colspan="38" rowspan="2">     </td>
<td colspan="9">Department:</td>
</tr>
<tr class="odd">
<td colspan="9" rowspan="2">     </td>
</tr>
<tr class="even">
<td colspan="38">Organizational DUNS:</td>
</tr>
<tr class="odd">
<td colspan="38" rowspan="2">     </td>
<td colspan="9">Division:</td>
</tr>
<tr class="even">
<td colspan="9" rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="38"><strong>Address:</strong></td>
</tr>
<tr class="even">
<td colspan="38">Street:</td>
<td colspan="9" rowspan="2"><strong>Name and telephone number of the
person to be contacted on matters involving this application <em>(give
area code)</em></strong></td>
</tr>
<tr class="odd">
<td colspan="38">     </td>
</tr>
<tr class="even">
<td colspan="38">City:</td>
<td colspan="5">Prefix:</td>
<td colspan="4">First Name:</td>
</tr>
<tr class="odd">
<td colspan="38">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="38">County:</td>
<td colspan="9">Middle Name:</td>
</tr>
<tr class="odd">
<td colspan="38">     </td>
<td colspan="9">     </td>
</tr>
<tr class="even">
<td colspan="21">State:</td>
<td colspan="17">ZIP:</td>
<td colspan="9">Last Name:</td>
</tr>
<tr class="odd">
<td colspan="21">     </td>
<td colspan="17">     </td>
<td colspan="9">     </td>
</tr>
<tr class="even">
<td colspan="38">Country:</td>
<td colspan="9">Suffix:</td>
</tr>
<tr class="odd">
<td colspan="38">     </td>
<td colspan="9">     </td>
</tr>
<tr class="even">
<td colspan="38"><strong>6. EMPLOYER IDENTIFICATION NUMBER</strong>
<em>(EIN<strong>):</strong></em></td>
<td colspan="5">Phone Number <em>(give area code):</em></td>
<td colspan="4">FAX Number <em>(give area code):</em></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"> </td>
<td colspan="2"> </td>
<td colspan="3">-</td>
<td> </td>
<td> </td>
<td colspan="3"> </td>
<td colspan="3"> </td>
<td colspan="4"> </td>
<td colspan="4"> </td>
<td colspan="3"> </td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td colspan="5">     </td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="38"></td>
<td colspan="5"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="38"><strong>8. TYPE OF APPLICATION:</strong></td>
<td colspan="9"><strong>7. TYPE OF APPLICANT:</strong> <em>(See back of
form for Application Types)<strong>:</strong></em></td>
</tr>
<tr class="even">
<td colspan="38"> New Continuation Revision</td>
<td colspan="9"><blockquote>
&#10;</blockquote></td>
</tr>
<tr class="odd">
<td colspan="20">If Revision, enter appropriate letter(s) in
box(es):<br />
(See back of form for description of letters)</td>
<td colspan="3"> </td>
<td colspan="4"></td>
<td colspan="2"> </td>
<td colspan="9"></td>
<td colspan="4" rowspan="2"><blockquote>
<p>Other <em>(Specify):</em></p>
</blockquote></td>
<td colspan="4" rowspan="2">     </td>
<td rowspan="2"></td>
</tr>
<tr class="even">
<td colspan="38"></td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="3">Other <em>(specify):</em></td>
<td colspan="33" rowspan="3">     </td>
<td rowspan="3"></td>
<td colspan="6"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="9"><strong>9. NAME OF FEDERAL AGENCY:</strong></td>
</tr>
<tr class="odd">
<td colspan="9" rowspan="2">     </td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="33"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="38"><strong>10. CATALOG OF FEDERAL DOMESTIC</strong></td>
<td colspan="9"><strong>11. DESCRIPTIVE TITLE OF APPLICANT’S
PROJECT:</strong></td>
</tr>
<tr class="even">
<td colspan="16"><strong>ASSISTANCE NUMBER:</strong></td>
<td colspan="3"> </td>
<td colspan="3"> </td>
<td colspan="4">-</td>
<td colspan="4"> </td>
<td colspan="2"> </td>
<td colspan="2"> </td>
<td colspan="4"></td>
<td colspan="9" rowspan="5">     </td>
</tr>
<tr class="odd">
<td colspan="11">TITLE: <em>(Name of Program)</em>:</td>
<td colspan="26">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"></td>
<td colspan="26"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="38"><strong>12. AREAS AFFECTED BY PROJECT</strong>
<em>(cities, counties, states, etc.<strong>):</strong></em></td>
</tr>
<tr class="even">
<td colspan="38">     </td>
</tr>
<tr class="odd">
<td colspan="38"><strong>13. PROPOSED PROJECT:</strong></td>
<td colspan="9"><strong>14. CONGRESSIONAL DISTRICTS OF:</strong></td>
</tr>
<tr class="even">
<td colspan="18">Start Date</td>
<td colspan="20">Ending Date</td>
<td colspan="5">a. Applicant</td>
<td colspan="4">b. Project</td>
</tr>
<tr class="odd">
<td colspan="18">     </td>
<td colspan="20">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="38"><strong>15. ESTIMATED FUNDING:</strong></td>
<td colspan="9"><strong>16. IS APPLICATION SUBJECT TO REVIEW BY STATE
EXECUTIVE ORDER 12372 PROCESS?</strong></td>
</tr>
<tr class="odd">
<td colspan="6">a. Federal</td>
<td colspan="2">$</td>
<td colspan="30">     </td>
<td colspan="9" rowspan="2">a. YES. THIS PREAPPLICATION/APPLICATION WAS
MADE AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW
ON:</td>
</tr>
<tr class="even">
<td colspan="6">b. Applicant</td>
<td colspan="2">$</td>
<td colspan="30">     </td>
</tr>
<tr class="odd">
<td colspan="6">c. State</td>
<td colspan="2">$</td>
<td colspan="30">     </td>
<td colspan="3"><blockquote>
<p>DATE</p>
</blockquote></td>
<td colspan="5">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="6">d. Local</td>
<td colspan="2">$</td>
<td colspan="30">     </td>
<td colspan="9" rowspan="2">b. NO. PROGRAM IS NOT COVERED BY E.O. 12372
OR PROGRAM HAS NOT BEEN SELECTED STATE FOR REVIEW</td>
</tr>
<tr class="odd">
<td colspan="6">e. Other</td>
<td colspan="2">$</td>
<td colspan="30">     </td>
</tr>
<tr class="even">
<td colspan="6">f. Program Income</td>
<td colspan="2">$</td>
<td colspan="30">     </td>
<td colspan="9"><strong>17. IS APPLICATION DELINQUENT ON ANY FEDERAL
DEBT?</strong></td>
</tr>
<tr class="odd">
<td colspan="6">g. TOTAL</td>
<td colspan="2">$</td>
<td colspan="30">0</td>
<td colspan="9"> YES If "Yes," attach an explanation. No</td>
</tr>
<tr class="even">
<td colspan="47"><p><strong>18. TO THE BEST OF MY KNOWLEDGE AND BELIEF,
ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT, THE
DOCUMENT HAS BEEN DULY</strong></p>
<p><strong>AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE
APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS
AWARDED.</strong></p></td>
</tr>
<tr class="odd">
<td colspan="47">a. Authorized Representative</td>
</tr>
<tr class="even">
<td colspan="15">Prefix</td>
<td colspan="24">First Name</td>
<td colspan="8">Middle Name</td>
</tr>
<tr class="odd">
<td colspan="15">     </td>
<td colspan="24">     </td>
<td colspan="8">     </td>
</tr>
<tr class="even">
<td colspan="39">Last Name</td>
<td colspan="8">Suffix</td>
</tr>
<tr class="odd">
<td colspan="39">     </td>
<td colspan="8">     </td>
</tr>
<tr class="even">
<td colspan="39">b. Title</td>
<td colspan="8">c. Telephone Number <em>(give area code)</em></td>
</tr>
<tr class="odd">
<td colspan="39">     </td>
<td colspan="8">     </td>
</tr>
<tr class="even">
<td colspan="39">d. Signature of Authorized Representative</td>
<td colspan="8">e. Date Signed</td>
</tr>
<tr class="odd">
<td colspan="39"></td>
<td colspan="8">     </td>
</tr>
</tbody>
</table>

+-----------------------------------+-----------------------------------+
| **INSTRUCTIONS FOR THE SF-424**   |                                   |
+-----------------------------------+-----------------------------------+
| Public reporting burden for this  |                                   |
| collection of information is      |                                   |
| estimated to average 45 minutes   |                                   |
| per response, including time for\ |                                   |
| reviewing instructions, searching |                                   |
| existing data sources, gathering  |                                   |
| and maintaining the data needed,  |                                   |
| and completing and\               |                                   |
| reviewing the collection of       |                                   |
| information. Send comments        |                                   |
| regarding the burden estimate or  |                                   |
| any other aspect of this          |                                   |
| collection of\                    |                                   |
| information, including            |                                   |
| suggestions for reducing this     |                                   |
| burden, to the Office of          |                                   |
| Management and Budget, Paperwork  |                                   |
| Reduction\                        |                                   |
| Project (0348-0043), Washington,  |                                   |
| DC 20503.                         |                                   |
|                                   |                                   |
| **PLEASE DO NOT RETURN YOUR       |                                   |
| COMPLETED FORM TO THE OFFICE OF   |                                   |
| MANAGEMENT AND BUDGET.**          |                                   |
|                                   |                                   |
| **SEND IT TO THE ADDRESS PROVIDED |                                   |
| BY THE SPONSORING AGENCY.**       |                                   |
+-----------------------------------+-----------------------------------+
| This is a standard form 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\. Select Type of Submission.    | > 9\. Name of Federal agency from |
|                                   | > which assistance is\            |
| > 2\. Date application submitted  | > being requested with this       |
| > to Federal agency (or\          | > application.                    |
| > State if applicable) &          |                                   |
| > applicant's control number (if\ | 10\. Use the Catalog of Federal   |
| > applicable).                    | Domestic Assistance\              |
| >                                 | number and title of the program   |
| > 3\. State use only (if          | under which\                      |
| > applicable).                    | assistance is requested.          |
| >                                 |                                   |
| > 4\. Enter Date Received by      | 11\. Enter a brief descriptive    |
| > Federal Agency\                 | title of the project. If\         |
| > Federal Identifier number: If   | more than one program is          |
| > this application is a\          | involved, you should\             |
| > continuation or revision to an  | append an explanation on a        |
| > existing award, enter\          | separate sheet. If\               |
| > the present Federal Identifier. | appropriate (e.g., construction   |
|                                   | or real property\                 |
| 5\. Enter legal name of           | projects), attach a map showing   |
| applicant, name of primary\       | project location.\                |
| organizational unit (including    | For preapplications, use a        |
| division, if\                     | separate sheet to\                |
| appliacable), which will          | provide a summary description of  |
| undertake the assistance\         | this project.                     |
| activity, enter the               |                                   |
| organization's DUNS number\       | 12\. List only the largest        |
| (received from Dun and            | political entities affected       |
| Bradstreet), enter the\           | (e.g.,\                           |
| complete address of the applicant | State, counties, cities).         |
| (including\                       |                                   |
| country), and name and telephone  | 13\. Enter the proposed start     |
| number, email\                    | date and end date of the\         |
| and FAX of the person to contact  | project.                          |
| on matters\                       |                                   |
| related to this application.      | 14\. List the applicant's         |
|                                   | Congressional District and any\   |
| 6\. Enter Employer Identification | District(s) affected by the       |
| Number (EIN) as\                  | program or project.               |
| assigned by Internal Revenue      |                                   |
| Service.                          | 15\. Amount requested or to be    |
|                                   | contributed during the\           |
| 7\. Select the appropriate letter | first funding/budget period by    |
| in the space\                     | each contributor.\                |
| provided.                         | Value of in-kind contributions    |
|                                   | should be included\               |
| A. State I. State Controlled\     | on appropriate lines as           |
| B. County Institution of Higher\  | applicable. If the action\        |
| C. Municipal Learning\            | will result in a dollar change to |
| D. Township J. Private            | an existing award,\               |
| University\                       | indicate *[only]{.underline}* the |
| E. Interstate K. Indian Tribe\    | amount of the change. For\        |
| F. Intermunicipal L. Individual\  | decreases, enclose the amounts in |
| G. Special District M. Profit     | parentheses.\                     |
| Organization\                     | If both basic and supplemental    |
| H. Independent School N. Other    | amounts are\                      |
| (Specify)\                        | included, show breakdown on an    |
| District O. Not for Profit\       | attached sheet.\                  |
| Organization                      | For multiple program funding, use |
|                                   | totals and\                       |
| 8\. Select the type from the      | show breakdown using same         |
| following list:                   | categories as item 15.            |
|                                   |                                   |
| -   \"New\" means a new           | 16\. Applicants should contact    |
|     assistance award.             | the State Single Point\           |
|                                   | of Contact (SPOC) for Federal     |
| -   \"Continuation\" means an     | Executive Order\                  |
|     extension for an\             | 12372 to determine whether the    |
|     additional funding/budget     | application is\                   |
|     period for a project\         | subject to the State              |
|     with a projected completion   | intergovernmental review\         |
|     date.                         | process.                          |
|                                   |                                   |
| -   \"Revision\" means any change | > 17\. This question applies to   |
|     in the Federal\               | > the applicant organization,\    |
|     Governments financial         | > not the person who signs as     |
|     obligation or contingent\     | > the\                            |
|     liability from an existing    | > authorized representative.      |
|     obligation.                   | > Categories of debt\             |
|                                   | > include delinquent audit        |
| A. Increase Award B. Decrease     | > disallowances, loans and\       |
| Award\                            | > taxes.                          |
| C.Increase Duration D. Decrease   | >                                 |
| Duration                          | > 18\. To be signed by the        |
|                                   | > authorized representative of\   |
|                                   | > the applicant. A copy of the    |
|                                   | > governing body's\               |
|                                   | > authorization for you to sign   |
|                                   | > this application as\            |
|                                   | > official representative must be |
|                                   | > on file in the\                 |
|                                   | > applicant's office. (Certain    |
|                                   | > Federal agencies may\           |
|                                   | > require that this authorization |
|                                   | > be submitted as\                |
|                                   | > part of the application.)       |
+-----------------------------------+-----------------------------------+

+---------+---------+---------+---------+---------+---------+---------+
| *       |         |         |         |         |         |         |
| *BUDGET |         |         |         |         |         |         |
| INFORM  |         |         |         |         |         |         |
| ATION - |         |         |         |         |         |         |
| Non-    |         |         |         |         |         |         |
| Const   |         |         |         |         |         |         |
| ruction |         |         |         |         |         |         |
| Pro     |         |         |         |         |         |         |
| grams** |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| **      |         |         |         |         |         |         |
| SECTION |         |         |         |         |         |         |
| A -     |         |         |         |         |         |         |
| BUDGET  |         |         |         |         |         |         |
| SU      |         |         |         |         |         |         |
| MMARY** |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| Grant   | Catalog | Es      |         | New or  |         |         |
| Program | of      | timated |         | Revised |         |         |
|         | Federal | Unob    |         | Budget  |         |         |
| F       |         | ligated |         |         |         |         |
| unction | D       | Funds   |         |         |         |         |
|         | omestic |         |         |         |         |         |
| or      | Ass     |         |         |         |         |         |
| A       | istance |         |         |         |         |         |
| ctivity |         |         |         |         |         |         |
|         | Number  |         |         |         |         |         |
| \(a\)   |         |         |         |         |         |         |
|         | \(b\)   |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         | Federal | Non-    | Federal | Non-    | Total   |
|         |         |         | Federal |         | Federal |         |
|         |         | \(c\)   |         | \(e\)   |         | \(g\)   |
|         |         |         | \(d\)   |         | \(f\)   |         |
+---------+---------+---------+---------+---------+---------+---------+
| 1\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| 2\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| 3\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| 4\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| 5\.     |         | \$ 0.00 | \$ 0.00 | \$ 0.00 | \$ 0.00 | \$ 0.00 |
| TOTALS  |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| **      |         |         |         |         |         |         |
| SECTION |         |         |         |         |         |         |
| B -     |         |         |         |         |         |         |
| BUDGET  |         |         |         |         |         |         |
| CATEG   |         |         |         |         |         |         |
| ORIES** |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| 6\.     |         | **GRANT |         |         |         | Total   |
| Object  |         | P       |         |         |         |         |
| Class   |         | ROGRAM, |         |         |         | \(5\)   |
| Cat     |         | F       |         |         |         |         |
| egories |         | UNCTION |         |         |         |         |
|         |         | OR      |         |         |         |         |
|         |         | ACT     |         |         |         |         |
|         |         | IVITY** |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         | \(1\)   | \(2\)   | \(3\)   | \(4\)   |         |
+---------+---------+---------+---------+---------+---------+---------+
| a\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
| Pe      |         |         |         |         |         |         |
| rsonnel |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| b\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
| Fringe  |         |         |         |         |         |         |
| B       |         |         |         |         |         |         |
| enefits |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| c\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
| Travel  |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| d\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
| Eq      |         |         |         |         |         |         |
| uipment |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| e\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
| S       |         |         |         |         |         |         |
| upplies |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| f\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
| Cont    |         |         |         |         |         |         |
| ractual |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| g\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
| Const   |         |         |         |         |         |         |
| ruction |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| h\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
| Other   |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| i.**i** |         | \$ 0.00 | \$ 0.00 | \$ 0.00 | \$ 0.00 | \$ 0.00 |
| Total   |         |         |         |         |         |         |
| Direct  |         |         |         |         |         |         |
| Charges |         |         |         |         |         |         |
| *(sum   |         |         |         |         |         |         |
| of 6a   |         |         |         |         |         |         |
| -6h)*   |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| j\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
| I       |         |         |         |         |         |         |
| ndirect |         |         |         |         |         |         |
| Charges |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| k\.     |         | \$ 0.00 | \$ 0.00 | \$ 0.00 | \$ 0.00 | \$ 0.00 |
| TOTALS  |         |         |         |         |         |         |
| *(sum   |         |         |         |         |         |         |
| of 6i   |         |         |         |         |         |         |
| and     |         |         |         |         |         |         |
| 6j)*    |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
|         |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+
| 7\.     |         | \$      | \$      | \$      | \$      | \$ 0.00 |
| Program |         |         |         |         |         |         |
| Income  |         |         |         |         |         |         |
+---------+---------+---------+---------+---------+---------+---------+

  -------------------- ----------- ------------- ---------- ----------- ----------- -----------
  **SECTION C - NON-                                                                
  FEDERAL RESOURCES**                                                               

  **(a) Grant                      **(b)                    **(c)       **(d) Other **(e)
  Program**                        Applicant**              State**     Sources**   TOTALS**

  8\.                              \$                       \$          \$          \$ 0.00

  9\.                              \$                       \$          \$          \$ 0.00

  10\.                             \$                       \$          \$          \$ 0.00

  11\.                             \$                       \$          \$          \$ 0.00

  12\. TOTALS *(sum of             \$ 0.00                  \$ 0.00     \$ 0.00     \$ 0.00
  lines 8 and 11)*                                                                  

  **SECTION D -                                                                     
  FORECASTED CASH                                                                   
  NEEDS**                                                                           

                       **Total for **1st                    **2nd       **3rd       **4th
                       1st Year**  Quarter**                Quarter**   Quarter**   Quarter**

  13\. Federal         \$ 0.00     \$                       \$          \$          \$      

  14\. Non- Federal    \$ 0.00     \$                       \$          \$          \$      

  15\. TOTAL *(sum of  \$ 0.00     \$ 0.00                  \$ 0.00     \$ 0.00     \$ 0.00
  lines 13 and 14)*                                                                 

  **SECTION E - BUDGET                                                              
  ESTIMATES OF FEDERAL                                                              
  FUNDS NEEDED FOR                                                                  
  BALANCE OF THE                                                                    
  PROJECT**                                                                         

  **(a) Grant                      **FUTURE                                         
  Program**                        FUNDING                                          
                                   PERIODS                                          
                                   (Years)**                                        

                                   **(b) First**            **(c)       **(d)       **(e)
                                                            Second**    Third**     Fourth**

  16\.                             \$                       \$          \$          \$      

  17\.                             \$                       \$          \$          \$      

  18\.                             \$                       \$          \$          \$      

  19\.                             \$                       \$          \$          \$      

  20\. TOTALS *(sum of             \$ 0.00                  \$ 0.00     \$ 0.00     \$ 0.00
  lines 16 -19)*                                                                    

  **SECTION F - OTHER                                                               
  BUDGET INFORMATION**                                                              

  21\. Direct Charges:                           22\.                               
                                                 Indirect                           
                                                 Charges:                           

                                                                                    

  23\. Remarks                                                                      

                                                                                    
  -------------------- ----------- ------------- ---------- ----------- ----------- -----------

+-----------------------------------+-----------------------------------+
| **INSTRUCTIONS FOR THE SF-424A**  |                                   |
+-----------------------------------+-----------------------------------+
| Public reporting burden for this  |                                   |
| collection of information is      |                                   |
| estimated to average 180 minutes  |                                   |
| per response, including time for\ |                                   |
| reviewing instructions, searching |                                   |
| existing data sources, gathering  |                                   |
| and maintaining the data needed,  |                                   |
| and completing and\               |                                   |
| reviewing the collection of       |                                   |
| information. Send comments        |                                   |
| regarding the burden estimate or  |                                   |
| any other aspect of this          |                                   |
| collection of\                    |                                   |
| information, including            |                                   |
| suggestions for reducing this     |                                   |
| burden, to the Office of          |                                   |
| Management and Budget, Paperwork  |                                   |
| Reduction\                        |                                   |
| Project (0348-0044), Washington,  |                                   |
| DC 20503.                         |                                   |
|                                   |                                   |
| **PLEASE DO NOT RETURN YOUR       |                                   |
| COMPLETED FORM TO THE OFFICE OF   |                                   |
| MANAGEMENT AND BUDGET.**          |                                   |
|                                   |                                   |
| **SEND IT TO THE ADDRESS PROVIDED |                                   |
| BY THE SPONSORING AGENCY.**       |                                   |
+-----------------------------------+-----------------------------------+
| **General Instructions**          | > **Lines 1 - 4, Columns (c)      |
|                                   | > through (g.)** *(continued)*    |
| This form is designed so that     | >                                 |
| application can be made\          | > For continuing grant program    |
| for funds from one or more grant  | > applications, submit\           |
| programs. In pre-\                | > these forms before the end of   |
| paring the budget, adhere to any  | > each funding period as\         |
| existing Federal\                 | > required by the grantor agency. |
| grantor agency guidelines which   | > Enter in Columns (c)\           |
| prescribe how and\                | > and (d) the estimated amounts   |
| whether budgeted amounts should   | > of funds which will\            |
| be separately shown\              | > remain unobligated at the end   |
| for different functions or        | > of the grant funding\           |
| activities within the program.\   | > period only if the Federal      |
| For some programs, grantor        | > grantor agency instructions\    |
| agencies may require\             | > provide for this. Otherwise,    |
| budgets to be separately shown by | > leave these columns blank.\     |
| function or activity.\            | > Enter in columns (e) and (f)    |
| For other programs, grantor       | > the amounts of funds\           |
| agencies may require a\           | > needed for the upcoming period. |
| breakdown by function or          | > The amount(s) in\               |
| activity. Sections A, B, C, and\  | > Column (g) should be the sum of |
| D should include budget estimates | > amounts in Columns\             |
| for the whole project\            | > (e) and (f).                    |
| except when applying for          | >                                 |
| assistance which requires\        | > For supplemental grants and     |
| Federal authorization in annual   | > changes to existing\            |
| or other funding period\          | > grants, do not use Columns (c)  |
| increments. In the latter case,   | > and (d). Enter in column\       |
| Sections A, B, C, and D\          | > (e) the amount of the increase  |
| should provide the budget for the | > or decrease of Federal\         |
| first budget period\              | > Funds and enter in Column (f)   |
| (usually a year) and Section E    | > the amount of the\              |
| should present the need\          | > increase or decrease of         |
| for Federal assistance in the     | > non-Federal funds. In Column\   |
| subsequent budget\                | > (g) enter the new total         |
| periods. All applications should  | > budgeted amount (Federal and\   |
| contain a breakdown by\           | > non-Federal) which includes the |
| the object class categories shown | > total previous\                 |
| in Lines a - k of\                | > authorized budgeted amounts     |
| Section B.                        | > plus or minus, as\              |
|                                   | > appropriate, the amounts shown  |
| **Section A. Budget Summary Lines | > in Columns (e) and (f).\        |
| 1 - 4, Columns\                   | > The amount(s) in Column (g)     |
| (a) and (b)**                     | > should not equal the sum\       |
|                                   | > of amounts in Columns (e) and   |
| For applications pertaining to a  | > (f).                            |
| single Federal grant\             | >                                 |
| program (Federal Domestic         | > **Line 5** - Show the totals    |
| Assistance Catalog\               | > for all columns used.           |
| number) and not requiring a       | >                                 |
| functional or activity\           | > **Section B. Budget             |
| breakdown, enter on Line 1 under  | > Categories**                    |
| Column (a) the\                   | >                                 |
| catalog program title and the     | > In the column heading (1)       |
| catalog number in Column\         | > through (4), enter the titles   |
| (b).                              | > of\                             |
|                                   | > the same programs, functions,   |
| For applications pertaining to a  | > and activities shown on\        |
| single program\                   | > Lines 1 - 4, Column (a),        |
| requiring budget amounts by       | > Section A. When additional\     |
| multiple functions or\            | > sheets are prepared for Section |
| activities, enter the name of     | > A, provide similar\             |
| each activity or function on\     | > column headings on each sheet.  |
| each line in Column (a), and      | > For each program,\              |
| enter the catalog number\         | > function or activity, fill in   |
| in Column (b). For applications   | > the total requirements for\     |
| pertaining to multiple\           | > funds (both Federal and         |
| programs where none of the        | > non-Federal) by object class\   |
| programs require a\               | > categories.                     |
| breakdown by function or          | >                                 |
| activity, enter the catalog\      | > **Lines 6a-i** - Show the       |
| program title on each line in     | > totals of Lines 6a to 6h in     |
| Column (a) and the\               | > each\                           |
| respective catalog number on each | > column.                         |
| line in Column (b).               | >                                 |
|                                   | > **Line 6j** - Show the amount   |
| For applications pertaining to    | > of indirect cost.               |
| multiple programs\                | >                                 |
| where one or more programs        | > **Line 6k** - Enter the total   |
| require a breakdown by\           | > of amounts on Lines 6i and 6j.\ |
| function or activity, prepare a   | > For all applications for new    |
| separate sheet for each\          | > grants and continuation\        |
| program requiring the breakdown.  | > grants the total amount in      |
| Additional sheets\                | > column (5), Line 6k, should\    |
| should be used when one form does | > be the same as the total amount |
| not provide\                      | > shown in Section A,\            |
| adequate space for all breakdown  | > Column (g), Line 5. For         |
| of data required.\                | > supplemental grants and\        |
| However, when more than one sheet | > changes to grants, the total    |
| is used, the first\               | > amount of the increase or\      |
| page should provide the summary   | > decrease as shown in Columns    |
| totals by programs.               | > (1) - (4), Line 6k should\      |
|                                   | > be the same as the sum of the   |
| **Lines 1 - 4, Columns (c)        | > amounts in Section A,\          |
| through (g.)**                    | > Columns (e) and (f) on Line 5.  |
|                                   | >                                 |
| For new applications, leave       | > **Line 7** - Enter the          |
| Columns (c) and (d) blank.\       | > estimated amount of income, if  |
| For each line entry in Columns    | > any,\                           |
| (a) and (b), enter in\            | > expected to be generated from   |
| Columns (e), (f), and (g) the     | > this project. Do not add\       |
| appropriate amounts of\           | > or subtract this amount from    |
| funds needed to support the       | > the total project amount.       |
| project for the first funding\    |                                   |
| period (usually a year).          |                                   |
+-----------------------------------+-----------------------------------+

+-----------------------------------+-----------------------------------+
| **INSTRUCTIONS FOR THE SF-424A**  |                                   |
| *(Continued)*                     |                                   |
+-----------------------------------+-----------------------------------+
| **Line 7** - *(continued)*        | > **Line 15** - Enter the totals  |
|                                   | > of amounts on Lines 13 and\     |
| Show under the program narrative  | > 14.                             |
| statement the nature\             | >                                 |
| and source of income. The         | > **Section E. Budget Estimates   |
| estimated amount of\              | > of Federal Funds\               |
| program income may be considered  | > Needed for Balance of the       |
| by the Federal\                   | > Project**                       |
| grantor agency in determining the | >                                 |
| total amount of the\              | > **Lines 16 - 19** - Enter in    |
| grant.                            | > Column (a) the same grant\      |
|                                   | > program titles shown in column  |
| **Section C. Non-Federal          | > (a), Section A. A\              |
| Resources**                       | > breakdown by function or        |
|                                   | > activity is not necessary. For\ |
| **Lines 8 - 11** - Enter amounts  | > new applications and            |
| of non-Federal resources\         | > continuation grant              |
| that will be used on the grant.   | > applications,\                  |
| If in-kind contributions are\     | > enter in the proper columns     |
| included, provide a brief         | > amounts of Federal funds\       |
| explanation on a separate\        | > which will be needed to         |
| sheet.                            | > complete the program or project |
|                                   | > over the succeeding funding     |
| > **Column (a)** - Enter the      | > periods (usually in years).     |
| > program titles identical to\    | > This section need not be        |
| > Column (a), Section A. A        | > completed for revisions         |
| > breakdown by function or\       | > (amendments, changes, or        |
| > activity is not necessary.      | > supplements) to funds for the   |
| >                                 | > current year of existing        |
| > **Column (b)** - Enter the      | > grants.                         |
| > contribution to be made by\     | >                                 |
| > the applicant.                  | > If more than four lines are     |
| >                                 | > needed to list the program\     |
| > **Column (c)** - Enter the      | > titles, submit additional       |
| > amount of the State's cash\     | > schedules as necessary.         |
| > and in-kind contribution if the | >                                 |
| > applicant is not a\             | > **Line 20** - Enter the total   |
| > State or State agency.          | > for each of the Columns (b) -\  |
| > Applicants which are a\         | > (e). When additional schedules  |
| > State or State agencies should  | > are prepared for this\          |
| > leave this column\              | > Section, annotate accordingly   |
| > blank.                          | > and show the overall\           |
| >                                 | > totals on this line.            |
| > **Column (d)** - Enter the      | >                                 |
| > amount of cash and in-kind\     | > **Section F. Other Budget       |
| > contributions to be made from   | > Information**                   |
| > all other sources.              | >                                 |
| >                                 | > **Line 21** - Use this space to |
| > **Column (e) -** Enter totals   | > explain amounts for\            |
| > of Columns (b), (c), and\       | > individual direct object-class  |
| > (d).                            | > cost categories that may\       |
|                                   | > appear to be out of the         |
| **Line 12** - Enter the total for | > ordinary or to explain the      |
| each of Columns (b) - (e).\       | > details\                        |
| The amount in Column (e) should   | > as required by the Federal      |
| be equal to the\                  | > grantor agency.                 |
| amount on Line 5, Column (f),     | >                                 |
| Section A.                        | > **Line 22** - Enter the type of |
|                                   | > indirect rate (provisional,\    |
| **Section D. Forecasted Cash      | > predetermined, final or fixed)  |
| Needs**                           | > that will be in effect during\  |
|                                   | > the funding period, the         |
| **Line 13** - Enter the amount of | > estimated amount of the base    |
| cash needed by quarter\           | > to\                             |
| from the grantor agency during    | > which the rate is applied, and  |
| the first year.                   | > the total indirect expense.     |
|                                   | >                                 |
| **Line 14** - Enter the amount of | > **Line 23** - Provide any other |
| cash from all other\              | > explanations or comments\       |
| sources needed by quarter during  | > deemed necessary.               |
| the first year.                   |                                   |
+-----------------------------------+-----------------------------------+

+-----------------------------------+-----------------------------------+
| **ASSURANCES - NON-CONSTRUCTION   |                                   |
| PROGRAMS**                        |                                   |
+-----------------------------------+-----------------------------------+
| Public reporting burden for this  |                                   |
| collection of information is      |                                   |
| estimated to average 15 minutes   |                                   |
| per response, including time for\ |                                   |
| reviewing instructions, searching |                                   |
| existing data sources, gathering  |                                   |
| and maintaining the data needed,  |                                   |
| and completing and\               |                                   |
| reviewing the collection of       |                                   |
| information. Send comments        |                                   |
| regarding the burden estimate or  |                                   |
| any other aspect of this          |                                   |
| collection of\                    |                                   |
| information, including            |                                   |
| suggestions for reducing this     |                                   |
| burden, to the Office of          |                                   |
| Management and Budget, Paperwork  |                                   |
| Reduction\                        |                                   |
| Project (0348-0040), Washington,  |                                   |
| DC 20503.                         |                                   |
|                                   |                                   |
| **PLEASE DO NOT RETURN YOUR       |                                   |
| COMPLETED FORM TO THE OFFICE OF   |                                   |
| MANAGEMENT AND BUDGET.**          |                                   |
|                                   |                                   |
| **SEND IT TO THE ADDRESS PROVIDED |                                   |
| BY THE SPONSORING AGENCY.**       |                                   |
+-----------------------------------+-----------------------------------+
| **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    | > \(e\) the Drug Abuse Office and |
| apply for Federal\                | > Treatment Act of\               |
| assistance, and the               | > 1972 (P.L. 92-255), as amended, |
| institutional, managerial and\    | > relating to\                    |
| financial capability (including   | > nondiscrimination on the basis  |
| funds sufficient to pay\          | > of drug abuse; (f) the\         |
| the non-Federal share of project  | > Comprehensive Alcohol Abuse and |
| costs) to ensure\                 | > Alcoholism\                     |
| proper planning, management and   | > Prevention, Treatment and       |
| completion of\                    | > Rehabilitation Act of\          |
| the project described in this     | > 1970 (P.L. 91-616), as amended, |
| application.                      | > relating to\                    |
|                                   | > nondiscrimination on the basis  |
| 2\. Will give the awarding        | > of alcohol abuse or\            |
| agency, the Comptroller\          | > alcoholism; (g) §§523 and 527   |
| General of the United States, and | > of the Public Health\           |
| if appropriate, the\              | > Service Act of 1912 (42 U.S.C.  |
| State, through any authorized     | > §§290 dd-3 and 290\             |
| representative,\                  | > ee-3), as amended, relating to  |
| access to and the right to        | > confidentiality of\             |
| examine all records,\             | > alcohol and drug abuse patient  |
| books, papers, or documents       | > records; (h) Title VIII\        |
| related to the award;\            | > of the Civil Rights Act of 1968 |
| and will establish a proper       | > (42 U.S.C. §§3601\              |
| accounting system in\             | > et seq.), as amended, relating  |
| accordance with generally         | > to non- discrimination\         |
| accepted accounting\              | > in the sale, rental or          |
| standard or agency directives.    | > financing of housing; (i) any\  |
|                                   | > other nondiscrimination         |
| 3\. Will establish safeguards to  | > provisions in the specific\     |
| prohibit employees from\          | > statute(s) under which          |
| using their positions for a       | > application for Federal\        |
| purpose that constitutes\         | > assistance is being made; and   |
| or presents the appearance of     | > (j) the requirements\           |
| personal or\                      | > of any other nondiscrimination  |
| organizational conflict of        | > statute(s) which may\           |
| interest, or personal gain.       | > apply to the application.       |
|                                   | >                                 |
| 4\. Will initiate and complete    | > 7\. Will comply, or has already |
| the work within the\              | > complied, with the\             |
| applicable time frame after       | > requirements of Title II and    |
| receipt of approval of the\       | > III of the Uniform\             |
| awarding agency.                  | > Relocation Assistance and Real  |
|                                   | > Property Acquisition Policies   |
| 5\. Will comply with the          | > Act of 1970 (P.L. 91-646)       |
| Intergovernmental Personnel\      | > which\                          |
| Act of 1970 (42 U.S.C.            | > provide for fair and equitable  |
| §§4728-4763) relating to\         | > treatment of persons\           |
| prescribed standards for merit    | > displaced or whose property is  |
| systems for\                      | > acquired as a result\           |
| programs funded under one of the  | > of Federal or federally         |
| nineteen statutes\                | > assisted programs. These\       |
| or regulations specified in       | > requirements apply to all       |
| Appendix A of OPM's\              | > interests in real property\     |
| Standard for a Merit System of    | > acquired for project purposes   |
| Personnel\                        | > regardless of Federal\          |
| Administration (5 C.F.R. 900,     | > participation in purchases.     |
| Subpart F).                       | >                                 |
|                                   | > 8\. Will comply with the        |
| 6\. Will comply with all Federal  | > provisions of the Hatch Act (5\ |
| statutes relating to\             | > U.S.C. §§1501-1508 and          |
| nondiscrimination. These include  | > 7324-7328) which limit the\     |
| but are not limited\              | > political activities of         |
| to: (a) Title VI of the Civil     | > employees whose principal\      |
| Rights Act of 1964 (P.L.\         | > employment activities are       |
| 88-352) which prohibits           | > funded in whole or in part\     |
| discrimination on the basis\      | > with Federal funds.             |
| of race, color or national        | >                                 |
| origin; (b) Title IX of the\      | > 9\. Will comply, as applicable, |
| Education Amendments of 1972, as  | > with the provisions of the\     |
| amended (20\                      | > Davis-Bacon Act (40 U.S.C.      |
| U.S.C. §§1681-1683, and 1685-     | > §§276a to 276a-7), the\         |
| 1686), which\                     | > Copeland Act (40 U.S.C. §276c   |
| prohibits discrimination on the   | > and 18 U.S.C.\                  |
| basis of sex; (c)\                | > §874), and the Contract Work    |
| Section 504 of the Rehabilitation | > Hours and Safety\               |
| Act of 1973, as\                  | > Standards Act (40 U.S.C. §§327- |
| amended (29 U.S.C. §§794), which  | > 333), regarding\                |
| prohibits\                        | > labor standards for federally   |
| discrimination on the basis of    | > assisted construction\          |
| handicaps; (d) the\               | > subagreements.                  |
| Age Discrimination Act of 1975,   |                                   |
| as amended (42\                   |                                   |
| U.S.C. §§6101-6107), which        |                                   |
| prohibits discrimination\         |                                   |
| on the basis of age;              |                                   |
+-----------------------------------+-----------------------------------+

+----------------------------------+-------------+--------------------+
| 10\. Will comply, if applicable, | > 13\. Will |                    |
| with flood insurance\            | > assist    |                    |
| purchase requirements of Section | > the       |                    |
| 102(a) of the\                   | > awarding  |                    |
| Flood Disaster Protection Act of | > agency in |                    |
| 1973 (P.L.\                      | > assuring\ |                    |
| 93-234) which requires           | >           |                    |
| recipients in a special flood\   |  compliance |                    |
| hazard area to participate in    | > with      |                    |
| the program and to\              | > Section   |                    |
| purchase flood insurance if the  | > 106 of    |                    |
| total cost of\                   | > the       |                    |
| insurable construction and       | > National\ |                    |
| acquisition is \$10,000\         | > Historic  |                    |
| or more.                         | > P         |                    |
|                                  | reservation |                    |
| 11\. Will comply with            | > Act of    |                    |
| environmental standards which\   | > 1966, as  |                    |
| may be prescribed pursuant to    | > amended   |                    |
| the following: (a)\              | > (16\      |                    |
| institution of environmental     | > U.S.C.    |                    |
| quality control\                 | > §470), EO |                    |
| measures under the National      | > 11593     |                    |
| Environmental Policy\            | > (ide      |                    |
| Act of 1969 (P.L. 91-190) and    | ntification |                    |
| Executive Order\                 | > and\      |                    |
| (EO) 11514; (b) notification of  | >           |                    |
| violating facilities\            |  protection |                    |
| pursuant to EO 11738; (c)        | > of        |                    |
| protection of wetland\           | > historic  |                    |
| pursuant to EO 11990; (d)        | > p         |                    |
| evaluation of flood\             | roperties), |                    |
| hazards in floodplains in        | > and the\  |                    |
| accordance with EO\              | > Arc       |                    |
| 11988; (e) assurance of project  | haeological |                    |
| consistency with\                | > and       |                    |
| the approved State management    | > Historic  |                    |
| program\                         | > P         |                    |
| developed under the Costal Zone  | reservation |                    |
| Management\                      | > Act of\   |                    |
| Act of 1972 (16 U.S.C. §§1451 et | > 1974 (16  |                    |
| seq.); (f)\                      | > U.S.C. §§ |                    |
| conformity of Federal actions to | > 469a-1 et |                    |
| State (Clear Air)\               | > seq.).    |                    |
| Implementation Plans under       | >           |                    |
| Section 176(c) of the\           | > 14\. Will |                    |
| Clear Air Act of 1955, as        | > comply    |                    |
| amended (42 U.S.C.\              | > with P.L. |                    |
| §§7401 et seq.); (g) protection  | > 93-348    |                    |
| of underground\                  | > regarding |                    |
| sources of drinking water under  | > the\      |                    |
| the Safe Drinking\               | >           |                    |
| Water Act of 1974, as amended,   |  protection |                    |
| (P.L. 93-523);\                  | > of human  |                    |
| and (h) protection of endangered | > subjects  |                    |
| species under\                   | > involved  |                    |
| the Endangered Species Act of    | > in        |                    |
| 1973, as\                        | >           |                    |
| amended, (P.L. 93-205).          |  research,\ |                    |
|                                  | > d         |                    |
| 12\. Will comply with the Wild   | evelopment, |                    |
| and Scenic Rivers Act of\        | > and       |                    |
| 1968 (16 U.S.C. §§1271 et seq.)  | > related   |                    |
| related to\                      | >           |                    |
| protecting components or         |  activities |                    |
| potential components of\         | > supported |                    |
| the national wild and scenic     | > by\       |                    |
| rivers system.                   | > this      |                    |
|                                  | > award of  |                    |
|                                  | >           |                    |
|                                  | assistance. |                    |
|                                  | >           |                    |
|                                  | > 15\. Will |                    |
|                                  | > comply    |                    |
|                                  | > with the  |                    |
|                                  | >           |                    |
|                                  |  Laboratory |                    |
|                                  | > Animal    |                    |
|                                  | > Welfare\  |                    |
|                                  | > Act of    |                    |
|                                  | > 1966      |                    |
|                                  | > (P.L.     |                    |
|                                  | > 89-544,   |                    |
|                                  | > as        |                    |
|                                  | > amended,  |                    |
|                                  | > 7\        |                    |
|                                  | > U.S.C.    |                    |
|                                  | > §§2131 et |                    |
|                                  | > seq.)     |                    |
|                                  | >           |                    |
|                                  |  pertaining |                    |
|                                  | > to the    |                    |
|                                  | > care,\    |                    |
|                                  | > handling, |                    |
|                                  | > and       |                    |
|                                  | > treatment |                    |
|                                  | > of warm   |                    |
|                                  | > blooded   |                    |
|                                  | > animals\  |                    |
|                                  | > held for  |                    |
|                                  | > research, |                    |
|                                  | > teaching, |                    |
|                                  | > or other  |                    |
|                                  | >           |                    |
|                                  | activities\ |                    |
|                                  | > supported |                    |
|                                  | > by this   |                    |
|                                  | > award of  |                    |
|                                  | >           |                    |
|                                  | assistance. |                    |
|                                  | >           |                    |
|                                  | > 16\. Will |                    |
|                                  | > comply    |                    |
|                                  | > with the  |                    |
|                                  | >           |                    |
|                                  |  Lead-Based |                    |
|                                  | > Paint     |                    |
|                                  | >           |                    |
|                                  |  Poisoning\ |                    |
|                                  | >           |                    |
|                                  |  Prevention |                    |
|                                  | > Act (42   |                    |
|                                  | > U.S.C.    |                    |
|                                  | > §§4801 et |                    |
|                                  | > seq.)     |                    |
|                                  | > which\    |                    |
|                                  | > prohibits |                    |
|                                  | > the use   |                    |
|                                  | > of lead   |                    |
|                                  | > based     |                    |
|                                  | > paint in  |                    |
|                                  | > co        |                    |
|                                  | n-struction |                    |
|                                  | > or        |                    |
|                                  | > reh       |                    |
|                                  | abilitation |                    |
|                                  | > of        |                    |
|                                  | > residence |                    |
|                                  | >           |                    |
|                                  | structures. |                    |
|                                  | >           |                    |
|                                  | > 17\. Will |                    |
|                                  | > cause to  |                    |
|                                  | > be        |                    |
|                                  | > performed |                    |
|                                  | > the       |                    |
|                                  | > required  |                    |
|                                  | >           |                    |
|                                  |  financial\ |                    |
|                                  | > and       |                    |
|                                  | >           |                    |
|                                  |  compliance |                    |
|                                  | > audits in |                    |
|                                  | >           |                    |
|                                  |  accordance |                    |
|                                  | > with the\ |                    |
|                                  | > Single    |                    |
|                                  | > Audit Act |                    |
|                                  | > of 1984.  |                    |
|                                  | >           |                    |
|                                  | > 18\. Will |                    |
|                                  | > comply    |                    |
|                                  | > with all  |                    |
|                                  | >           |                    |
|                                  |  applicable |                    |
|                                  | > r         |                    |
|                                  | equirements |                    |
|                                  | > of all\   |                    |
|                                  | > other     |                    |
|                                  | > Federal   |                    |
|                                  | > laws,     |                    |
|                                  | > executive |                    |
|                                  | > orders,   |                    |
|                                  | > r         |                    |
|                                  | egulations\ |                    |
|                                  | > and       |                    |
|                                  | > policies  |                    |
|                                  | > governing |                    |
|                                  | > this      |                    |
|                                  | > program.  |                    |
+----------------------------------+-------------+--------------------+
| SIGNATURE OF AUTHORIZED          | TITLE       |                    |
| CERTIFYING OFFICIAL              |             |                    |
+----------------------------------+-------------+--------------------+
|                                  |             |                    |
+----------------------------------+-------------+--------------------+
| APPLICANT ORGANIZATION           |             | DATE SUBMITTED     |
+----------------------------------+-------------+--------------------+
|                                  |             |                    |
+----------------------------------+-------------+--------------------+

+-----------------------------+---+-------+---+------------+------------+
| **OMB Approval No. 0348-    |   |       |   |            |            |
| 0041**                      |   |       |   |            |            |
|                             |   |       |   |            |            |
| **BUDGET INFORMATION -      |   |       |   |            |            |
| Construction Programs**     |   |       |   |            |            |
|                             |   |       |   |            |            |
| ***NOTE:** Certain Federal  |   |       |   |            |            |
| assistance programs require |   |       |   |            |            |
| additional computations to  |   |       |   |            |            |
| arrive at the Federal share |   |       |   |            |            |
| of project costs eligible   |   |       |   |            |            |
| for participation. If such  |   |       |   |            |            |
| is the case you will be     |   |       |   |            |            |
| notified.*                  |   |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| **COST CLASSIFICATION**     | * |       |   | **b. Costs | **c. Total |
|                             | * |       |   | Not        | Allowable  |
|                             | a |       |   | A          | Costs**    |
|                             | . |       |   | llowable** |            |
|                             | T |       |   |            | **(Column  |
|                             | o |       |   | **for      | a- b)**    |
|                             | t |       |   | Parti      |            |
|                             | a |       |   | cipation** |            |
|                             | l |       |   |            |            |
|                             | C |       |   |            |            |
|                             | o |       |   |            |            |
|                             | s |       |   |            |            |
|                             | t |       |   |            |            |
|                             | * |       |   |            |            |
|                             | * |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 1\. Administrative and      | \ |       |   | \$         | \$ 0.00    |
| legal expenses              | $ |       |   |      .00   |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 2\. Land, structures,       | \ |       |   | \$         | \$ 0.00    |
| rights-of-way, appraisals,  | $ |       |   |      .00   |            |
| etc.                        |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 3\. Relocation expenses and | \ |       |   | \$         | \$ 0.00    |
| payments                    | $ |       |   |      .00   |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 4\. Architectural and       | \ |       |   | \$         | \$ 0.00    |
| engineering fees            | $ |       |   |      .00   |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 5\. Other architectural and | \ |       |   | \$         | \$ 0.00    |
| engineering fees            | $ |       |   |      .00   |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 6\. Project inspection fees | \ |       |   | \$         | \$ 0.00    |
|                             | $ |       |   |      .00   |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 7\. Site work               | \ |       |   | \$         | \$ 0.00    |
|                             | $ |       |   |      .00   |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 8\. Demolition and removal  | \ |       |   | \$         | \$ 0.00    |
|                             | $ |       |   |      .00   |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 9\. Construction            | \ |       |   | \$         | \$ 0.00    |
|                             | $ |       |   |      .00   |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 10\. Equipment              | \ |       |   | \$         | \$ 0.00    |
|                             | $ |       |   |      .00   |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 11\. Miscellaneous          | \ |       |   | \$         | \$ 0.00    |
|                             | $ |       |   |      .00   |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 12\. SUBTOTAL *(sum of      | \ |       |   | \$ 0.00    | \$ 0.00    |
| lines 1- 11)*               | $ |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 13\. Contingencies          | \ |       |   | \$         | \$ 0.00    |
|                             | $ |       |   |      .00   |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 14\. SUBTOTAL               | \ |       |   | \$ 0.00    | \$ 0.00    |
|                             | $ |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 15\. Project (program)      | \ |       |   | \$         | \$ 0.00    |
| income                      | $ |       |   |      .00   |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             |   |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 16\. TOTAL PROJECT COSTS    | \ |       |   | \$ 0.00    | \$ 0.00    |
| *(subtract #15 from #14)*   | $ |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | . |       |   |            |            |
|                             | 0 |       |   |            |            |
|                             | 0 |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| **FEDERAL FUNDING**         |   |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| 17\. Federal assistance     |   |       |   |            |            |
| requested, calculate as     |   |       |   |            |            |
| follows:                    |   |       |   |            |            |
|                             |   |       |   |            |            |
| (Consult Federal agency for |   |       |   |            |            |
| Federal percentage share).  |   |       |   |            |            |
|                             |   |       |   |            |            |
| Enter the resulting Federal |   |       |   |            |            |
| share.                      |   |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
| Enter eligible costs from   |   |       |   |            | \$ 0.00    |
| line 16c Multiply X         |   |       |   |            |            |
| (include decimal point in   |   |       |   |            |            |
| number)                     |   |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+
|                             |   |       |   |            |            |
+-----------------------------+---+-------+---+------------+------------+

+----------------------------------+---+----------------------------------+
| **INSTRUCTIONS FOR THE SF-424C** |   |                                  |
+----------------------------------+---+----------------------------------+
| Public reporting burden for this |   |                                  |
| collection of information is     |   |                                  |
| estimated to average 180 minutes |   |                                  |
| per response, including time     |   |                                  |
| for\                             |   |                                  |
| reviewing instructions,          |   |                                  |
| searching existing data sources, |   |                                  |
| gathering and maintaining the    |   |                                  |
| data needed, and completing and\ |   |                                  |
| reviewing the collection of      |   |                                  |
| information. Send comments       |   |                                  |
| regarding the burden estimate or |   |                                  |
| any other aspect of this         |   |                                  |
| collection of\                   |   |                                  |
| information, including           |   |                                  |
| suggestions for reducing this    |   |                                  |
| burden, to the Office of         |   |                                  |
| Management and Budget, Paperwork |   |                                  |
| Reduction\                       |   |                                  |
| Project (0348-0041), Washington, |   |                                  |
| DC 20503.                        |   |                                  |
|                                  |   |                                  |
| **PLEASE DO NOT RETURN YOUR      |   |                                  |
| COMPLETED FORM TO THE OFFICE OF  |   |                                  |
| MANAGEMENT AND BUDGET.**         |   |                                  |
|                                  |   |                                  |
| **SEND IT TO THE ADDRESS         |   |                                  |
| PROVIDED BY THE SPONSORING       |   |                                  |
| AGENCY.**                        |   |                                  |
+----------------------------------+---+----------------------------------+
| This sheet is to be used for the |   |                                  |
| following types of applications: |   |                                  |
| (1) \"New\" (means a new         |   |                                  |
| \[previously unfunded\]\         |   |                                  |
| assistance award); (2)           |   |                                  |
| \"Continuation\" (means funding  |   |                                  |
| in a succeeding budget period    |   |                                  |
| which stemmed from a prior\      |   |                                  |
| agreement to fund); and (3)      |   |                                  |
| \"Revised\" (means any changes   |   |                                  |
| in the Federal government's      |   |                                  |
| financial obligations or\        |   |                                  |
| contingent liability from an     |   |                                  |
| existing obligation). If there   |   |                                  |
| is no change in the award amount |   |                                  |
| there is no need to\             |   |                                  |
| complete this form. Certain      |   |                                  |
| Federal agencies may require     |   |                                  |
| only an explanatory letter to    |   |                                  |
| effect minor (no cost)\          |   |                                  |
| changes. If you have questions   |   |                                  |
| please contact the Federal       |   |                                  |
| agency.                          |   |                                  |
+----------------------------------+---+----------------------------------+
| Column a.- If this is an         |   | > Line 4 - Enter estimated basic |
| application for a \"New\"        |   | > engineering fees related\      |
| project,\                        |   | > to construction (this includes |
| enter the total estimated cost   |   | > start-up services and\         |
| of each of the items\            |   | > preparation of project         |
| listed on the lines 1 through 16 |   | > performance work plan).        |
| (as applicable) under\           |   | >                                |
| \"COST CLASSIFICATIONS.\"        |   | > Line 5 - Enter estimated       |
|                                  |   | > engineering costs, such as\    |
| If this application entails a    |   | > surveys, tests, soil borings,  |
| change to an existing\           |   | > etc.                           |
| award, enter the eligible        |   | >                                |
| amounts *approved under the\     |   | > Line 6 - Enter estimated       |
| previous award* for the items    |   | > engineering inspection costs.  |
| under \"COST\                    |   | >                                |
| CLASSIFICATION.\"                |   | > Line 7 - Enter estimated costs |
|                                  |   | > of site preparation and\       |
| Column b. - If this is an        |   | > restoration which are not      |
| application for \"New\"          |   | > included in the basic\         |
| project,\                        |   | > construction contract.         |
| enter that portion of the cost   |   | >                                |
| of each item in Column a.\       |   | > Line 9 - Enter estimated cost  |
| which is not allowable for       |   | > of the construction\           |
| Federal assistance. Contact\     |   | > contract.                      |
| the Federal agency for           |   | >                                |
| assistance in determining the\   |   | > Line 10 - Enter estimated cost |
| allowability of specific costs.  |   | > of office, shop,\              |
|                                  |   | > laboratory, safety equipment,  |
| If this application entails a    |   | > etc. to be used at the\        |
| change to an existing\           |   | > facility, if such costs are    |
| award, enter the adjustment \[+  |   | > not included in the\           |
| or (-)\] to the previously\      |   | > construction contract.         |
| approved costs (from column a.)  |   | >                                |
| reflected in this\               |   | > Line 11 - Enter estimated      |
| application.                     |   | > miscellaneous costs.           |
|                                  |   | >                                |
| Column c. - This is the net of   |   | > Line 12 - Total of items 1     |
| lines 1 through 16 in\           |   | > through 11.                    |
| columns \"a.\" and \"b.\"        |   | >                                |
|                                  |   | > Line 13 - Enter estimated      |
| Line 1 - Enter estimated amounts |   | > contingency costs. (Consult\   |
| needed to cover\                 |   | > the Federal agency for the     |
| administrative expenses. Do not  |   | > percentage of the\             |
| include costs which\             |   | > estimated construction cost to |
| are related to the normal        |   | > use.)                          |
| functions of the government.\    |   | >                                |
| Allowable legal costs are        |   | > Line 14 - Enter the total of   |
| generally only those\            |   | > lines 12 and 13.               |
| associated with the purchase of  |   | >                                |
| the land which is\               |   | > Line 15 - Enter estimated      |
| allowable for Federal            |   | > program income to be\          |
| participation and certain        |   | > earned during the grant        |
| services\                        |   | > period, e.g., salvaged\        |
| in support of construction of    |   | > materials, etc.                |
| the project.                     |   | >                                |
|                                  |   | > Line 16 - Subtract line 15     |
| Line 2 - Enter estimated site    |   | > from line 14.                  |
| and right(s)-of-way\             |   | >                                |
| acquisition costs (this includes |   | > Line 17 - This block is for    |
| purchase, lease, and/or\         |   | > the computation of the\        |
| easements).                      |   | > Federal share. Multiply the    |
|                                  |   | > total allowable project\       |
| Line 3 - Enter estimated costs   |   | > costs from line 16, column     |
| related to relocation\           |   | > \"c.\" by the Federal\         |
| advisory assistance, replacement |   | > percentage share (this may be  |
| housing, relocation\             |   | > up to 100 percent;\            |
| payments to displaced persons    |   | > consult Federal agency for     |
| and businesses, etc.             |   | > Federal percentage share)\     |
|                                  |   | > and enter the product in line  |
|                                  |   | > 17.                            |
+----------------------------------+---+----------------------------------+
| **ASSURANCES - CONSTRUCTION      |   |                                  |
| PROGRAMS**                       |   |                                  |
+----------------------------------+---+----------------------------------+
| Public reporting burden for this |   |                                  |
| collection of information is     |   |                                  |
| estimated to average 180 minutes |   |                                  |
| per response, including time     |   |                                  |
| for\                             |   |                                  |
| reviewing instructions,          |   |                                  |
| searching existing data sources, |   |                                  |
| gathering and maintaining the    |   |                                  |
| data needed, and completing and\ |   |                                  |
| reviewing the collection of      |   |                                  |
| information. Send comments       |   |                                  |
| regarding the burden estimate or |   |                                  |
| any other aspect of this         |   |                                  |
| collection of\                   |   |                                  |
| information, including           |   |                                  |
| suggestions for reducing this    |   |                                  |
| burden, to the Office of         |   |                                  |
| Management and Budget, Paperwork |   |                                  |
| Reduction\                       |   |                                  |
| Project (0348-0041), Washington, |   |                                  |
| DC 20503.                        |   |                                  |
|                                  |   |                                  |
| **PLEASE DO NOT RETURN YOUR      |   |                                  |
| COMPLETED FORM TO THE OFFICE OF  |   |                                  |
| MANAGEMENT AND BUDGET.**         |   |                                  |
|                                  |   |                                  |
| **SEND IT TO THE ADDRESS         |   |                                  |
| PROVIDED BY THE SPONSORING       |   |                                  |
| AGENCY.**                        |   |                                  |
+----------------------------------+---+----------------------------------+
| **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 |   |                                  |
| assistance 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, and the              | 8 |                                  |
| institutional, managerial and\   | \ |                                  |
| financial capability (including  | . |                                  |
| funds sufficient to pay\         | > |                                  |
| the non-Federal share of project |   |                                  |
| costs) to ensure\                | W |                                  |
| proper planning, management and  | i |                                  |
| completion of\                   | l |                                  |
| the project described in this    | l |                                  |
| application.                     | > |                                  |
|                                  |   |                                  |
| 2\. Will give the awarding       | c |                                  |
| agency, the Comptroller\         | o |                                  |
| General of the United States,    | m |                                  |
| and if appropriate, the\         | p |                                  |
| State, through any authorized    | l |                                  |
| representative,\                 | y |                                  |
| access to and the right to       | > |                                  |
| examine all records,\            |   |                                  |
| books, papers, or documents      | w |                                  |
| related to the\                  | i |                                  |
| assistance; and will establish a | t |                                  |
| proper accounting\               | h |                                  |
| system in accordance with        | > |                                  |
| generally accepted\              |   |                                  |
| accounting standards or agency   | t |                                  |
| directives.                      | h |                                  |
|                                  | e |                                  |
| 3\. Will not dispose of, modify  | > |                                  |
| the use of, or change the\       |   |                                  |
| terms of the real property       | I |                                  |
| title, or other interest in\     | n |                                  |
| the site and facilities without  | t |                                  |
| permission and\                  | e |                                  |
| instructions from the awarding   | r |                                  |
| agency. Will record\             | g |                                  |
| the Federal interest in the      | o |                                  |
| title of real property in\       | v |                                  |
| accordance with awarding agency  | e |                                  |
| directives and\                  | r |                                  |
| will include a covenant in the   | n |                                  |
| title of real property\          | m |                                  |
| acquired in whole or in part     | e |                                  |
| with Federal assistance\         | n |                                  |
| funds to assure non-             | t |                                  |
| discrimination during the\       | a |                                  |
| useful life of the project.      | l |                                  |
|                                  | > |                                  |
| 4\. Will comply with the         |   |                                  |
| requirements of the assistance\  | P |                                  |
| awarding agency with regard to   | e |                                  |
| the drafting, review\            | r |                                  |
| and approval of construction     | s |                                  |
| plans and\                       | o |                                  |
| specifications.                  | n |                                  |
|                                  | n |                                  |
| 5\. Will provide and maintain    | e |                                  |
| competent and adequate\          | l |                                  |
| engineering supervision at the   | \ |                                  |
| construction site to\            | > |                                  |
| ensure that the complete work    |   |                                  |
| conforms with the\               | A |                                  |
| approved plans and               | c |                                  |
| specifications and will furnish\ | t |                                  |
| progress reports and such other  | > |                                  |
| information as\                  |   |                                  |
| may be required by the           | o |                                  |
| assistance awarding agency\      | f |                                  |
| or State.                        | > |                                  |
|                                  |   |                                  |
| 6\. Will initiate and complete   | 1 |                                  |
| the work within the\             | 9 |                                  |
| applicable time frame after      | 7 |                                  |
| receipt of approval of the\      | 0 |                                  |
| awarding agency.                 | > |                                  |
|                                  |   |                                  |
| 7\. Will establish safeguards to | ( |                                  |
| prohibit employees from\         | 4 |                                  |
| using their positions for a      | 2 |                                  |
| purpose that constitutes\        | > |                                  |
| or represents the appearance of  |   |                                  |
| personal or\                     | U |                                  |
| organizational conflict of       | . |                                  |
| interest, or personal gain.      | S |                                  |
|                                  | . |                                  |
|                                  | C |                                  |
|                                  | . |                                  |
|                                  | > |                                  |
|                                  |   |                                  |
|                                  | § |                                  |
|                                  | § |                                  |
|                                  | 4 |                                  |
|                                  | 7 |                                  |
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|                                  | 8 |                                  |
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|                                  | . |                                  |
+----------------------------------+---+----------------------------------+

+---+----------------------------------+---+-------------+--------------------+
|   | 11\. Will comply, or has already |   | > En        |                    |
|   | complied, with the\              |   | vironmental |                    |
|   | requirements of Titles II and    |   | > Policy    |                    |
|   | III of the Uniform\              |   | > Act of    |                    |
|   | Relocation Assistance and Real   |   | > 1969      |                    |
|   | Property\                        |   | > (P.L.     |                    |
|   | Acquisition Policies Act of 1970 |   | > 91-190)\  |                    |
|   | (P.L. 91-646)\                   |   | > and       |                    |
|   | which provides for fair and      |   | > Executive |                    |
|   | equitable treatment of\          |   | > Order     |                    |
|   | persons displaced or whose       |   | > (EO)      |                    |
|   | property is acquired\            |   | > 11514;    |                    |
|   | as a result of Federal and       |   | > (b)       |                    |
|   | federally assisted\              |   | > n         |                    |
|   | programs. These requirements     |   | otification |                    |
|   | apply to all\                    |   | > of\       |                    |
|   | interests in real property       |   | > violating |                    |
|   | acquired for project\            |   | >           |                    |
|   | purposes regardless of Federal   |   |  facilities |                    |
|   | participation in\                |   | > pursuant  |                    |
|   | purchases.                       |   | > to EO     |                    |
|   |                                  |   | > 11738;    |                    |
|   | 12\. Will comply with the        |   | > (c)\      |                    |
|   | provisions of the Hatch Act (5\  |   | >           |                    |
|   | U.S.C. §§1501-1508 and           |   |  protection |                    |
|   | 7324-7328) which limit\          |   | > of        |                    |
|   | the political activities of      |   | > wetlands  |                    |
|   | employee whose principal\        |   | > pursuant  |                    |
|   | employment activities are funded |   | > to EO     |                    |
|   | in whole or in\                  |   | > 11990;    |                    |
|   | part with Federal funds.         |   | > (d)\      |                    |
|   |                                  |   | >           |                    |
|   | 13\. Will comply, as applicable, |   |  evaluation |                    |
|   | with the provisions of\          |   | > of flood  |                    |
|   | the Davis-Bacon Act (40 U.S.C.   |   | > hazards   |                    |
|   | §§276a to 276a-7),\              |   | > in        |                    |
|   | the Copeland Act (40 U.S.C.      |   | >           |                    |
|   | §276c and 18\                    |   | floodplains |                    |
|   | U.S.C. §874), the Contract Work  |   | > in\       |                    |
|   | Hours and Safety\                |   | >           |                    |
|   | Standards Act (40 U.S.C.         |   |  accordance |                    |
|   | §§327-333) regarding\            |   | > with EO   |                    |
|   | labor standards for federal      |   | > 11988;    |                    |
|   | assisted construction\           |   | > (e)       |                    |
|   | subagreements.                   |   | > assurance |                    |
|   |                                  |   | > of\       |                    |
|   | 14\. Will comply with the flood  |   | > project   |                    |
|   | insurance purchase\              |   | >           |                    |
|   | requirements of Section 102(a)   |   | consistency |                    |
|   | of the Flood\                    |   | > with the  |                    |
|   | Disaster Protection Act of 1973  |   | > approved  |                    |
|   | (P.L. 93-234)\                   |   | > State\    |                    |
|   | which requires recipients in a   |   | >           |                    |
|   | special flood hazard\            |   |  management |                    |
|   | area to participate in the       |   | > program   |                    |
|   | program and to purchase\         |   | > developed |                    |
|   | flood insurance if the total     |   | > under     |                    |
|   | cost of insurable\               |   | > the\      |                    |
|   | construction and acquisition is  |   | > Coastal   |                    |
|   | \$10,000 or more.                |   | > Zone      |                    |
|   |                                  |   | >           |                    |
|   | 15\. Will comply with            |   |  Management |                    |
|   | environmental standards which\   |   | > Act of    |                    |
|   | may be prescribed pursuant to    |   | > 1972 (16\ |                    |
|   | the following: (a)\              |   | > U.S.C.    |                    |
|   | institution of environmental     |   | > §§1451 et |                    |
|   | quality control\                 |   | > seq.);    |                    |
|   | measures under the National      |   | > (f)       |                    |
|   | Environmental Policy\            |   | >           |                    |
|   | Act of 1969 (P.L. 91-190) and    |   |  conformity |                    |
|   | Executive Order\                 |   | > of        |                    |
|   | (EO) 11514; (b)                  |   | > Federal\  |                    |
|   |                                  |   | > actions   |                    |
|   |                                  |   | > to State  |                    |
|   |                                  |   | > (Clean    |                    |
|   |                                  |   | > Air)      |                    |
|   |                                  |   | > Imp       |                    |
|   |                                  |   | lementation |                    |
|   |                                  |   | > Plans\    |                    |
|   |                                  |   | > under     |                    |
|   |                                  |   | > Section   |                    |
|   |                                  |   | > 176(c) of |                    |
|   |                                  |   | > the Clean |                    |
|   |                                  |   | > Air Act   |                    |
|   |                                  |   | > of 1955,\ |                    |
|   |                                  |   | > as        |                    |
|   |                                  |   | > amended   |                    |
|   |                                  |   | > (42       |                    |
|   |                                  |   | > U.S.C.    |                    |
|   |                                  |   | > §§7401 et |                    |
|   |                                  |   | > seq.);    |                    |
|   |                                  |   | > (g)\      |                    |
|   |                                  |   | >           |                    |
|   |                                  |   |  protection |                    |
|   |                                  |   | > of        |                    |
|   |                                  |   | >           |                    |
|   |                                  |   | underground |                    |
|   |                                  |   | > sources   |                    |
|   |                                  |   | > of        |                    |
|   |                                  |   | > drinking\ |                    |
|   |                                  |   | > water     |                    |
|   |                                  |   | > under the |                    |
|   |                                  |   | > Safe      |                    |
|   |                                  |   | > Drinking  |                    |
|   |                                  |   | > Water Act |                    |
|   |                                  |   | > of 1974,\ |                    |
|   |                                  |   | > as        |                    |
|   |                                  |   | > amended,  |                    |
|   |                                  |   | > (P.L.     |                    |
|   |                                  |   | > 93-523);  |                    |
|   |                                  |   | > and (h)   |                    |
|   |                                  |   | >           |                    |
|   |                                  |   |  protection |                    |
|   |                                  |   | > of\       |                    |
|   |                                  |   | >           |                    |
|   |                                  |   |  endangered |                    |
|   |                                  |   | > species   |                    |
|   |                                  |   | > under the |                    |
|   |                                  |   | >           |                    |
|   |                                  |   | Endangered\ |                    |
|   |                                  |   | > Species   |                    |
|   |                                  |   | > Act of    |                    |
|   |                                  |   | > 1973, as  |                    |
|   |                                  |   | > amended,  |                    |
|   |                                  |   | > (P.L.     |                    |
|   |                                  |   | > 93-205).  |                    |
|   |                                  |   |             |                    |
|   |                                  |   | 16. Will    |                    |
|   |                                  |   |     comply  |                    |
|   |                                  |   |     with    |                    |
|   |                                  |   |     the     |                    |
|   |                                  |   |     Wild    |                    |
|   |                                  |   |     and     |                    |
|   |                                  |   |     Scenic  |                    |
|   |                                  |   |     Rivers  |                    |
|   |                                  |   |     Act of\ |                    |
|   |                                  |   |     1968    |                    |
|   |                                  |   |     (16     |                    |
|   |                                  |   |     U.S.C.  |                    |
|   |                                  |   |     §§1271  |                    |
|   |                                  |   |     et      |                    |
|   |                                  |   |     seq.)   |                    |
|   |                                  |   |     related |                    |
|   |                                  |   |     to\     |                    |
|   |                                  |   |             |                    |
|   |                                  |   |  protecting |                    |
|   |                                  |   |             |                    |
|   |                                  |   |  components |                    |
|   |                                  |   |     or      |                    |
|   |                                  |   |             |                    |
|   |                                  |   |   potential |                    |
|   |                                  |   |             |                    |
|   |                                  |   |  components |                    |
|   |                                  |   |     of\     |                    |
|   |                                  |   |     the     |                    |
|   |                                  |   |             |                    |
|   |                                  |   |    national |                    |
|   |                                  |   |     wild    |                    |
|   |                                  |   |     and     |                    |
|   |                                  |   |     scenic  |                    |
|   |                                  |   |     rivers  |                    |
|   |                                  |   |     system. |                    |
|   |                                  |   |             |                    |
|   |                                  |   | 17. Will    |                    |
|   |                                  |   |     assist  |                    |
|   |                                  |   |     the     |                    |
|   |                                  |   |             |                    |
|   |                                  |   |    awarding |                    |
|   |                                  |   |     agency  |                    |
|   |                                  |   |     in      |                    |
|   |                                  |   |             |                    |
|   |                                  |   |   assuring\ |                    |
|   |                                  |   |             |                    |
|   |                                  |   |  compliance |                    |
|   |                                  |   |     with    |                    |
|   |                                  |   |     Section |                    |
|   |                                  |   |     106 of  |                    |
|   |                                  |   |     the     |                    |
|   |                                  |   |             |                    |
|   |                                  |   |   National\ |                    |
|   |                                  |   |             |                    |
|   |                                  |   |    Historic |                    |
|   |                                  |   |     P       |                    |
|   |                                  |   | reservation |                    |
|   |                                  |   |     Act of  |                    |
|   |                                  |   |     1966,   |                    |
|   |                                  |   |     as      |                    |
|   |                                  |   |     amended |                    |
|   |                                  |   |     (16\    |                    |
|   |                                  |   |     U.S.C.  |                    |
|   |                                  |   |     §470),  |                    |
|   |                                  |   |     EO      |                    |
|   |                                  |   |     11593   |                    |
|   |                                  |   |     (ide    |                    |
|   |                                  |   | ntification |                    |
|   |                                  |   |     and\    |                    |
|   |                                  |   |     p       |                    |
|   |                                  |   | reservation |                    |
|   |                                  |   |     of      |                    |
|   |                                  |   |             |                    |
|   |                                  |   |    historic |                    |
|   |                                  |   |     p       |                    |
|   |                                  |   | roperties), |                    |
|   |                                  |   |     and     |                    |
|   |                                  |   |     the\    |                    |
|   |                                  |   |     Arc     |                    |
|   |                                  |   | haeological |                    |
|   |                                  |   |     and     |                    |
|   |                                  |   |             |                    |
|   |                                  |   |    Historic |                    |
|   |                                  |   |     P       |                    |
|   |                                  |   | reservation |                    |
|   |                                  |   |     Act of\ |                    |
|   |                                  |   |     1974    |                    |
|   |                                  |   |     (16     |                    |
|   |                                  |   |     U.S.C.  |                    |
|   |                                  |   |             |                    |
|   |                                  |   |    §§469a-1 |                    |
|   |                                  |   |     et      |                    |
|   |                                  |   |     seq.).  |                    |
|   |                                  |   |             |                    |
|   |                                  |   | 18. Will    |                    |
|   |                                  |   |     cause   |                    |
|   |                                  |   |     to be   |                    |
|   |                                  |   |             |                    |
|   |                                  |   |   performed |                    |
|   |                                  |   |     the     |                    |
|   |                                  |   |             |                    |
|   |                                  |   |    required |                    |
|   |                                  |   |             |                    |
|   |                                  |   |   financial |                    |
|   |                                  |   |     and     |                    |
|   |                                  |   |             |                    |
|   |                                  |   |  compliance |                    |
|   |                                  |   |     audits  |                    |
|   |                                  |   |     in      |                    |
|   |                                  |   |             |                    |
|   |                                  |   |  accordance |                    |
|   |                                  |   |     with    |                    |
|   |                                  |   |     the     |                    |
|   |                                  |   |     Single  |                    |
|   |                                  |   |     Audit   |                    |
|   |                                  |   |     Act of  |                    |
|   |                                  |   |     1984.   |                    |
|   |                                  |   |             |                    |
|   |                                  |   | > 19\. Will |                    |
|   |                                  |   | > comply    |                    |
|   |                                  |   | > with all  |                    |
|   |                                  |   | >           |                    |
|   |                                  |   |  applicable |                    |
|   |                                  |   | > r         |                    |
|   |                                  |   | equirements |                    |
|   |                                  |   | > of all\   |                    |
|   |                                  |   | > other     |                    |
|   |                                  |   | > Federal   |                    |
|   |                                  |   | > laws,     |                    |
|   |                                  |   | > Executive |                    |
|   |                                  |   | > Orders,   |                    |
|   |                                  |   | > r         |                    |
|   |                                  |   | egulations\ |                    |
|   |                                  |   | > and       |                    |
|   |                                  |   | > policies  |                    |
|   |                                  |   | > governing |                    |
|   |                                  |   | > this      |                    |
|   |                                  |   | > program.  |                    |
+---+----------------------------------+---+-------------+--------------------+
|   | SIGNATURE OF AUTHORIZED          |   | TITLE       |                    |
|   | CERTIFYING OFFICIAL              |   |             |                    |
+---+----------------------------------+---+-------------+--------------------+
|   |                                  |   |             |                    |
+---+----------------------------------+---+-------------+--------------------+
|   | APPLICANT ORGANIZATION           |   |             | DATE SUBMITTED     |
+---+----------------------------------+---+-------------+--------------------+
|   |                                  |   |             |                    |
+---+----------------------------------+---+-------------+--------------------+
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+---+----------------------------------+---+-------------+--------------------+
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|   |                                  | i |             |                    |
|   |                                  | g |             |                    |
|   |                                  | n |             |                    |
|   |                                  | a |             |                    |
|   |                                  | t |             |                    |
|   |                                  | e |             |                    |
|   |                                  | d |             |                    |
|   |                                  | > |             |                    |
|   |                                  |   |             |                    |
|   |                                  | a |             |                    |
|   |                                  | > |             |                    |
|   |                                  |   |             |                    |
|   |                                  | c |             |                    |
|   |                                  | e |             |                    |
|   |                                  | n |             |                    |
|   |                                  | t |             |                    |
|   |                                  | r |             |                    |
|   |                                  | a |             |                    |
|   |                                  | l |             |                    |
+---+----------------------------------+---+-------------+--------------------+

+---+----------------------------------+---+---+-------------+------------------+---+
| > |                                  | > |   |             |                  |   |
|   |                                  |   |   |             |                  |   |
| p |                                  | s |   |             |                  |   |
| o |                                  | i |   |             |                  |   |
| i |                                  | g |   |             |                  |   |
| n |                                  | n |   |             |                  |   |
| t |                                  | e |   |             |                  |   |
| > |                                  | d |   |             |                  |   |
|   |                                  | , |   |             |                  |   |
| f |                                  | > |   |             |                  |   |
| o |                                  |   |   |             |                  |   |
| r |                                  | t |   |             |                  |   |
| > |                                  | o |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| t |                                  |   |   |             |                  |   |
| h |                                  | a |   |             |                  |   |
| e |                                  | n |   |             |                  |   |
| > |                                  | y |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| r |                                  |   |   |             |                  |   |
| e |                                  | p |   |             |                  |   |
| c |                                  | e |   |             |                  |   |
| e |                                  | r |   |             |                  |   |
| i |                                  | s |   |             |                  |   |
| p |                                  | o |   |             |                  |   |
| t |                                  | n |   |             |                  |   |
| > |                                  | > |   |             |                  |   |
|   |                                  |   |   |             |                  |   |
| o |                                  | f |   |             |                  |   |
| f |                                  | o |   |             |                  |   |
| > |                                  | r |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| s |                                  |   |   |             |                  |   |
| u |                                  | i |   |             |                  |   |
| c |                                  | n |   |             |                  |   |
| h |                                  | f |   |             |                  |   |
| > |                                  | l |   |             |                  |   |
|   |                                  | u |   |             |                  |   |
| n |                                  | e |   |             |                  |   |
| o |                                  | n |   |             |                  |   |
| t |                                  | c |   |             |                  |   |
| i |                                  | i |   |             |                  |   |
| c |                                  | n |   |             |                  |   |
| e |                                  | g |   |             |                  |   |
| s |                                  | > |   |             |                  |   |
| . |                                  |   |   |             |                  |   |
| > |                                  | o |   |             |                  |   |
|   |                                  | r |   |             |                  |   |
| N |                                  | > |   |             |                  |   |
| o |                                  |   |   |             |                  |   |
| t |                                  | a |   |             |                  |   |
| i |                                  | t |   |             |                  |   |
| c |                                  | t |   |             |                  |   |
| e |                                  | e |   |             |                  |   |
| > |                                  | m |   |             |                  |   |
|   |                                  | p |   |             |                  |   |
| s |                                  | t |   |             |                  |   |
| h |                                  | i |   |             |                  |   |
| a |                                  | n |   |             |                  |   |
| l |                                  | g |   |             |                  |   |
| l |                                  | \ |   |             |                  |   |
| \ |                                  | > |   |             |                  |   |
| > |                                  |   |   |             |                  |   |
|   |                                  | t |   |             |                  |   |
| i |                                  | o |   |             |                  |   |
| n |                                  | > |   |             |                  |   |
| c |                                  |   |   |             |                  |   |
| l |                                  | i |   |             |                  |   |
| u |                                  | n |   |             |                  |   |
| d |                                  | f |   |             |                  |   |
| e |                                  | l |   |             |                  |   |
| > |                                  | u |   |             |                  |   |
|   |                                  | e |   |             |                  |   |
| t |                                  | n |   |             |                  |   |
| h |                                  | c |   |             |                  |   |
| e |                                  | e |   |             |                  |   |
| > |                                  | > |   |             |                  |   |
|   |                                  |   |   |             |                  |   |
| i |                                  | a |   |             |                  |   |
| d |                                  | n |   |             |                  |   |
| e |                                  | > |   |             |                  |   |
| n |                                  |   |   |             |                  |   |
| t |                                  | o |   |             |                  |   |
| i |                                  | f |   |             |                  |   |
| f |                                  | f |   |             |                  |   |
| i |                                  | i |   |             |                  |   |
| c |                                  | c |   |             |                  |   |
| a |                                  | e |   |             |                  |   |
| t |                                  | r |   |             |                  |   |
| i |                                  | > |   |             |                  |   |
| o |                                  |   |   |             |                  |   |
| n |                                  | o |   |             |                  |   |
| > |                                  | r |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| n |                                  |   |   |             |                  |   |
| u |                                  | e |   |             |                  |   |
| m |                                  | m |   |             |                  |   |
| b |                                  | p |   |             |                  |   |
| e |                                  | l |   |             |                  |   |
| r |                                  | o |   |             |                  |   |
| ( |                                  | y |   |             |                  |   |
| s |                                  | e |   |             |                  |   |
| ) |                                  | e |   |             |                  |   |
| > |                                  | > |   |             |                  |   |
|   |                                  |   |   |             |                  |   |
| o |                                  | o |   |             |                  |   |
| f |                                  | f |   |             |                  |   |
| > |                                  | > |   |             |                  |   |
|   |                                  |   |   |             |                  |   |
| e |                                  | a |   |             |                  |   |
| a |                                  | n |   |             |                  |   |
| c |                                  | y |   |             |                  |   |
| h |                                  | > |   |             |                  |   |
| \ |                                  |   |   |             |                  |   |
| > |                                  | a |   |             |                  |   |
|   |                                  | g |   |             |                  |   |
| a |                                  | e |   |             |                  |   |
| f |                                  | n |   |             |                  |   |
| f |                                  | c |   |             |                  |   |
| e |                                  | y |   |             |                  |   |
| c |                                  | , |   |             |                  |   |
| t |                                  | > |   |             |                  |   |
| e |                                  |   |   |             |                  |   |
| d |                                  | a |   |             |                  |   |
| > |                                  | \ |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| g |                                  |   |   |             |                  |   |
| r |                                  | M |   |             |                  |   |
| a |                                  | e |   |             |                  |   |
| n |                                  | m |   |             |                  |   |
| t |                                  | b |   |             |                  |   |
| ; |                                  | e |   |             |                  |   |
| > |                                  | r |   |             |                  |   |
| > |                                  | > |   |             |                  |   |
|   |                                  |   |   |             |                  |   |
| \ |                                  | o |   |             |                  |   |
| ( |                                  | f |   |             |                  |   |
| f |                                  | > |   |             |                  |   |
| \ |                                  |   |   |             |                  |   |
| ) |                                  | C |   |             |                  |   |
| > |                                  | o |   |             |                  |   |
|   |                                  | n |   |             |                  |   |
| T |                                  | g |   |             |                  |   |
| a |                                  | r |   |             |                  |   |
| k |                                  | e |   |             |                  |   |
| i |                                  | s |   |             |                  |   |
| n |                                  | s |   |             |                  |   |
| g |                                  | , |   |             |                  |   |
| > |                                  | > |   |             |                  |   |
|   |                                  |   |   |             |                  |   |
| o |                                  | a |   |             |                  |   |
| n |                                  | n |   |             |                  |   |
| e |                                  | > |   |             |                  |   |
| > |                                  |   |   |             |                  |   |
|   |                                  | o |   |             |                  |   |
| o |                                  | f |   |             |                  |   |
| f |                                  | f |   |             |                  |   |
| > |                                  | i |   |             |                  |   |
|   |                                  | c |   |             |                  |   |
| t |                                  | e |   |             |                  |   |
| h |                                  | r |   |             |                  |   |
| e |                                  | > |   |             |                  |   |
| > |                                  |   |   |             |                  |   |
|   |                                  | o |   |             |                  |   |
| f |                                  | r |   |             |                  |   |
| o |                                  | > |   |             |                  |   |
| l |                                  |   |   |             |                  |   |
| l |                                  | e |   |             |                  |   |
| o |                                  | m |   |             |                  |   |
| w |                                  | p |   |             |                  |   |
| i |                                  | l |   |             |                  |   |
| n |                                  | o |   |             |                  |   |
| g |                                  | y |   |             |                  |   |
| > |                                  | e |   |             |                  |   |
|   |                                  | e |   |             |                  |   |
| a |                                  | > |   |             |                  |   |
| c |                                  |   |   |             |                  |   |
| t |                                  | o |   |             |                  |   |
| i |                                  | f |   |             |                  |   |
| o |                                  | \ |   |             |                  |   |
| n |                                  | > |   |             |                  |   |
| s |                                  |   |   |             |                  |   |
| , |                                  | C |   |             |                  |   |
| > |                                  | o |   |             |                  |   |
|   |                                  | n |   |             |                  |   |
| w |                                  | g |   |             |                  |   |
| i |                                  | r |   |             |                  |   |
| t |                                  | e |   |             |                  |   |
| h |                                  | s |   |             |                  |   |
| i |                                  | s |   |             |                  |   |
| n |                                  | , |   |             |                  |   |
| > |                                  | > |   |             |                  |   |
|   |                                  |   |   |             |                  |   |
| 3 |                                  | o |   |             |                  |   |
| 0 |                                  | r |   |             |                  |   |
| \ |                                  | > |   |             |                  |   |
| > |                                  |   |   |             |                  |   |
|   |                                  | a |   |             |                  |   |
| c |                                  | n |   |             |                  |   |
| a |                                  | > |   |             |                  |   |
| l |                                  |   |   |             |                  |   |
| e |                                  | e |   |             |                  |   |
| n |                                  | m |   |             |                  |   |
| d |                                  | p |   |             |                  |   |
| a |                                  | l |   |             |                  |   |
| r |                                  | o |   |             |                  |   |
| > |                                  | y |   |             |                  |   |
|   |                                  | e |   |             |                  |   |
| d |                                  | e |   |             |                  |   |
| a |                                  | > |   |             |                  |   |
| y |                                  |   |   |             |                  |   |
| s |                                  | o |   |             |                  |   |
| > |                                  | f |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| o |                                  |   |   |             |                  |   |
| f |                                  | a |   |             |                  |   |
| > |                                  | > |   |             |                  |   |
|   |                                  |   |   |             |                  |   |
| r |                                  | M |   |             |                  |   |
| e |                                  | e |   |             |                  |   |
| c |                                  | m |   |             |                  |   |
| e |                                  | b |   |             |                  |   |
| i |                                  | e |   |             |                  |   |
| v |                                  | r |   |             |                  |   |
| i |                                  | > |   |             |                  |   |
| n |                                  |   |   |             |                  |   |
| g |                                  | o |   |             |                  |   |
| > |                                  | f |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| n |                                  |   |   |             |                  |   |
| o |                                  | C |   |             |                  |   |
| t |                                  | o |   |             |                  |   |
| i |                                  | n |   |             |                  |   |
| c |                                  | g |   |             |                  |   |
| e |                                  | r |   |             |                  |   |
| > |                                  | e |   |             |                  |   |
|   |                                  | s |   |             |                  |   |
| u |                                  | s |   |             |                  |   |
| n |                                  | \ |   |             |                  |   |
| d |                                  | > |   |             |                  |   |
| e |                                  |   |   |             |                  |   |
| r |                                  | i |   |             |                  |   |
| \ |                                  | n |   |             |                  |   |
| > |                                  | > |   |             |                  |   |
|   |                                  |   |   |             |                  |   |
| p |                                  | c |   |             |                  |   |
| a |                                  | o |   |             |                  |   |
| r |                                  | n |   |             |                  |   |
| a |                                  | n |   |             |                  |   |
| g |                                  | e |   |             |                  |   |
| r |                                  | c |   |             |                  |   |
| a |                                  | t |   |             |                  |   |
| p |                                  | i |   |             |                  |   |
| h |                                  | o |   |             |                  |   |
| > |                                  | n |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| ( |                                  |   |   |             |                  |   |
| d |                                  | w |   |             |                  |   |
| ) |                                  | i |   |             |                  |   |
| > |                                  | t |   |             |                  |   |
|   |                                  | h |   |             |                  |   |
| ( |                                  | > |   |             |                  |   |
| 2 |                                  |   |   |             |                  |   |
| ) |                                  | t |   |             |                  |   |
| , |                                  | h |   |             |                  |   |
| > |                                  | e |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| w |                                  |   |   |             |                  |   |
| i |                                  | a |   |             |                  |   |
| t |                                  | w |   |             |                  |   |
| h |                                  | a |   |             |                  |   |
| > |                                  | r |   |             |                  |   |
|   |                                  | d |   |             |                  |   |
| r |                                  | i |   |             |                  |   |
| e |                                  | n |   |             |                  |   |
| s |                                  | g |   |             |                  |   |
| p |                                  | > |   |             |                  |   |
| e |                                  |   |   |             |                  |   |
| c |                                  | o |   |             |                  |   |
| t |                                  | f |   |             |                  |   |
| > |                                  | > |   |             |                  |   |
|   |                                  |   |   |             |                  |   |
| t |                                  | a |   |             |                  |   |
| o |                                  | n |   |             |                  |   |
| > |                                  | y |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| a |                                  |   |   |             |                  |   |
| n |                                  | F |   |             |                  |   |
| y |                                  | e |   |             |                  |   |
| > |                                  | d |   |             |                  |   |
|   |                                  | e |   |             |                  |   |
| e |                                  | r |   |             |                  |   |
| m |                                  | a |   |             |                  |   |
| p |                                  | l |   |             |                  |   |
| l |                                  | \ |   |             |                  |   |
| o |                                  | > |   |             |                  |   |
| y |                                  |   |   |             |                  |   |
| e |                                  | c |   |             |                  |   |
| e |                                  | o |   |             |                  |   |
| \ |                                  | n |   |             |                  |   |
| > |                                  | t |   |             |                  |   |
|   |                                  | r |   |             |                  |   |
| w |                                  | a |   |             |                  |   |
| h |                                  | c |   |             |                  |   |
| o |                                  | t |   |             |                  |   |
| > |                                  | , |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| i |                                  |   |   |             |                  |   |
| s |                                  | t |   |             |                  |   |
| > |                                  | h |   |             |                  |   |
|   |                                  | e |   |             |                  |   |
| s |                                  | > |   |             |                  |   |
| o |                                  |   |   |             |                  |   |
| > |                                  | m |   |             |                  |   |
|   |                                  | a |   |             |                  |   |
| c |                                  | k |   |             |                  |   |
| o |                                  | i |   |             |                  |   |
| n |                                  | n |   |             |                  |   |
| v |                                  | g |   |             |                  |   |
| i |                                  | > |   |             |                  |   |
| c |                                  |   |   |             |                  |   |
| t |                                  | o |   |             |                  |   |
| e |                                  | f |   |             |                  |   |
| d |                                  | > |   |             |                  |   |
| \ |                                  |   |   |             |                  |   |
| - |                                  | a |   |             |                  |   |
| - |                                  | n |   |             |                  |   |
| > |                                  | y |   |             |                  |   |
| > |                                  | > |   |             |                  |   |
|   |                                  |   |   |             |                  |   |
| \ |                                  | F |   |             |                  |   |
| ( |                                  | e |   |             |                  |   |
| 1 |                                  | d |   |             |                  |   |
| \ |                                  | e |   |             |                  |   |
| ) |                                  | r |   |             |                  |   |
| > |                                  | a |   |             |                  |   |
|   |                                  | l |   |             |                  |   |
| T |                                  | > |   |             |                  |   |
| a |                                  |   |   |             |                  |   |
| k |                                  | g |   |             |                  |   |
| i |                                  | r |   |             |                  |   |
| n |                                  | a |   |             |                  |   |
| g |                                  | n |   |             |                  |   |
| > |                                  | t |   |             |                  |   |
|   |                                  | , |   |             |                  |   |
| a |                                  | > |   |             |                  |   |
| p |                                  |   |   |             |                  |   |
| p |                                  | t |   |             |                  |   |
| r |                                  | h |   |             |                  |   |
| o |                                  | e |   |             |                  |   |
| p |                                  | \ |   |             |                  |   |
| r |                                  | > |   |             |                  |   |
| i |                                  |   |   |             |                  |   |
| a |                                  | m |   |             |                  |   |
| t |                                  | a |   |             |                  |   |
| e |                                  | k |   |             |                  |   |
| > |                                  | i |   |             |                  |   |
|   |                                  | n |   |             |                  |   |
| p |                                  | g |   |             |                  |   |
| e |                                  | > |   |             |                  |   |
| r |                                  |   |   |             |                  |   |
| s |                                  | o |   |             |                  |   |
| o |                                  | f |   |             |                  |   |
| n |                                  | > |   |             |                  |   |
| n |                                  |   |   |             |                  |   |
| e |                                  | a |   |             |                  |   |
| l |                                  | n |   |             |                  |   |
| > |                                  | y |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| a |                                  |   |   |             |                  |   |
| c |                                  | F |   |             |                  |   |
| t |                                  | e |   |             |                  |   |
| i |                                  | d |   |             |                  |   |
| o |                                  | e |   |             |                  |   |
| n |                                  | r |   |             |                  |   |
| > |                                  | a |   |             |                  |   |
|   |                                  | l |   |             |                  |   |
| a |                                  | > |   |             |                  |   |
| g |                                  |   |   |             |                  |   |
| a |                                  | l |   |             |                  |   |
| i |                                  | o |   |             |                  |   |
| n |                                  | a |   |             |                  |   |
| s |                                  | n |   |             |                  |   |
| t |                                  | , |   |             |                  |   |
| \ |                                  | > |   |             |                  |   |
| > |                                  |   |   |             |                  |   |
|   |                                  | t |   |             |                  |   |
| s |                                  | h |   |             |                  |   |
| u |                                  | e |   |             |                  |   |
| c |                                  | > |   |             |                  |   |
| h |                                  |   |   |             |                  |   |
| > |                                  | e |   |             |                  |   |
|   |                                  | n |   |             |                  |   |
| a |                                  | t |   |             |                  |   |
| n |                                  | e |   |             |                  |   |
| > |                                  | r |   |             |                  |   |
|   |                                  | i |   |             |                  |   |
| e |                                  | n |   |             |                  |   |
| m |                                  | g |   |             |                  |   |
| p |                                  | > |   |             |                  |   |
| l |                                  |   |   |             |                  |   |
| o |                                  | i |   |             |                  |   |
| y |                                  | n |   |             |                  |   |
| e |                                  | t |   |             |                  |   |
| e |                                  | o |   |             |                  |   |
| , |                                  | > |   |             |                  |   |
| > |                                  |   |   |             |                  |   |
|   |                                  | o |   |             |                  |   |
| u |                                  | f |   |             |                  |   |
| p |                                  | > |   |             |                  |   |
| > |                                  |   |   |             |                  |   |
|   |                                  | a |   |             |                  |   |
| t |                                  | n |   |             |                  |   |
| o |                                  | y |   |             |                  |   |
| > |                                  | \ |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| a |                                  |   |   |             |                  |   |
| n |                                  | c |   |             |                  |   |
| d |                                  | o |   |             |                  |   |
| > |                                  | o |   |             |                  |   |
|   |                                  | p |   |             |                  |   |
| i |                                  | e |   |             |                  |   |
| n |                                  | r |   |             |                  |   |
| c |                                  | a |   |             |                  |   |
| l |                                  | t |   |             |                  |   |
| u |                                  | i |   |             |                  |   |
| d |                                  | v |   |             |                  |   |
| i |                                  | e |   |             |                  |   |
| n |                                  | > |   |             |                  |   |
| g |                                  |   |   |             |                  |   |
| \ |                                  | a |   |             |                  |   |
| > |                                  | g |   |             |                  |   |
|   |                                  | r |   |             |                  |   |
| t |                                  | e |   |             |                  |   |
| e |                                  | e |   |             |                  |   |
| r |                                  | m |   |             |                  |   |
| m |                                  | e |   |             |                  |   |
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| > |                                  | f |   |             |                  |   |
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|   |                                  | t |   |             |                  |   |
| d |                                  | h |   |             |                  |   |
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| 3 |                                  |   |   |             |                  |   |
| . |                                  | t |   |             |                  |   |
| C |                                  | h |   |             |                  |   |
| E |                                  | i |   |             |                  |   |
| R |                                  | s |   |             |                  |   |
| T |                                  | > |   |             |                  |   |
| I |                                  |   |   |             |                  |   |
| F |                                  | a |   |             |                  |   |
| I |                                  | p |   |             |                  |   |
| C |                                  | p |   |             |                  |   |
| A |                                  | l |   |             |                  |   |
| T |                                  | i |   |             |                  |   |
| I |                                  | c |   |             |                  |   |
| O |                                  | a |   |             |                  |   |
| N |                                  | t |   |             |                  |   |
| R |                                  | i |   |             |                  |   |
| E |                                  | o |   |             |                  |   |
| G |                                  | n |   |             |                  |   |
| A |                                  | > |   |             |                  |   |
| R |                                  |   |   |             |                  |   |
| D |                                  | f |   |             |                  |   |
| I |                                  | o |   |             |                  |   |
| N |                                  | r |   |             |                  |   |
| G |                                  | m |   |             |                  |   |
| L |                                  | . |   |             |                  |   |
| O |                                  | ) |   |             |                  |   |
| B |                                  | > |   |             |                  |   |
| B |                                  | > |   |             |                  |   |
| Y |                                  |   |   |             |                  |   |
| I |                                  | \ |   |             |                  |   |
| N |                                  | ( |   |             |                  |   |
| G |                                  | 3 |   |             |                  |   |
| * |                                  | \ |   |             |                  |   |
| * |                                  | ) |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
| T |                                  |   |   |             |                  |   |
| i |                                  | T |   |             |                  |   |
| t |                                  | h |   |             |                  |   |
| l |                                  | e |   |             |                  |   |
| e |                                  | > |   |             |                  |   |
| 3 |                                  |   |   |             |                  |   |
| 1 |                                  | u |   |             |                  |   |
| , |                                  | n |   |             |                  |   |
| U |                                  | d |   |             |                  |   |
| n |                                  | e |   |             |                  |   |
| i |                                  | r |   |             |                  |   |
| t |                                  | s |   |             |                  |   |
| e |                                  | i |   |             |                  |   |
| d |                                  | g |   |             |                  |   |
| S |                                  | n |   |             |                  |   |
| t |                                  | e |   |             |                  |   |
| a |                                  | d |   |             |                  |   |
| t |                                  | > |   |             |                  |   |
| e |                                  |   |   |             |                  |   |
| s |                                  | s |   |             |                  |   |
| C |                                  | h |   |             |                  |   |
| o |                                  | a |   |             |                  |   |
| d |                                  | l |   |             |                  |   |
| e |                                  | l |   |             |                  |   |
| , |                                  | > |   |             |                  |   |
| S |                                  |   |   |             |                  |   |
| e |                                  | r |   |             |                  |   |
| c |                                  | e |   |             |                  |   |
| t |                                  | q |   |             |                  |   |
| i |                                  | u |   |             |                  |   |
| o |                                  | i |   |             |                  |   |
| n |                                  | r |   |             |                  |   |
| 1 |                                  | e |   |             |                  |   |
| 3 |                                  | > |   |             |                  |   |
| 5 |                                  |   |   |             |                  |   |
| 2 |                                  | t |   |             |                  |   |
| , |                                  | h |   |             |                  |   |
| e |                                  | a |   |             |                  |   |
| n |                                  | t |   |             |                  |   |
| t |                                  | > |   |             |                  |   |
| i |                                  |   |   |             |                  |   |
| t |                                  | t |   |             |                  |   |
| l |                                  | h |   |             |                  |   |
| e |                                  | e |   |             |                  |   |
| d |                                  | > |   |             |                  |   |
| \ |                                  |   |   |             |                  |   |
| \ |                                  | l |   |             |                  |   |
| " |                                  | a |   |             |                  |   |
| L |                                  | n |   |             |                  |   |
| i |                                  | g |   |             |                  |   |
| m |                                  | u |   |             |                  |   |
| i |                                  | a |   |             |                  |   |
| t |                                  | g |   |             |                  |   |
| a |                                  | e |   |             |                  |   |
| t |                                  | > |   |             |                  |   |
| i |                                  |   |   |             |                  |   |
| o |                                  | o |   |             |                  |   |
| n |                                  | f |   |             |                  |   |
| o |                                  | \ |   |             |                  |   |
| n |                                  | > |   |             |                  |   |
| u |                                  |   |   |             |                  |   |
| s |                                  | t |   |             |                  |   |
| e |                                  | h |   |             |                  |   |
| o |                                  | i |   |             |                  |   |
| f |                                  | s |   |             |                  |   |
| a |                                  | > |   |             |                  |   |
| p |                                  |   |   |             |                  |   |
| p |                                  | c |   |             |                  |   |
| r |                                  | e |   |             |                  |   |
| o |                                  | r |   |             |                  |   |
| p |                                  | t |   |             |                  |   |
| r |                                  | i |   |             |                  |   |
| i |                                  | f |   |             |                  |   |
| a |                                  | i |   |             |                  |   |
| t |                                  | c |   |             |                  |   |
| e |                                  | a |   |             |                  |   |
| d |                                  | t |   |             |                  |   |
| f |                                  | i |   |             |                  |   |
| u |                                  | o |   |             |                  |   |
| n |                                  | n |   |             |                  |   |
| d |                                  | > |   |             |                  |   |
| s |                                  |   |   |             |                  |   |
| t |                                  | b |   |             |                  |   |
| o |                                  | e |   |             |                  |   |
| i |                                  | > |   |             |                  |   |
| n |                                  |   |   |             |                  |   |
| f |                                  | i |   |             |                  |   |
| l |                                  | n |   |             |                  |   |
| u |                                  | c |   |             |                  |   |
| e |                                  | l |   |             |                  |   |
| n |                                  | u |   |             |                  |   |
| c |                                  | d |   |             |                  |   |
| e |                                  | e |   |             |                  |   |
| \ |                                  | d |   |             |                  |   |
| c |                                  | > |   |             |                  |   |
| e |                                  |   |   |             |                  |   |
| r |                                  | i |   |             |                  |   |
| t |                                  | n |   |             |                  |   |
| a |                                  | > |   |             |                  |   |
| i |                                  |   |   |             |                  |   |
| n |                                  | t |   |             |                  |   |
| F |                                  | h |   |             |                  |   |
| e |                                  | e |   |             |                  |   |
| d |                                  | > |   |             |                  |   |
| e |                                  |   |   |             |                  |   |
| r |                                  | a |   |             |                  |   |
| a |                                  | w |   |             |                  |   |
| l |                                  | a |   |             |                  |   |
| c |                                  | r |   |             |                  |   |
| o |                                  | d |   |             |                  |   |
| n |                                  | > |   |             |                  |   |
| t |                                  |   |   |             |                  |   |
| r |                                  | d |   |             |                  |   |
| a |                                  | o |   |             |                  |   |
| c |                                  | c |   |             |                  |   |
| t |                                  | u |   |             |                  |   |
| i |                                  | m |   |             |                  |   |
| n |                                  | e |   |             |                  |   |
| g |                                  | n |   |             |                  |   |
| a |                                  | t |   |             |                  |   |
| n |                                  | s |   |             |                  |   |
| d |                                  | \ |   |             |                  |   |
| f |                                  | > |   |             |                  |   |
| i |                                  |   |   |             |                  |   |
| n |                                  | f |   |             |                  |   |
| a |                                  | o |   |             |                  |   |
| n |                                  | r |   |             |                  |   |
| c |                                  | > |   |             |                  |   |
| i |                                  |   |   |             |                  |   |
| a |                                  | a |   |             |                  |   |
| l |                                  | l |   |             |                  |   |
| \ |                                  | l |   |             |                  |   |
| t |                                  | > |   |             |                  |   |
| r |                                  |   |   |             |                  |   |
| a |                                  | s |   |             |                  |   |
| n |                                  | u |   |             |                  |   |
| s |                                  | b |   |             |                  |   |
| a |                                  | a |   |             |                  |   |
| c |                                  | w |   |             |                  |   |
| t |                                  | a |   |             |                  |   |
| i |                                  | r |   |             |                  |   |
| o |                                  | d |   |             |                  |   |
| n |                                  | s |   |             |                  |   |
| s |                                  | > |   |             |                  |   |
| , |                                  |   |   |             |                  |   |
| \ |                                  | a |   |             |                  |   |
| " |                                  | t |   |             |                  |   |
| g |                                  | > |   |             |                  |   |
| e |                                  |   |   |             |                  |   |
| n |                                  | a |   |             |                  |   |
| e |                                  | l |   |             |                  |   |
| r |                                  | l |   |             |                  |   |
| a |                                  | > |   |             |                  |   |
| l |                                  |   |   |             |                  |   |
| l |                                  | t |   |             |                  |   |
| y |                                  | i |   |             |                  |   |
| p |                                  | e |   |             |                  |   |
| r |                                  | r |   |             |                  |   |
| o |                                  | s |   |             |                  |   |
| h |                                  | > |   |             |                  |   |
| i |                                  |   |   |             |                  |   |
| b |                                  | ( |   |             |                  |   |
| i |                                  | i |   |             |                  |   |
| t |                                  | n |   |             |                  |   |
| s |                                  | c |   |             |                  |   |
| r |                                  | l |   |             |                  |   |
| e |                                  | u |   |             |                  |   |
| c |                                  | d |   |             |                  |   |
| i |                                  | i |   |             |                  |   |
| p |                                  | n |   |             |                  |   |
| i |                                  | g |   |             |                  |   |
| e |                                  | \ |   |             |                  |   |
| n |                                  | > |   |             |                  |   |
| t |                                  |   |   |             |                  |   |
| s |                                  | s |   |             |                  |   |
| o |                                  | u |   |             |                  |   |
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| \ |                                  | c |   |             |                  |   |
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| e |                                  | n |   |             |                  |   |
| d |                                  | t |   |             |                  |   |
| e |                                  | r |   |             |                  |   |
| r |                                  | a |   |             |                  |   |
| a |                                  | c |   |             |                  |   |
| l |                                  | t |   |             |                  |   |
| g |                                  | s |   |             |                  |   |
| r |                                  | , |   |             |                  |   |
| a |                                  | > |   |             |                  |   |
| n |                                  |   |   |             |                  |   |
| t |                                  | s |   |             |                  |   |
| s |                                  | u |   |             |                  |   |
| a |                                  | b |   |             |                  |   |
| n |                                  | g |   |             |                  |   |
| d |                                  | r |   |             |                  |   |
| c |                                  | a |   |             |                  |   |
| o |                                  | n |   |             |                  |   |
| o |                                  | t |   |             |                  |   |
| p |                                  | s |   |             |                  |   |
| e |                                  | , |   |             |                  |   |
| r |                                  | > |   |             |                  |   |
| a |                                  |   |   |             |                  |   |
| t |                                  | a |   |             |                  |   |
| i |                                  | n |   |             |                  |   |
| v |                                  | d |   |             |                  |   |
| e |                                  | > |   |             |                  |   |
| a |                                  |   |   |             |                  |   |
| g |                                  | c |   |             |                  |   |
| r |                                  | o |   |             |                  |   |
| e |                                  | n |   |             |                  |   |
| e |                                  | t |   |             |                  |   |
| m |                                  | r |   |             |                  |   |
| e |                                  | a |   |             |                  |   |
| n |                                  | c |   |             |                  |   |
| t |                                  | t |   |             |                  |   |
| s |                                  | s |   |             |                  |   |
| f |                                  | > |   |             |                  |   |
| r |                                  |   |   |             |                  |   |
| o |                                  | u |   |             |                  |   |
| m |                                  | n |   |             |                  |   |
| \ |                                  | d |   |             |                  |   |
| u |                                  | e |   |             |                  |   |
| s |                                  | r |   |             |                  |   |
| i |                                  | > |   |             |                  |   |
| n |                                  |   |   |             |                  |   |
| g |                                  | g |   |             |                  |   |
| F |                                  | r |   |             |                  |   |
| e |                                  | a |   |             |                  |   |
| d |                                  | n |   |             |                  |   |
| e |                                  | t |   |             |                  |   |
| r |                                  | s |   |             |                  |   |
| a |                                  | , |   |             |                  |   |
| l |                                  | \ |   |             |                  |   |
| ( |                                  | > |   |             |                  |   |
| a |                                  |   |   |             |                  |   |
| p |                                  | l |   |             |                  |   |
| p |                                  | o |   |             |                  |   |
| r |                                  | a |   |             |                  |   |
| o |                                  | n |   |             |                  |   |
| p |                                  | s |   |             |                  |   |
| r |                                  | > |   |             |                  |   |
| i |                                  |   |   |             |                  |   |
| a |                                  | a |   |             |                  |   |
| t |                                  | n |   |             |                  |   |
| e |                                  | d |   |             |                  |   |
| d |                                  | > |   |             |                  |   |
| ) |                                  |   |   |             |                  |   |
| f |                                  | c |   |             |                  |   |
| u |                                  | o |   |             |                  |   |
| n |                                  | o |   |             |                  |   |
| d |                                  | p |   |             |                  |   |
| s |                                  | e |   |             |                  |   |
| f |                                  | r |   |             |                  |   |
| o |                                  | a |   |             |                  |   |
| r |                                  | t |   |             |                  |   |
| l |                                  | i |   |             |                  |   |
| o |                                  | v |   |             |                  |   |
| b |                                  | e |   |             |                  |   |
| b |                                  | > |   |             |                  |   |
| y |                                  |   |   |             |                  |   |
| i |                                  | a |   |             |                  |   |
| n |                                  | g |   |             |                  |   |
| g |                                  | r |   |             |                  |   |
| t |                                  | e |   |             |                  |   |
| h |                                  | e |   |             |                  |   |
| e |                                  | m |   |             |                  |   |
| \ |                                  | e |   |             |                  |   |
| E |                                  | n |   |             |                  |   |
| x |                                  | t |   |             |                  |   |
| e |                                  | s |   |             |                  |   |
| c |                                  | ) |   |             |                  |   |
| u |                                  | > |   |             |                  |   |
| t |                                  |   |   |             |                  |   |
| i |                                  | a |   |             |                  |   |
| v |                                  | n |   |             |                  |   |
| e |                                  | d |   |             |                  |   |
| o |                                  | > |   |             |                  |   |
| r |                                  |   |   |             |                  |   |
| L |                                  | t |   |             |                  |   |
| e |                                  | h |   |             |                  |   |
| g |                                  | a |   |             |                  |   |
| i |                                  | t |   |             |                  |   |
| s |                                  | > |   |             |                  |   |
| l |                                  |   |   |             |                  |   |
| a |                                  | a |   |             |                  |   |
| t |                                  | l |   |             |                  |   |
| i |                                  | l |   |             |                  |   |
| v |                                  | \ |   |             |                  |   |
| e |                                  | > |   |             |                  |   |
| B |                                  |   |   |             |                  |   |
| r |                                  | s |   |             |                  |   |
| a |                                  | u |   |             |                  |   |
| n |                                  | b |   |             |                  |   |
| c |                                  | r |   |             |                  |   |
| h |                                  | e |   |             |                  |   |
| e |                                  | c |   |             |                  |   |
| s |                                  | i |   |             |                  |   |
| o |                                  | p |   |             |                  |   |
| f |                                  | i |   |             |                  |   |
| t |                                  | e |   |             |                  |   |
| h |                                  | n |   |             |                  |   |
| e |                                  | t |   |             |                  |   |
| F |                                  | s |   |             |                  |   |
| e |                                  | > |   |             |                  |   |
| d |                                  |   |   |             |                  |   |
| e |                                  | s |   |             |                  |   |
| r |                                  | h |   |             |                  |   |
| a |                                  | a |   |             |                  |   |
| l |                                  | l |   |             |                  |   |
| \ |                                  | l |   |             |                  |   |
| G |                                  | > |   |             |                  |   |
| o |                                  |   |   |             |                  |   |
| v |                                  | c |   |             |                  |   |
| e |                                  | e |   |             |                  |   |
| r |                                  | r |   |             |                  |   |
| n |                                  | t |   |             |                  |   |
| m |                                  | i |   |             |                  |   |
| e |                                  | f |   |             |                  |   |
| n |                                  | y |   |             |                  |   |
| t |                                  | > |   |             |                  |   |
| i |                                  |   |   |             |                  |   |
| n |                                  | a |   |             |                  |   |
| c |                                  | n |   |             |                  |   |
| o |                                  | d |   |             |                  |   |
| n |                                  | > |   |             |                  |   |
| n |                                  |   |   |             |                  |   |
| e |                                  | d |   |             |                  |   |
| c |                                  | i |   |             |                  |   |
| t |                                  | s |   |             |                  |   |
| i |                                  | c |   |             |                  |   |
| o |                                  | l |   |             |                  |   |
| n |                                  | o |   |             |                  |   |
| w |                                  | s |   |             |                  |   |
| i |                                  | e |   |             |                  |   |
| t |                                  | > |   |             |                  |   |
| h |                                  |   |   |             |                  |   |
| a |                                  | a |   |             |                  |   |
| S |                                  | c |   |             |                  |   |
| P |                                  | c |   |             |                  |   |
| E |                                  | o |   |             |                  |   |
| C |                                  | r |   |             |                  |   |
| I |                                  | d |   |             |                  |   |
| F |                                  | i |   |             |                  |   |
| I |                                  | n |   |             |                  |   |
| C |                                  | g |   |             |                  |   |
| g |                                  | l |   |             |                  |   |
| r |                                  | y |   |             |                  |   |
| a |                                  | . |   |             |                  |   |
| n |                                  | > |   |             |                  |   |
| t |                                  | > |   |             |                  |   |
| o |                                  |   |   |             |                  |   |
| r |                                  | T |   |             |                  |   |
| \ |                                  | h |   |             |                  |   |
| c |                                  | i |   |             |                  |   |
| o |                                  | s |   |             |                  |   |
| o |                                  | > |   |             |                  |   |
| p |                                  |   |   |             |                  |   |
| e |                                  | c |   |             |                  |   |
| r |                                  | e |   |             |                  |   |
| a |                                  | r |   |             |                  |   |
| t |                                  | t |   |             |                  |   |
| i |                                  | i |   |             |                  |   |
| v |                                  | f |   |             |                  |   |
| e |                                  | i |   |             |                  |   |
| a |                                  | c |   |             |                  |   |
| g |                                  | a |   |             |                  |   |
| r |                                  | t |   |             |                  |   |
| e |                                  | i |   |             |                  |   |
| e |                                  | o |   |             |                  |   |
| m |                                  | n |   |             |                  |   |
| e |                                  | > |   |             |                  |   |
| n |                                  |   |   |             |                  |   |
| t |                                  | i |   |             |                  |   |
| . |                                  | s |   |             |                  |   |
| S |                                  | > |   |             |                  |   |
| e |                                  |   |   |             |                  |   |
| c |                                  | a |   |             |                  |   |
| t |                                  | > |   |             |                  |   |
| i |                                  |   |   |             |                  |   |
| o |                                  | m |   |             |                  |   |
| n |                                  | a |   |             |                  |   |
| 1 |                                  | t |   |             |                  |   |
| 3 |                                  | e |   |             |                  |   |
| 5 |                                  | r |   |             |                  |   |
| 2 |                                  | i |   |             |                  |   |
| a |                                  | a |   |             |                  |   |
| l |                                  | l |   |             |                  |   |
| s |                                  | > |   |             |                  |   |
| o |                                  |   |   |             |                  |   |
| r |                                  | r |   |             |                  |   |
| e |                                  | e |   |             |                  |   |
| q |                                  | p |   |             |                  |   |
| u |                                  | r |   |             |                  |   |
| i |                                  | e |   |             |                  |   |
| r |                                  | s |   |             |                  |   |
| e |                                  | e |   |             |                  |   |
| s |                                  | n |   |             |                  |   |
| \ |                                  | t |   |             |                  |   |
| t |                                  | a |   |             |                  |   |
| h |                                  | t |   |             |                  |   |
| a |                                  | i |   |             |                  |   |
| t |                                  | o |   |             |                  |   |
| e |                                  | n |   |             |                  |   |
| a |                                  | > |   |             |                  |   |
| c |                                  |   |   |             |                  |   |
| h |                                  | o |   |             |                  |   |
| p |                                  | f |   |             |                  |   |
| e |                                  | > |   |             |                  |   |
| r |                                  |   |   |             |                  |   |
| s |                                  | f |   |             |                  |   |
| o |                                  | a |   |             |                  |   |
| n |                                  | c |   |             |                  |   |
| w |                                  | t |   |             |                  |   |
| h |                                  | \ |   |             |                  |   |
| o |                                  | > |   |             |                  |   |
| r |                                  |   |   |             |                  |   |
| e |                                  | u |   |             |                  |   |
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|   |                                  | > |   |             |                  |   |
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|   |                                  | e |   |             |                  |   |
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|   |                                  | e |   |             |                  |   |
|   |                                  | n |   |             |                  |   |
|   |                                  | t |   |             |                  |   |
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|   |                                  | \ |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
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|   |                                  | h |   |             |                  |   |
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|   |                                  | > |   |             |                  |   |
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|   |                                  | a |   |             |                  |   |
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|   |                                  | > |   |             |                  |   |
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|   |                                  | , |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
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|   |                                  | c |   |             |                  |   |
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|   |                                  | e |   |             |                  |   |
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|   |                                  | , |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
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|   |                                  | a |   |             |                  |   |
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|   |                                  | > |   |             |                  |   |
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|   |                                  | a |   |             |                  |   |
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|   |                                  | u |   |             |                  |   |
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|   |                                  | a |   |             |                  |   |
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|   |                                  | > |   |             |                  |   |
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|   |                                  | > |   |             |                  |   |
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|   |                                  | e |   |             |                  |   |
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|   |                                  | > |   |             |                  |   |
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|   |                                  | o |   |             |                  |   |
|   |                                  | f |   |             |                  |   |
|   |                                  | \ |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  | h |   |             |                  |   |
|   |                                  | i |   |             |                  |   |
|   |                                  | s |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
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|   |                                  | o |   |             |                  |   |
|   |                                  | r |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
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|   |                                  | e |   |             |                  |   |
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|   |                                  | > |   |             |                  |   |
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|   |                                  | d |   |             |                  |   |
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|   |                                  | e |   |             |                  |   |
|   |                                  | , |   |             |                  |   |
|   |                                  | > |   |             |                  |   |
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|   |                                  | a |   |             |                  |   |
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|   |                                  | d |   |             |                  |   |
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|   |                                  | > |   |             |                  |   |
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|   |                                  | > |   |             |                  |   |
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|   |                                  | a |   |             |                  |   |
|   |                                  | l |   |             |                  |   |
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|   |                                  | e |   |             |                  |   |
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|   |                                  | > |   |             |                  |   |
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|   |                                  | . |   |             |                  |   |
+---+----------------------------------+---+---+-------------+------------------+---+
|   | > **5. CERTIFICATION REGARDING** |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   | **ENVIRONMENTAL TOBACCO SMOKE**  |   | F |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   | Public Law 103-227, also known   |   | i |             |                  |   |
|   | as the Pro-Children\             |   | l |             |                  |   |
|   | Act of 1994 (Act), requires that |   | u |             |                  |   |
|   | smoking not be\                  |   | r |             |                  |   |
|   | permitted in any portion of any  |   | e |             |                  |   |
|   | indoor facility owned\           |   | > |             |                  |   |
|   | or leased or contracted for by   |   |   |             |                  |   |
|   | an entity and used\              |   | t |             |                  |   |
|   | routinely or regularly for the   |   | o |             |                  |   |
|   | provision of health, day\        |   | > |             |                  |   |
|   | care, early childhood            |   |   |             |                  |   |
|   | development services,\           |   | c |             |                  |   |
|   | education or library services to |   | o |             |                  |   |
|   | children under the\              |   | m |             |                  |   |
|   | age of 18, if the services are   |   | p |             |                  |   |
|   | funded by Federal\               |   | l |             |                  |   |
|   | programs either directly or      |   | y |             |                  |   |
|   | through State or local\          |   | > |             |                  |   |
|   | governments, by Federal grant,   |   |   |             |                  |   |
|   | contract, loan, or loan\         |   | w |             |                  |   |
|   | guarantee. The law also applies  |   | i |             |                  |   |
|   | to children's\                   |   | t |             |                  |   |
|   | services that are provided in    |   | h |             |                  |   |
|   | indoor facilities that are\      |   | > |             |                  |   |
|   | constructed, operated, or        |   |   |             |                  |   |
|   | maintained with such\            |   | t |             |                  |   |
|   | Federal funds. The law does not  |   | h |             |                  |   |
|   | apply to children's\             |   | e |             |                  |   |
|   | services provided in private     |   | > |             |                  |   |
|   | residence, portions of\          |   |   |             |                  |   |
|   | facilities used for inpatient    |   | p |             |                  |   |
|   | drug or alcohol treatment,\      |   | r |             |                  |   |
|   | service providers whose sole     |   | o |             |                  |   |
|   | source of applicable\            |   | v |             |                  |   |
|   | Federal funds is Medicare or     |   | i |             |                  |   |
|   | Medicaid, or facilities\         |   | s |             |                  |   |
|   | where WIC coupons are redeemed.  |   | i |             |                  |   |
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|   |                                  |   | n |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | o |             |                  |   |
|   |                                  |   | f |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | a |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | a |             |                  |   |
|   |                                  |   | d |             |                  |   |
|   |                                  |   | m |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | i |             |                  |   |
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|   |                                  |   | a |             |                  |   |
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|   |                                  |   | i |             |                  |   |
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|   |                                  |   | e |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | c |             |                  |   |
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|   |                                  |   | m |             |                  |   |
|   |                                  |   | p |             |                  |   |
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|   |                                  |   | i |             |                  |   |
|   |                                  |   | a |             |                  |   |
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|   |                                  |   | e |             |                  |   |
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|   |                                  |   | d |             |                  |   |
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|   |                                  |   | r |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | > |             |                  |   |
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|   |                                  |   | > |             |                  |   |
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|   |                                  |   | e |             |                  |   |
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|   |                                  |   | p |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | n |             |                  |   |
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|   |                                  |   | i |             |                  |   |
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|   |                                  |   | n |             |                  |   |
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|   |                                  |   | i |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | y |             |                  |   |
|   |                                  |   | . |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | B |             |                  |   |
|   |                                  |   | y |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | s |             |                  |   |
|   |                                  |   | i |             |                  |   |
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|   |                                  |   | n |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | g |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | e |             |                  |   |
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|   |                                  |   | e |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | f |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | a |             |                  |   |
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|   |                                  |   | i |             |                  |   |
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|   |                                  |   | n |             |                  |   |
|   |                                  |   | , |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | t |             |                  |   |
|   |                                  |   | h |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | u |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | d |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | s |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | g |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | d |             |                  |   |
|   |                                  |   | \ |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | f |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | s |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | t |             |                  |   |
|   |                                  |   | h |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | t |             |                  |   |
|   |                                  |   | h |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | p |             |                  |   |
|   |                                  |   | p |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | g |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | z |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | w |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | m |             |                  |   |
|   |                                  |   | p |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | y |             |                  |   |
|   |                                  |   | \ |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | w |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | h |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | t |             |                  |   |
|   |                                  |   | h |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | e |             |                  |   |
|   |                                  |   | q |             |                  |   |
|   |                                  |   | u |             |                  |   |
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|   |                                  |   | e |             |                  |   |
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|   |                                  |   | e |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | s |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | o |             |                  |   |
|   |                                  |   | f |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | t |             |                  |   |
|   |                                  |   | h |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | A |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | d |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | w |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | w |             |                  |   |
|   |                                  |   | \ |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | s |             |                  |   |
|   |                                  |   | m |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | k |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | g |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | w |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | h |             |                  |   |
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|   |                                  |   | n |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | y |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | p |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
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|   |                                  |   |   |             |                  |   |
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|   |                                  |   | n |             |                  |   |
|   |                                  |   | d |             |                  |   |
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|   |                                  |   | t |             |                  |   |
|   |                                  |   | y |             |                  |   |
|   |                                  |   | \ |             |                  |   |
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|   |                                  |   | i |             |                  |   |
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|   |                                  |   | l |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | q |             |                  |   |
|   |                                  |   | u |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | \ |             |                  |   |
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|   |                                  |   |   |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | h |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | t |             |                  |   |
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|   |                                  |   | t |             |                  |   |
|   |                                  |   | h |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | g |             |                  |   |
|   |                                  |   | u |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | g |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | f |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | t |             |                  |   |
|   |                                  |   | h |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | s |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | f |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | t |             |                  |   |
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|   |                                  |   | o |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | b |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | c |             |                  |   |
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|   |                                  |   | u |             |                  |   |
|   |                                  |   | d |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | d |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | \ |             |                  |   |
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|   |                                  |   |   |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | n |             |                  |   |
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|   |                                  |   | a |             |                  |   |
|   |                                  |   | w |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | d |             |                  |   |
|   |                                  |   | s |             |                  |   |
|   |                                  |   | > |             |                  |   |
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|   |                                  |   | w |             |                  |   |
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|   |                                  |   | i |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | h |             |                  |   |
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|   |                                  |   |   |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | p |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | v |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | s |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | s |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | f |             |                  |   |
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|   |                                  |   | r |             |                  |   |
|   |                                  |   | \ |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | h |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | d |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | ' |             |                  |   |
|   |                                  |   | s |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | s |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | v |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | s |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | d |             |                  |   |
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|   |                                  |   |   |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | h |             |                  |   |
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|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | s |             |                  |   |
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|   |                                  |   | b |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | e |             |                  |   |
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|   |                                  |   | i |             |                  |   |
|   |                                  |   | e |             |                  |   |
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|   |                                  |   | t |             |                  |   |
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|   |                                  |   | t |             |                  |   |
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|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | d |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | g |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | y |             |                  |   |
|   |                                  |   | . |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | T |             |                  |   |
|   |                                  |   | h |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | P |             |                  |   |
|   |                                  |   | u |             |                  |   |
|   |                                  |   | b |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | H |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | h |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | S |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | v |             |                  |   |
|   |                                  |   | i |             |                  |   |
|   |                                  |   | c |             |                  |   |
|   |                                  |   | e |             |                  |   |
|   |                                  |   | s |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
|   |                                  |   | s |             |                  |   |
|   |                                  |   | t |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | o |             |                  |   |
|   |                                  |   | n |             |                  |   |
|   |                                  |   | g |             |                  |   |
|   |                                  |   | l |             |                  |   |
|   |                                  |   | y |             |                  |   |
|   |                                  |   | > |             |                  |   |
|   |                                  |   |   |             |                  |   |
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|   |                                  |   | n |             |                  |   |
|   |                                  |   | c |             |                  |   |
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|   |                                  |   | u |             |                  |   |
|   |                                  |   | r |             |                  |   |
|   |                                  |   | a |             |                  |   |
|   |                                  |   | g |             |                  |   |
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|   |                                  |   | l |             |                  |   |
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|   |                                  |   | \ |             |                  |   |
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|   |                                  |   | d |             |                  |   |
|   |                                  |   | v |             |                  |   |
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|   |                                  |   | . |             |                  |   |
+---+----------------------------------+---+---+-------------+------------------+---+
|   | SIGNATURE OF AUTHORIZED          |   |   | TITLE       |                  |   |
|   | CERTIFYING OFFICIAL              |   |   |             |                  |   |
+---+----------------------------------+---+---+-------------+------------------+---+
|   |                                  |   |   |             |                  |   |
+---+----------------------------------+---+---+-------------+------------------+---+
|   | APPLICANT ORGANIZATION           |   |   |             | DATE SUBMITTED   |   |
+---+----------------------------------+---+---+-------------+------------------+---+
|   |                                  |   |   |             |                  |   |
+---+----------------------------------+---+---+-------------+------------------+---+

+-----------------------------------+----------------------------------+
| OMB Approval No. 0920-0428        |                                  |
|                                   |                                  |
| **PROGRAM NARRATIVE**             |                                  |
+-----------------------------------+----------------------------------+
| ***Public Burden Statement:***    | > which the applicant estimates  |
| Public reporting burden of\       | > are required to carry\         |
| this collection of information is | > out activities under the       |
| estimated to average 4\           | > proposed project. (A\          |
| hours per response, including the | > narrative budget justification |
| time for reviewing\               | > must also be provided;\        |
| instructions, searching existing  | > see *Budget Narrativ*e,        |
| data sources, gathering\          | > below.)                        |
| and maintaining the data needed,  | >                                |
| and completing and\               | > Applicants must clearly        |
| reviewing the collection of       | > identify the physical,\        |
| information. An agency may\       | > economic, social, financial,   |
| not conduct or sponsor, and a     | > institutional, or other\       |
| person is not required to\        | > problem(s) requiring a         |
| respond to a collection of        | > solution. The need for\        |
| information unless it displays\   | > assistance must be             |
| a currently valid OMB control     | > demonstrated and the           |
| number. Send comments\            | > principal\                     |
| regarding this burden estimate or | > and subordinate objectives of  |
| any other aspect of\              | > the project must be\           |
| this collection of information,   | > clearly stated; supporting     |
| including suggestions for\        | > documentation or other\        |
| reducing this burden to CDC,      | > testimonies from concerned     |
| Project Clearance Officer,\       | > interests other than the\      |
| 1600 Clifton Road, MS D-24,       | > applicant may be included. Any |
| Atlanta, GA 30333,\               | > relevant data based\           |
| ATTN: PRA (0920-0428). Do not     | > on planning studies should be  |
| send the completed\               | > included or\                   |
| form to this address.             | > referenced in footnotes.       |
|                                   | >                                |
| Prepare the program narrative     | > In developing the narrative,   |
| statement in accordance\          | > the applicant may\             |
| with the following instructions   | > volunteer or be requested to   |
| for all new and\                  | > provide information on\        |
| competing continuation            | > the total range of health      |
| applications. Noncompeting\       | > programs currently\            |
| continuation applications and     | > conducted and supported (or to |
| requests for changes to an\       | > be initiated), some\           |
| approved project should respond   | > of which may be outside the    |
| to Item 6(b) only.\               | > scope of the program\          |
| Requests for supplemental         | > announcement.                  |
| assistance should respond to\     | >                                |
| Item 6(c) only.                   | > Applicants are encouraged to   |
|                                   | > provide information\           |
| The Program Narrative provides a  | > on their organizational        |
| major means by\                   | > structure, staff, related\     |
| which the application is          | > experience, and other          |
| evaluated and ranked to\          | > information considered to be\  |
| compete with other applications   | > relevant. Awarding offices use |
| for available funds. It\          | > this and other\                |
| should be concise and complete    | > information to determine       |
| and should address the\           | > whether the applicant has\     |
| activity for which Federal funds  | > the capability and resources   |
| are requested.\                   | > necessary to carry out\        |
| Supporting documents should be    | > the proposed project. It is    |
| included where they\              | > important, therefore, that\    |
| can present information clearly   | > this information be included   |
| and succinctly.\                  | > in the application. It is\     |
| Cross-referencing should be used  | > equally important that the     |
| rather than repetition.\          | > narrative distinguish\         |
| PHS is particularly interested in | > between applicant resources    |
| specific factual\                 | > which are directly\            |
| information and statements of     | > related to the proposed budget |
| measurable goals in\              | > and those which will\          |
| quantitative terms. Narratives    | > not be used in support of the  |
| are evaluated on the basis\       | > specific project for\          |
| of substance, not length.         | > which funds are requested.     |
| Extensive exhibits are not\       | >                                |
| required. (Supporting information | > **2. RESULTS OR BENEFITS       |
| concerning activities\            | > EXPECTED**                     |
| which will not be directly funded | >                                |
| by the grant or\                  | > Identify results and benefits  |
| information which does not        | > to be derived. For\            |
| directly pertain to an\           | > example, when applying for a   |
| integral part of the grant-funded | > grant to establish a\          |
| activity should be\               | > neighborhood health center,    |
| placed in an appendix.) Pages     | > provide a description of\      |
| should be numbered for\           | > who will occupy the facility,  |
| easy reference, continuing the    | > how the facility will be\      |
| numerical sequence of\            | > used, and how the facility     |
| the printed form.                 | > will benefit the general\      |
|                                   | > public.                        |
| **1. PROJECT DESCRIPTION**        | >                                |
|                                   | > **3. APPROACH**                |
| Because many and varied programs  | >                                |
| employ this\                      | > \(a\) Outline a plan of action |
| application form, it is not       | > which describes the\           |
| possible to provide specific\     | > scope and detail of how the    |
| guidance for developing a project | > proposed work will\            |
| description which\                | > be accomplished for each grant |
| would be appropriate in all       | > program,\                      |
| cases. One aspect of the\         | > function or activity provided  |
| description that is applicable to | > in the budget. Cite\           |
| all proposals,\                   | > factors which might accelerate |
| however, is the requirement that  | > or decelerate the\             |
| all project\                      | > work and state your reason for |
| information described in this     | > takings this                   |
| part relate directly to\          |                                  |
| the budget information requested. |                                  |
| The budget\                       |                                  |
| consists of the funds (both       |                                  |
| Federal and non-Federal)          |                                  |
+-----------------------------------+----------------------------------+

+-----------------------------------+-----------------------------------+
| > approach rather than others.    | > **6. ADDITIONAL INFORMATION**   |
| > Describe any\                   | >                                 |
| > unusual features of the project | > **(INCLUDE IF APPLICABLE)**     |
| > such as design or technological | >                                 |
| > innovations, reductions in cost | > \(a\) *STAFF AND POSITION DATA* |
| > or time, or extraordinary       | >                                 |
| > social and community            | > Some programs require a         |
| > involvement.                    | > biographical sketch for\        |
| >                                 | > key personnel appointed and a   |
| > \(b\) Provide quantitative      | > job description\                |
| > monthly or quarterly\           | > for a vacant key position;      |
| > projections of the              | > others require both for\        |
| > accomplishments to be\          | > all positions. Refer to         |
| > achieved for each grant         | > appropriate program\            |
| > program, function or\           | > guidelines for guidance in      |
| > activity in such terms as the   | > fulfilling this\                |
| > number of people to be served   | > requirement. Generally, a       |
| > and the number of patients to   | > biographical sketch is\         |
| > be\                             | > required for original staff and |
| > treated. When accomplishments   | > new members as\                 |
| > cannot be\                      | > appointed. Below are the        |
| > quantified by activity or       | > suggested contents for\         |
| > function, list them in\         | > the biographical sketch and job |
| > chronological order to show the | > description\                    |
| > schedule of\                    | > where not otherwise set forth:  |
| > accomplishments and their       | >                                 |
| > target dates.                   | > *Biographical Sketch:*          |
| >                                 | >                                 |
| > \(c\) Identify the kinds of     | > Existing curricula vitae of     |
| > data to be collected and\       | > project staff members\          |
| > maintained.                     | > may be used if they are updated |
| >                                 | > and contain all\                |
| > \(d\) List organizations,       | > items of information requested  |
| > cooperating entities,           | > below. You may\                 |
| > consultants, or other key       | > add any information items       |
| > individuals who will work on    | > listed below to\                |
| > the project along with a short  | > complete existing documents.    |
| > description of the nature of    | > For development\                |
| > their effort or contribution.   | > of new curricula vitae include  |
|                                   | > items below in the\             |
| **4. EVALUATION**                 | > most suitable format:           |
|                                   | >                                 |
| Provide a narrative addressing    | > \(1\) Name of staff member.     |
| how you will\                     | >                                 |
| evaluate 1) the results of your   | > \(2\) Educational background:   |
| project, and 2) the\              | > school(s), location,\           |
| conduct of your program.          | > dates attended, degrees earned  |
|                                   | > (specify\                       |
| > In addressing the evaluation of | > year), major field of study.    |
| > results, state how\             | >                                 |
| > you will determine the extent   | > \(3\) Professional experience.  |
| > to which the program\           | >                                 |
| > has achieved its stated         | > \(4\) Honors received and       |
| > objectives and the extent to\   | > dates.                          |
| > which the accomplishment of     | >                                 |
| > objectives can be\              | > \(5\) Recent relevant           |
| > attributed to the program.      | > publications.                   |
| > Discuss the criteria to be\     | >                                 |
| > used to evaluate results and    | > \(6\) Other sources of support. |
| > successes; explain the\         | > \[Other support is\             |
| > methodology that will be used   | > defined as all funds or         |
| > to determine if the\            | > resources, whether\             |
| > needs identified and discussed  | > Federal, non-Federal, or        |
| > are being met and if\           | > institutional,\                 |
| > the results and benefits        | > available to the Project        |
| > identified in Item 2 (above)\   | > Director/Program\               |
| > are being achieved.             | > Director (and other key         |
| >                                 | > personnel named in\             |
| > With respect to the conduct of  | > the application) in direct      |
| > your program, define\           | > support of their\               |
| > the procedures you will employ  | > activities through grants,      |
| > to determine\                   | > cooperative\                    |
| > whether the program is being    | > agreements, contracts,          |
| > conducted in a\                 | > fellowships, gifts,\            |
| > manner consistent with the work | > prizes, and other means.\]      |
| > plan you presented\             | >                                 |
| > and discuss the impact of the   | > *Job Description:*              |
| > program's various\              | >                                 |
| > activities upon the program's   | > \(1\) Title of position.        |
| > effectiveness.                  | >                                 |
|                                   | > \(2\) Description of duties and |
| **5. GEOGRAPHIC LOCATION**        | > responsibilities.               |
|                                   | >                                 |
| > Give the precise location of    | > \(3\) Qualifications for        |
| > the project or area to be\      | > position.                       |
| > served by the proposed project. | >                                 |
| > Maps or other\                  | > \(4\) Supervisory               |
| > graphic aids may be attached.   | > relationships.                  |
|                                   | >                                 |
|                                   | > \(5\) Skills and knowledge      |
|                                   | > required.                       |
|                                   | >                                 |
|                                   | > \(6\) Prior experience          |
|                                   | > required.                       |
|                                   | >                                 |
|                                   | > \(7\) Personal qualities.       |
|                                   | >                                 |
|                                   | > \(8\) Amount of travel and any  |
|                                   | > other special                   |
|                                   | >                                 |
|                                   | > conditions or requirements.     |
|                                   | >                                 |
|                                   | > \(9\) Salary range.             |
|                                   | >                                 |
|                                   | > \(10\) Hours per day or week.   |
+-----------------------------------+-----------------------------------+

+-----------------------------------+-----------------------------------+
| **(b) OTHER INFORMATION**         | > If the total budget has been    |
|                                   | > exceeded, or if\                |
| Discuss accomplishments to date   | > individual budget items have    |
| and list in\                      | > changed more than the\          |
| chronological order a schedule of | > prescribed limits contained in  |
| accomplishments, progress or      | > the applicable Office\          |
| milestones anticipated with the   | > of Management and Budget        |
| new\                              | > Circular (A-102 or\             |
| funding request. If there have    | > A-110), explain and justify the |
| been significant\                 | > change and its effect\          |
| changes in the project            | > on the project.                 |
| objectives, location or\          | >                                 |
| approach, or time delays, explain | > **(c) SUPPLEMENTAL REQUESTS**   |
| and justify. For\                 | >                                 |
| other requests for changes or     | > For supplemental assistance     |
| amendments, explain\              | > requests, explain the\          |
| the reason for the change(s). If  | > reason for the request and      |
| the scope or\                     | > justify the need for\           |
| objectives have changed or an     | > additional funding.             |
| extension of time is\             |                                   |
| necessary, explain the            |                                   |
| circumstances and justify.        |                                   |
+-----------------------------------+-----------------------------------+
| > **BUDGET NARRATIVE**            |                                   |
+-----------------------------------+-----------------------------------+
| Provide a narrative budget        | > Describe the specific functions |
| justification which describes\    | > of the personnel, consultants,  |
| how the categorical costs are     | > and collaborators. For all      |
| derived. Discuss the\             | > years, explain and\             |
| necessity, reasonableness, and    | > justify any unusual items such  |
| allocability of the\              | > as major equipment,\            |
| proposed costs.                   | > foreign travel, alterations and |
|                                   | > renovations, patient care\      |
| Only the direct costs requested   | > costs, and tuition remission.   |
| in this application need\         | > For additional years of\        |
| to be justified. Do not include   | > support requested, itemize and  |
| any items that are treated\       | > justify any significant\        |
| by the applicant organization as  | > increases or decreases in any   |
| indirect costs according\         | > category over the first 12\     |
| to a Federal rate negotiation     | > month budget period. Identify   |
| agreement except for those\       | > such significant changes\       |
| indirect costs included in        | > with asterisks against the      |
| consortium/ contractual costs.    | > appropriate amounts. If a\      |
|                                   | > recurring annual increase or    |
| If funds to be used for           | > decrease in personnel or\       |
| Matching/Cost Participation\      | > other costs is anticipated,     |
| (whether voluntary or required)   | > give the percentage. In\        |
| are included in the\              | > addition, for *Competing        |
| budget, only funds which will be  | > Continuation* applications,\    |
| used for this specific\           | > justify any significant         |
| project should be so identified.  | > increases or decreases in any\  |
| If an award is made, all\         | > category over the current level |
| funds identified as dedicated to  | > of support.                     |
| this project (including\          | >                                 |
| funds used for cost               | > **INDIRECT COSTS**              |
| participation) will be subject to | >                                 |
| the\                              | > If indirect costs are requested |
| applicable cost principles, audit | > in the budget, submit a\        |
| and reporting\                    | > copy of the applicant           |
| requirements.                     | > organization's most current\    |
|                                   | > Federal negotiated indirect     |
| For a Supplemental application,   | > cost rate agreement. If your\   |
| you need justify only\            | > organization does not have a    |
| those items for which additional  | > Federally negotiated rate,\     |
| funds are requested,\             | > contact the grants management   |
| prorating the personnel costs and | > office identified in the\       |
| other appropriate parts\          | > program announcement for        |
| of the detailed budget if the     | > information on a contact\       |
| first budget period of the\       | > point to assist in the          |
| zapplication is less than 12      | > development of such a rate.     |
| months.                           |                                   |
+-----------------------------------+-----------------------------------+

<table>
<colgroup>
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 30%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 15%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="21"><p>OMB Approval No. 0920-0428</p>
<p><strong>CHECKLIST</strong></p></td>
</tr>
<tr class="even">
<td colspan="9"><strong>Public Burden Statement:</strong> Public
reporting burden of this<br />
collection of information is estimated to average 4 - 50 hours per<br />
response, including the time for reviewing instructions, searching<br />
existing data sources, gathering and maintaining the data needed,<br />
and completing and reviewing the collection of information. An<br />
agency may not conduct or sponsor, and a person is not required<br />
to respond to a collection of information unless it displays a<br />
currently valid OMB control number. Send comments regarding<br />
this burden estimate or any other aspect of this collection of<br />
information, including suggestions for reducing this burden to CDC,</td>
<td colspan="12"><blockquote>
<p>Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA
30333,<br />
ATTN: PRA (0920-0428). Do not send the completed form to this<br />
address.</p>
<p><strong>NOTE TO APPLICANT:</strong> This form must be completed
and<br />
submitted with the original of your application. Be sure to
complete<br />
both sides of this form. Check the appropriate boxes and provide<br />
the information requested. This form should be attached as the
last<br />
page of the signed original of the application. This page is
reserved<br />
for PHS staff use only.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="21"><blockquote>
<p>Noncompeting Competing</p>
</blockquote>
<p>Type of Application: NEW Continuation Continuation
Supplemental</p></td>
</tr>
<tr class="even">
<td colspan="21"><p><strong>PART A: The following checklist is provided
to assure that proper signatures, assurances, and certifications have
been</strong></p>
<p><strong>submitted.</strong> NOT</p>
<blockquote>
<p>Included Applicable</p>
<p>1. Proper Signature and Date for Item 18 on SF 424 (FACE PAGE)
............................ </p>
<p>2. Proper Signature and Date on PHS-5161-1 "Certifications" page.
............................ </p>
<p>3. Proper Signature and Date on appropriate "Assurances" page,
i.e.,</p>
<p>SF-424B (Non-Construction Programs) or SF-424D (Construction
Programs) ......... </p>
<p>4. If your organization currently has on file with DHHS the
following</p>
<p>assurances, please identify which have been filed by indicating
the</p>
<p>date of such filing on the line provided. (All four have been</p>
<p>consolidated into a single form, HHS Form 690)</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="12"><blockquote>
<p> Civil Rights Assurance (45 CFR 80)
...........................................</p>
</blockquote></td>
<td colspan="8">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="12"><blockquote>
<p> Assurance Concerning the Handicapped (45 CFR 84) ...............</p>
</blockquote></td>
<td colspan="8">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="12"><blockquote>
<p> Assurance Concerning Sex Discrimination (45 CFR 86) ............</p>
</blockquote></td>
<td colspan="8">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="12"><blockquote>
<p> Assurance Concerning Age Discrimination (45 CFR 90 &amp;<br />
45 CFR 91)
................................................................................</p>
</blockquote></td>
<td colspan="8">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="21">5. Human Subjects Certification, when applicable (45
CFR 46) ....................................... </td>
</tr>
<tr class="even">
<td colspan="21"><p><strong>PART B: This part is provided to assure that
pertinent information has been addressed and included in the
application.</strong></p>
<p>NOT</p>
<p>YES Applicable</p>
<blockquote>
<p>1. Has a Public Health System Impact Statement for the proposed
program/project</p>
<p>been completed and distributed as required? </p>
<p>2. Has the appropriate box been checked for item # 16 on the SF-424
(FACE PAGE)</p>
<p>regarding intergovernmental review under E.O. 12372 ? (45 CFR Part
100) </p>
<p>3. Has the entire proposed project period been identified in item #
13 of the FACE</p>
<p>PAGE? </p>
<p>4. Have biographical sketch(es) with job description(s) been
attached, when</p>
<p>required </p>
<p>5. Has the "Budget Information" page, SF-424A (Non-Construction
Programs) or</p>
<p>SF-424C (Construction Programs), been completed and included? </p>
<p>6. Has the 12 month detailed budget been provided? </p>
<p>7. Has the budget for the entire proposed project period with
sufficient detail been</p>
<p>provided? </p>
<p>8. For a Supplemental application, does the detailed budget address
only the additional</p>
<p>funds requested? </p>
<p>9. For Competing Continuation and Supplemental applications, has a
progress report</p>
<p>been included? </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="21"><strong>PART C: In the spaces provided below, please
provide the requested information.</strong></td>
</tr>
<tr class="even">
<td colspan="8">Business Official to be notified if an award is to be
made.</td>
<td colspan="13"><blockquote>
<p>Program Director/Project Director/Principal Investigator designated
to direct</p>
<p>the proposed project or program.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="6"><strong>Name</strong></td>
<td colspan="2">     </td>
<td colspan="2"></td>
<td><strong>Name</strong></td>
<td colspan="10">     </td>
</tr>
<tr class="even">
<td colspan="2"><strong>Title</strong></td>
<td colspan="6">     </td>
<td colspan="2"></td>
<td><strong>Title</strong></td>
<td colspan="10">     </td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Organization</strong></td>
<td colspan="4">     </td>
<td colspan="2"></td>
<td colspan="4"><strong>Organization</strong></td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>Address</strong></td>
<td colspan="5">     </td>
<td colspan="2"></td>
<td colspan="3"><strong>Address</strong></td>
<td colspan="8">     </td>
</tr>
<tr class="odd">
<td colspan="5"><strong>E-mail Address</strong></td>
<td colspan="3">     </td>
<td colspan="2"></td>
<td colspan="5"><strong>E-mail Address</strong></td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="7"><strong>Telephone Number</strong></td>
<td>     </td>
<td colspan="2"></td>
<td colspan="6"><strong>Telephone Number</strong></td>
<td colspan="5">     </td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Fax Number</strong></td>
<td colspan="4">     </td>
<td colspan="2"></td>
<td colspan="4"><strong>Fax Number</strong></td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="8">APPLICANT ORGANIZATION’S 12-DIGIT DHHS EIN (If already
assigned)</td>
<td colspan="2"></td>
<td colspan="8"><strong>SOCIAL SECURITY NUMBER</strong></td>
<td colspan="3"><strong>HIGHEST DEGREE EARNED</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">     </td>
<td colspan="2"></td>
<td colspan="7">     </td>
<td colspan="2"></td>
<td colspan="2">     </td>
</tr>
</tbody>
</table>

*(OVER)*

+------+---------------------------+--------------+------+------------+
| **   |                           |              |      |            |
| PART |                           |              |      |            |
| D: A |                           |              |      |            |
| priv |                           |              |      |            |
| ate, |                           |              |      |            |
| n    |                           |              |      |            |
| onpr |                           |              |      |            |
| ofit |                           |              |      |            |
| orga |                           |              |      |            |
| niza |                           |              |      |            |
| tion |                           |              |      |            |
| must |                           |              |      |            |
| inc  |                           |              |      |            |
| lude |                           |              |      |            |
| evid |                           |              |      |            |
| ence |                           |              |      |            |
| of   |                           |              |      |            |
| its  |                           |              |      |            |
| n    |                           |              |      |            |
| onpr |                           |              |      |            |
| ofit |                           |              |      |            |
| st   |                           |              |      |            |
| atus |                           |              |      |            |
| with |                           |              |      |            |
| the  |                           |              |      |            |
| appl |                           |              |      |            |
| icat |                           |              |      |            |
| ion. |                           |              |      |            |
| Any  |                           |              |      |            |
| of   |                           |              |      |            |
| t    |                           |              |      |            |
| he** |                           |              |      |            |
|      |                           |              |      |            |
| **f  |                           |              |      |            |
| ollo |                           |              |      |            |
| wing |                           |              |      |            |
| is   |                           |              |      |            |
| ac   |                           |              |      |            |
| cept |                           |              |      |            |
| able |                           |              |      |            |
| e    |                           |              |      |            |
| vide |                           |              |      |            |
| nce. |                           |              |      |            |
| C    |                           |              |      |            |
| heck |                           |              |      |            |
| the  |                           |              |      |            |
| app  |                           |              |      |            |
| ropr |                           |              |      |            |
| iate |                           |              |      |            |
| box  |                           |              |      |            |
| or   |                           |              |      |            |
| comp |                           |              |      |            |
| lete |                           |              |      |            |
| the  |                           |              |      |            |
| \"Pr |                           |              |      |            |
| evio |                           |              |      |            |
| usly |                           |              |      |            |
| Fil  |                           |              |      |            |
| ed\" |                           |              |      |            |
| se   |                           |              |      |            |
| ctio |                           |              |      |            |
| n,** |                           |              |      |            |
|      |                           |              |      |            |
| **w  |                           |              |      |            |
| hich |                           |              |      |            |
| ever |                           |              |      |            |
| is   |                           |              |      |            |
| a    |                           |              |      |            |
| ppli |                           |              |      |            |
| cabl |                           |              |      |            |
| e.** |                           |              |      |            |
|      |                           |              |      |            |
| (a)  |                           |              |      |            |
| A    |                           |              |      |            |
| r    |                           |              |      |            |
| efer |                           |              |      |            |
| ence |                           |              |      |            |
| to   |                           |              |      |            |
| the  |                           |              |      |            |
| or   |                           |              |      |            |
| gani |                           |              |      |            |
| zati |                           |              |      |            |
| on's |                           |              |      |            |
| lis  |                           |              |      |            |
| ting |                           |              |      |            |
| in   |                           |              |      |            |
| the  |                           |              |      |            |
| Inte |                           |              |      |            |
| rnal |                           |              |      |            |
| Rev  |                           |              |      |            |
| enue |                           |              |      |            |
| S    |                           |              |      |            |
| ervi |                           |              |      |            |
| ce's |                           |              |      |            |
| (    |                           |              |      |            |
| IRS) |                           |              |      |            |
| most |                           |              |      |            |
| re   |                           |              |      |            |
| cent |                           |              |      |            |
| list |                           |              |      |            |
| of   |                           |              |      |            |
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| empt |                           |              |      |            |
| o    |                           |              |      |            |
| rgan |                           |              |      |            |
| izat |                           |              |      |            |
| ions |                           |              |      |            |
| d    |                           |              |      |            |
| escr |                           |              |      |            |
| ibed |                           |              |      |            |
| in   |                           |              |      |            |
| sec  |                           |              |      |            |
| tion |                           |              |      |            |
| 5    |                           |              |      |            |
| 01(c |                           |              |      |            |
| )(3) |                           |              |      |            |
| of   |                           |              |      |            |
| the  |                           |              |      |            |
| IRS  |                           |              |      |            |
| C    |                           |              |      |            |
| ode. |                           |              |      |            |
|      |                           |              |      |            |
| (b)  |                           |              |      |            |
| A    |                           |              |      |            |
| copy |                           |              |      |            |
| of a |                           |              |      |            |
| c    |                           |              |      |            |
| urre |                           |              |      |            |
| ntly |                           |              |      |            |
| v    |                           |              |      |            |
| alid |                           |              |      |            |
| Inte |                           |              |      |            |
| rnal |                           |              |      |            |
| Rev  |                           |              |      |            |
| enue |                           |              |      |            |
| Ser  |                           |              |      |            |
| vice |                           |              |      |            |
| Tax  |                           |              |      |            |
| e    |                           |              |      |            |
| xemp |                           |              |      |            |
| tion |                           |              |      |            |
| cert |                           |              |      |            |
| ific |                           |              |      |            |
| ate. |                           |              |      |            |
|      |                           |              |      |            |
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| tate |                           |              |      |            |
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| from |                           |              |      |            |
| a    |                           |              |      |            |
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| ta   |                           |              |      |            |
| xing |                           |              |      |            |
| b    |                           |              |      |            |
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| tate |                           |              |      |            |
| Atto |                           |              |      |            |
| rney |                           |              |      |            |
| Gene |                           |              |      |            |
| ral, |                           |              |      |            |
| or   |                           |              |      |            |
| o    |                           |              |      |            |
| ther |                           |              |      |            |
| app  |                           |              |      |            |
| ropr |                           |              |      |            |
| iate |                           |              |      |            |
| S    |                           |              |      |            |
| tate |                           |              |      |            |
| offi |                           |              |      |            |
| cial |                           |              |      |            |
|      |                           |              |      |            |
| ce   |                           |              |      |            |
| rtif |                           |              |      |            |
| ying |                           |              |      |            |
| that |                           |              |      |            |
| the  |                           |              |      |            |
| a    |                           |              |      |            |
| ppli |                           |              |      |            |
| cant |                           |              |      |            |
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| niza |                           |              |      |            |
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| a    |                           |              |      |            |
| n    |                           |              |      |            |
| onpr |                           |              |      |            |
| ofit |                           |              |      |            |
| st   |                           |              |      |            |
| atus |                           |              |      |            |
| and  |                           |              |      |            |
| that |                           |              |      |            |
| none |                           |              |      |            |
| of   |                           |              |      |            |
| the  |                           |              |      |            |
| net  |                           |              |      |            |
| earn |                           |              |      |            |
| ings |                           |              |      |            |
| ac   |                           |              |      |            |
| crue |                           |              |      |            |
|      |                           |              |      |            |
| to   |                           |              |      |            |
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| pri  |                           |              |      |            |
| vate |                           |              |      |            |
| shar |                           |              |      |            |
| ehol |                           |              |      |            |
| ders |                           |              |      |            |
| or   |                           |              |      |            |
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| als. |                           |              |      |            |
|      |                           |              |      |            |
| (d)  |                           |              |      |            |
| A    |                           |              |      |            |
| c    |                           |              |      |            |
| erti |                           |              |      |            |
| fied |                           |              |      |            |
| copy |                           |              |      |            |
| of   |                           |              |      |            |
| the  |                           |              |      |            |
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| gani |                           |              |      |            |
| zati |                           |              |      |            |
| on's |                           |              |      |            |
| cer  |                           |              |      |            |
| tifi |                           |              |      |            |
| cate |                           |              |      |            |
| of   |                           |              |      |            |
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| ncor |                           |              |      |            |
| pora |                           |              |      |            |
| tion |                           |              |      |            |
| or   |                           |              |      |            |
| sim  |                           |              |      |            |
| ilar |                           |              |      |            |
| docu |                           |              |      |            |
| ment |                           |              |      |            |
| if   |                           |              |      |            |
| it   |                           |              |      |            |
| cle  |                           |              |      |            |
| arly |                           |              |      |            |
|      |                           |              |      |            |
| est  |                           |              |      |            |
| abli |                           |              |      |            |
| shes |                           |              |      |            |
| the  |                           |              |      |            |
| n    |                           |              |      |            |
| onpr |                           |              |      |            |
| ofit |                           |              |      |            |
| st   |                           |              |      |            |
| atus |                           |              |      |            |
| of   |                           |              |      |            |
| the  |                           |              |      |            |
| o    |                           |              |      |            |
| rgan |                           |              |      |            |
| izat |                           |              |      |            |
| ion. |                           |              |      |            |
|      |                           |              |      |            |
| (e)  |                           |              |      |            |
| Any  |                           |              |      |            |
| of   |                           |              |      |            |
| the  |                           |              |      |            |
| a    |                           |              |      |            |
| bove |                           |              |      |            |
| p    |                           |              |      |            |
| roof |                           |              |      |            |
| for  |                           |              |      |            |
| a    |                           |              |      |            |
| S    |                           |              |      |            |
| tate |                           |              |      |            |
| or   |                           |              |      |            |
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| pa   |                           |              |      |            |
| rent |                           |              |      |            |
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| rgan |                           |              |      |            |
| izat |                           |              |      |            |
| ion, |                           |              |      |            |
| and  |                           |              |      |            |
| a    |                           |              |      |            |
| s    |                           |              |      |            |
| tate |                           |              |      |            |
| ment |                           |              |      |            |
| si   |                           |              |      |            |
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| by   |                           |              |      |            |
| the  |                           |              |      |            |
| pa   |                           |              |      |            |
| rent |                           |              |      |            |
|      |                           |              |      |            |
| orga |                           |              |      |            |
| niza |                           |              |      |            |
| tion |                           |              |      |            |
| that |                           |              |      |            |
| the  |                           |              |      |            |
| a    |                           |              |      |            |
| ppli |                           |              |      |            |
| cant |                           |              |      |            |
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| l    |                           |              |      |            |
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| n    |                           |              |      |            |
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| ofit |                           |              |      |            |
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|      |                           |              |      |            |
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| an   |                           |              |      |            |
| a    |                           |              |      |            |
| ppli |                           |              |      |            |
| cant |                           |              |      |            |
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| evid |                           |              |      |            |
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| rent |                           |              |      |            |
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| file |                           |              |      |            |
| with |                           |              |      |            |
| an   |                           |              |      |            |
| ag   |                           |              |      |            |
| ency |                           |              |      |            |
| of   |                           |              |      |            |
| PHS, |                           |              |      |            |
| it   |                           |              |      |            |
| will |                           |              |      |            |
| not  |                           |              |      |            |
| be   |                           |              |      |            |
| n    |                           |              |      |            |
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| file |                           |              |      |            |
| sim  |                           |              |      |            |
| ilar |                           |              |      |            |
| pa   |                           |              |      |            |
| pers |                           |              |      |            |
| ag   |                           |              |      |            |
| ain, |                           |              |      |            |
| but  |                           |              |      |            |
| the  |                           |              |      |            |
| p    |                           |              |      |            |
| lace |                           |              |      |            |
| and  |                           |              |      |            |
| date |                           |              |      |            |
| of   |                           |              |      |            |
| fi   |                           |              |      |            |
| ling |                           |              |      |            |
| must |                           |              |      |            |
| be   |                           |              |      |            |
| in   |                           |              |      |            |
| dica |                           |              |      |            |
| ted. |                           |              |      |            |
|      |                           |              |      |            |
| Pr   |                           |              |      |            |
| evio |                           |              |      |            |
| usly |                           |              |      |            |
| F    |                           |              |      |            |
| iled |                           |              |      |            |
| w    |                           |              |      |            |
| ith: |                           |              |      |            |
| *(   |                           |              |      |            |
| Agen |                           |              |      |            |
| cy)* |                           |              |      |            |
| on   |                           |              |      |            |
| *(Da |                           |              |      |            |
| te)* |                           |              |      |            |
+------+---------------------------+--------------+------+------------+
|      |                           |              |      |            |
+------+---------------------------+--------------+------+------------+
|      |                           |              |      |            |
+------+---------------------------+--------------+------+------------+
| # IN |                           |              |      |            |
| VENT |                           |              |      |            |
| IONS |                           |              |      |            |
|      |                           |              |      |            |
| If   |                           |              |      |            |
| this |                           |              |      |            |
| is   |                           |              |      |            |
| an   |                           |              |      |            |
| app  |                           |              |      |            |
| lica |                           |              |      |            |
| tion |                           |              |      |            |
| for  |                           |              |      |            |
| c    |                           |              |      |            |
| onti |                           |              |      |            |
| nued |                           |              |      |            |
| supp |                           |              |      |            |
| ort, |                           |              |      |            |
| incl |                           |              |      |            |
| ude: |                           |              |      |            |
| (1)  |                           |              |      |            |
| the  |                           |              |      |            |
| re   |                           |              |      |            |
| port |                           |              |      |            |
| of   |                           |              |      |            |
| in   |                           |              |      |            |
| vent |                           |              |      |            |
| ions |                           |              |      |            |
| c    |                           |              |      |            |
| once |                           |              |      |            |
| ived |                           |              |      |            |
| or   |                           |              |      |            |
| red  |                           |              |      |            |
| uced |                           |              |      |            |
| to   |                           |              |      |            |
| prac |                           |              |      |            |
| tice |                           |              |      |            |
| requ |                           |              |      |            |
| ired |                           |              |      |            |
| by   |                           |              |      |            |
| the  |                           |              |      |            |
|      |                           |              |      |            |
| t    |                           |              |      |            |
| erms |                           |              |      |            |
| and  |                           |              |      |            |
| co   |                           |              |      |            |
| ndit |                           |              |      |            |
| ions |                           |              |      |            |
| of   |                           |              |      |            |
| the  |                           |              |      |            |
| gr   |                           |              |      |            |
| ant; |                           |              |      |            |
| or   |                           |              |      |            |
| (2)  |                           |              |      |            |
| a    |                           |              |      |            |
| list |                           |              |      |            |
| of   |                           |              |      |            |
| in   |                           |              |      |            |
| vent |                           |              |      |            |
| ions |                           |              |      |            |
| alr  |                           |              |      |            |
| eady |                           |              |      |            |
| r    |                           |              |      |            |
| epor |                           |              |      |            |
| ted, |                           |              |      |            |
| or   |                           |              |      |            |
| (3)  |                           |              |      |            |
| a    |                           |              |      |            |
| nega |                           |              |      |            |
| tive |                           |              |      |            |
| ce   |                           |              |      |            |
| rtif |                           |              |      |            |
| icat |                           |              |      |            |
| ion. |                           |              |      |            |
+------+---------------------------+--------------+------+------------+
| # E  |                           |              |      |            |
| XECU |                           |              |      |            |
| TIVE |                           |              |      |            |
|  ORD |                           |              |      |            |
| ER 1 |                           |              |      |            |
| 2372 |                           |              |      |            |
+------+---------------------------+--------------+------+------------+
| E    |                           | >            |      |            |
| ffec |                           | Department's |      |            |
| tive |                           | > programs   |      |            |
| S    |                           | > that are   |      |            |
| epte |                           | > subject to |      |            |
| mber |                           | > the        |      |            |
| 30,  |                           | > provisions |      |            |
| 1    |                           | > of         |      |            |
| 983, |                           | > Executive\ |      |            |
| E    |                           | > Order      |      |            |
| xecu |                           | > 12372.     |      |            |
| tive |                           | >            |      |            |
| O    |                           |  Information |      |            |
| rder |                           | > regarding  |      |            |
| 12   |                           | > PHS        |      |            |
| 372\ |                           | > programs   |      |            |
| (I   |                           | > subject    |      |            |
| nter |                           | > to\        |      |            |
| gove |                           | > Executive  |      |            |
| rnme |                           | > Order      |      |            |
| ntal |                           | > 12372 is   |      |            |
| Re   |                           | > also       |      |            |
| view |                           | > available  |      |            |
| of   |                           | > from the   |      |            |
| Fed  |                           | >            |      |            |
| eral |                           | appropriate\ |      |            |
| P    |                           | > awarding   |      |            |
| rogr |                           | > office.    |      |            |
| ams) |                           | >            |      |            |
| dire |                           | > States     |      |            |
| cted |                           | > p          |      |            |
| OMB  |                           | articipating |      |            |
| to\  |                           | > in this    |      |            |
| abo  |                           | > program    |      |            |
| lish |                           | > establish  |      |            |
| OMB  |                           | > State      |      |            |
| Circ |                           | > Single     |      |            |
| ular |                           | > Points of\ |      |            |
| A-95 |                           | > Contact    |      |            |
| and  |                           | > (SPOCs) to |      |            |
| e    |                           | > coordinate |      |            |
| stab |                           | > and manage |      |            |
| lish |                           | > the review |      |            |
| a    |                           | > and        |      |            |
| new  |                           | > comment\   |      |            |
| pro  |                           | > on         |      |            |
| cess |                           | > proposed   |      |            |
| for\ |                           | > Federal    |      |            |
| co   |                           | > financial  |      |            |
| nsul |                           | >            |      |            |
| ting |                           |  assistance. |      |            |
| with |                           | > Applicants |      |            |
| S    |                           | > should     |      |            |
| tate |                           | > contact\   |      |            |
| and  |                           | > the        |      |            |
| l    |                           | > Governor's |      |            |
| ocal |                           | > office for |      |            |
| ele  |                           | >            |      |            |
| cted |                           |  information |      |            |
| o    |                           | > regarding  |      |            |
| ffic |                           | > the SPOC,  |      |            |
| ials |                           | > programs\  |      |            |
| on   |                           | > selected   |      |            |
| prop |                           | > for        |      |            |
| osed |                           | > review,    |      |            |
| Fede |                           | > and the    |      |            |
| ral\ |                           | >            |      |            |
| f    |                           | consultation |      |            |
| inan |                           | > (review)   |      |            |
| cial |                           | > process    |      |            |
| ass  |                           | > designed   |      |            |
| ista |                           | > by\        |      |            |
| nce. |                           | > their      |      |            |
| The  |                           | > State.     |      |            |
| De   |                           | >            |      |            |
| part |                           | > Applicants |      |            |
| ment |                           | > are to     |      |            |
| of   |                           | > certify on |      |            |
| He   |                           | > the face   |      |            |
| alth |                           | > page of    |      |            |
| and  |                           | > the SF-424 |      |            |
| H    |                           | >            |      |            |
| uman |                           |  (attached)\ |      |            |
| S    |                           | > whether    |      |            |
| ervi |                           | > the        |      |            |
| ces\ |                           | > request is |      |            |
| imp  |                           | > for a      |      |            |
| leme |                           | > program    |      |            |
| nted |                           | > covered    |      |            |
| the  |                           | > under      |      |            |
| E    |                           | > Executive  |      |            |
| xecu |                           | > Order\     |      |            |
| tive |                           | > 12372 and, |      |            |
| O    |                           | > where      |      |            |
| rder |                           | >            |      |            |
| thr  |                           | appropriate, |      |            |
| ough |                           | > whether    |      |            |
| reg  |                           | > the State  |      |            |
| ulat |                           | > has been   |      |            |
| ions |                           | > given an\  |      |            |
| at   |                           | >            |      |            |
| 45   |                           |  opportunity |      |            |
| CFR  |                           | > to         |      |            |
| P    |                           | > comment.   |      |            |
| art\ |                           |              |      |            |
| 100  |                           | #            |      |            |
| (In  |                           |              |      |            |
| ter- |                           |              |      |            |
| gove |                           |              |      |            |
| rnme |                           |              |      |            |
| ntal |                           |              |      |            |
| Re   |                           |              |      |            |
| view |                           |              |      |            |
| of   |                           |              |      |            |
| De   |                           |              |      |            |
| part |                           |              |      |            |
| ment |                           |              |      |            |
| of   |                           |              |      |            |
| He   |                           |              |      |            |
| alth |                           |              |      |            |
| and  |                           |              |      |            |
| Hu   |                           |              |      |            |
| man\ |                           |              |      |            |
| Serv |                           |              |      |            |
| ices |                           |              |      |            |
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| ives |                           |              |      |            |
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| the  |                           |              |      |            |
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| ecut |                           |              |      |            |
| ive\ |                           |              |      |            |
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| are  |                           |              |      |            |
| to   |                           |              |      |            |
| (1)  |                           |              |      |            |
| incr |                           |              |      |            |
| ease |                           |              |      |            |
| S    |                           |              |      |            |
| tate |                           |              |      |            |
| fle  |                           |              |      |            |
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| lity |                           |              |      |            |
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| a    |                           |              |      |            |
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| onsu |                           |              |      |            |
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| ion\ |                           |              |      |            |
| pro  |                           |              |      |            |
| cess |                           |              |      |            |
| and  |                           |              |      |            |
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| lect |                           |              |      |            |
| the  |                           |              |      |            |
| prog |                           |              |      |            |
| rams |                           |              |      |            |
| it   |                           |              |      |            |
| wi   |                           |              |      |            |
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| rev  |                           |              |      |            |
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| (2)  |                           |              |      |            |
| incr |                           |              |      |            |
| ease |                           |              |      |            |
| the\ |                           |              |      |            |
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| and  |                           |              |      |            |
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| ocal |                           |              |      |            |
| ele  |                           |              |      |            |
| cted |                           |              |      |            |
| o    |                           |              |      |            |
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| ials |                           |              |      |            |
| to   |                           |              |      |            |
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| ral\ |                           |              |      |            |
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| ecis |                           |              |      |            |
| ions |                           |              |      |            |
| and  |                           |              |      |            |
| (3)  |                           |              |      |            |
| co   |                           |              |      |            |
| mpel |                           |              |      |            |
| Fed  |                           |              |      |            |
| eral |                           |              |      |            |
| o    |                           |              |      |            |
| ffic |                           |              |      |            |
| ials |                           |              |      |            |
| to   |                           |              |      |            |
| be   |                           |              |      |            |
| re   |                           |              |      |            |
| spon |                           |              |      |            |
| sive |                           |              |      |            |
| to   |                           |              |      |            |
| St   |                           |              |      |            |
| ate\ |                           |              |      |            |
| c    |                           |              |      |            |
| once |                           |              |      |            |
| rns, |                           |              |      |            |
| or   |                           |              |      |            |
| exp  |                           |              |      |            |
| lain |                           |              |      |            |
| the  |                           |              |      |            |
| reas |                           |              |      |            |
| ons. |                           |              |      |            |
|      |                           |              |      |            |
| The  |                           |              |      |            |
| reg  |                           |              |      |            |
| ulat |                           |              |      |            |
| ions |                           |              |      |            |
| at   |                           |              |      |            |
| 45   |                           |              |      |            |
| CFR  |                           |              |      |            |
| Part |                           |              |      |            |
| 100  |                           |              |      |            |
| were |                           |              |      |            |
| p    |                           |              |      |            |
| ubli |                           |              |      |            |
| shed |                           |              |      |            |
| in   |                           |              |      |            |
| the  |                           |              |      |            |
| *    |                           |              |      |            |
| Fede |                           |              |      |            |
| ral\ |                           |              |      |            |
| R    |                           |              |      |            |
| egis |                           |              |      |            |
| ter* |                           |              |      |            |
| on   |                           |              |      |            |
| June |                           |              |      |            |
| 24,  |                           |              |      |            |
| 1    |                           |              |      |            |
| 983, |                           |              |      |            |
| a    |                           |              |      |            |
| long |                           |              |      |            |
| with |                           |              |      |            |
| a    |                           |              |      |            |
| no   |                           |              |      |            |
| tice |                           |              |      |            |
| ide  |                           |              |      |            |
| ntif |                           |              |      |            |
| ying |                           |              |      |            |
| the  |                           |              |      |            |
+------+---------------------------+--------------+------+------------+

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="30"><p><strong>DISCLOSURE OF LOBBYING ACTIVITIES</strong>
Approved by OMB</p>
<p>0348-0046</p>
<p>Complete this form to disclose lobbying activities pursuant to 31
U.S.C. 1352</p>
<p>(See reverse for public burden disclosure.)</p></td>
</tr>
<tr class="even">
<td colspan="7"><strong>1. Type of Federal Action:</strong></td>
<td colspan="10"><strong>2. Status of Federal Action</strong></td>
<td colspan="13"><strong>3. Report Type:</strong></td>
</tr>
<tr class="odd">
<td></td>
<td> </td>
<td colspan="5" rowspan="4"><p>a. contract</p>
<p>b. grant</p>
<p>c. cooperative agreement</p>
<p>d. loan</p>
<p>e. loan guarantee</p>
<p>f. loan insurance</p></td>
<td></td>
<td colspan="2"> </td>
<td colspan="7" rowspan="4"><p>a. bid/offer/application</p>
<p>b. initial award</p>
<p>c. post-award</p></td>
<td></td>
<td colspan="2"> </td>
<td colspan="10"><p>a. initial filing</p>
<p>b. material change</p></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="3"></td>
<td colspan="3" rowspan="3"></td>
<td colspan="13"><strong>For Material Change Only:</strong></td>
</tr>
<tr class="odd">
<td colspan="5">Year</td>
<td colspan="3">     </td>
<td colspan="3">Quarter</td>
<td>     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="10">date of last report</td>
<td colspan="2">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td colspan="10"></td>
<td colspan="10"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="12"><strong>4. Name and Address of Reporting
Entity:</strong></td>
<td colspan="18"><p><strong>5. If Reporting Entity in No. 4 is
Subawardee, Enter Name and</strong></p>
<p><strong>Address of Prime:</strong></p></td>
</tr>
<tr class="odd">
<td colspan="12"> Prime Subawardee</td>
<td colspan="18" rowspan="5">     </td>
</tr>
<tr class="even">
<td colspan="4">Tier</td>
<td colspan="2">     </td>
<td colspan="3">, if known:</td>
<td colspan="2">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="12" rowspan="3">     </td>
</tr>
<tr class="even">
</tr>
<tr class="odd">
</tr>
<tr class="even">
<td colspan="5"><strong>Congressional Distric</strong>t, <em>if
known:</em></td>
<td colspan="6">     </td>
<td></td>
<td colspan="12"><strong>Congressional Distric</strong>t, <em>if
known:</em></td>
<td colspan="5">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="12"></td>
<td colspan="18"></td>
</tr>
<tr class="even">
<td colspan="12"><strong>6. Federal Department/Agency:</strong></td>
<td colspan="18"><strong>7. Federal Program
Name/Description:</strong></td>
</tr>
<tr class="odd">
<td colspan="12" rowspan="2">     </td>
<td colspan="18">     </td>
</tr>
<tr class="even">
<td colspan="9"><strong>CFDA Numbe</strong>r, <em>if
applicable:</em></td>
<td colspan="8">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="12"></td>
<td colspan="9"></td>
<td colspan="8"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="12"><strong>8. Federal Action Number,</strong> if
known:</td>
<td colspan="17"><strong>9. Award Amount,</strong> if known:</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="12">     </td>
<td colspan="18">$      </td>
</tr>
<tr class="even">
<td colspan="12"><p><strong>10. a. Name and Address of Lobbying
Entity</strong></p>
<p><em>(if individual, last name, first name, MI):</em></p></td>
<td colspan="18"><p><strong>b. Individuals Performing Service</strong>s
<em>(including address if different</em></p>
<p><em>from No. 10a.) (last name, first name, MI):</em></p></td>
</tr>
<tr class="odd">
<td colspan="12">     </td>
<td colspan="18">     </td>
</tr>
<tr class="even">
<td colspan="12" rowspan="5"><strong>11. Information requested through
this form is authorized by<br />
title 31 U.S.C. section 1352. This disclosure of lobbying<br />
activities is a material representation of fact upon which<br />
reliance was placed by the tier above when this transaction<br />
was made or entered into. This disclosure is required<br />
pursuant to 31 U.S.C. 1352. This information will be reported<br />
to the Congress semi-annually and will be available for<br />
public inspection. Any person who fails to file the required<br />
disclosure shall be subject to a civil penalty of not less than<br />
$10,000 and not more than $100,000 for each such failure.</strong></td>
<td colspan="2"><strong>Signature:</strong></td>
<td colspan="15"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Print Name:</strong></td>
<td colspan="14">     </td>
<td></td>
</tr>
<tr class="even">
<td><strong>Title:</strong></td>
<td colspan="16">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Telephone No.:</strong></td>
<td colspan="7">     </td>
<td colspan="3"><strong>Date:</strong></td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="17"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>F</strong><strong>ederal Use Only:</strong></td>
<td colspan="16">     </td>
<td colspan="10"><p>Authorized for Local Reproduction</p>
<p>Standard Form - LLL (Rev. 7-97)</p></td>
<td></td>
</tr>
</tbody>
</table>

+----------+---------------------------------+---+---+-------+---+------+---+
| **INST   |                                 |   |   |       |   |      |   |
| RUCTIONS |                                 |   |   |       |   |      |   |
| FOR      |                                 |   |   |       |   |      |   |
| CO       |                                 |   |   |       |   |      |   |
| MPLETION |                                 |   |   |       |   |      |   |
| OF       |                                 |   |   |       |   |      |   |
| SF-LLL,  |                                 |   |   |       |   |      |   |
| DI       |                                 |   |   |       |   |      |   |
| SCLOSURE |                                 |   |   |       |   |      |   |
| OF       |                                 |   |   |       |   |      |   |
| LOBBYING |                                 |   |   |       |   |      |   |
| ACTI     |                                 |   |   |       |   |      |   |
| VITIES** |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| This     |                                 |   |   |       |   |      |   |
| di       |                                 |   |   |       |   |      |   |
| sclosure |                                 |   |   |       |   |      |   |
| form     |                                 |   |   |       |   |      |   |
| shall be |                                 |   |   |       |   |      |   |
| c        |                                 |   |   |       |   |      |   |
| ompleted |                                 |   |   |       |   |      |   |
| by the   |                                 |   |   |       |   |      |   |
| r        |                                 |   |   |       |   |      |   |
| eporting |                                 |   |   |       |   |      |   |
| entity,  |                                 |   |   |       |   |      |   |
| whether  |                                 |   |   |       |   |      |   |
| su       |                                 |   |   |       |   |      |   |
| bawardee |                                 |   |   |       |   |      |   |
| or prime |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| re       |                                 |   |   |       |   |      |   |
| cipient, |                                 |   |   |       |   |      |   |
| at the\  |                                 |   |   |       |   |      |   |
| in       |                                 |   |   |       |   |      |   |
| itiation |                                 |   |   |       |   |      |   |
| or       |                                 |   |   |       |   |      |   |
| receipt  |                                 |   |   |       |   |      |   |
| of a     |                                 |   |   |       |   |      |   |
| covered  |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| action,  |                                 |   |   |       |   |      |   |
| or a     |                                 |   |   |       |   |      |   |
| material |                                 |   |   |       |   |      |   |
| change   |                                 |   |   |       |   |      |   |
| to a     |                                 |   |   |       |   |      |   |
| previous |                                 |   |   |       |   |      |   |
| filing,  |                                 |   |   |       |   |      |   |
| pursuant |                                 |   |   |       |   |      |   |
| to title |                                 |   |   |       |   |      |   |
| 31       |                                 |   |   |       |   |      |   |
| U.S.C.   |                                 |   |   |       |   |      |   |
| Section  |                                 |   |   |       |   |      |   |
| 1352.    |                                 |   |   |       |   |      |   |
| The      |                                 |   |   |       |   |      |   |
| filing   |                                 |   |   |       |   |      |   |
| of a     |                                 |   |   |       |   |      |   |
| form is  |                                 |   |   |       |   |      |   |
| required |                                 |   |   |       |   |      |   |
| for each |                                 |   |   |       |   |      |   |
| payment  |                                 |   |   |       |   |      |   |
| or       |                                 |   |   |       |   |      |   |
| a        |                                 |   |   |       |   |      |   |
| greement |                                 |   |   |       |   |      |   |
| to make  |                                 |   |   |       |   |      |   |
| payment  |                                 |   |   |       |   |      |   |
| to any   |                                 |   |   |       |   |      |   |
| lobbying |                                 |   |   |       |   |      |   |
| entity   |                                 |   |   |       |   |      |   |
| for      |                                 |   |   |       |   |      |   |
| inf      |                                 |   |   |       |   |      |   |
| luencing |                                 |   |   |       |   |      |   |
| or       |                                 |   |   |       |   |      |   |
| at       |                                 |   |   |       |   |      |   |
| tempting |                                 |   |   |       |   |      |   |
| to       |                                 |   |   |       |   |      |   |
| i        |                                 |   |   |       |   |      |   |
| nfluence |                                 |   |   |       |   |      |   |
| an       |                                 |   |   |       |   |      |   |
| officer  |                                 |   |   |       |   |      |   |
| or       |                                 |   |   |       |   |      |   |
| employee |                                 |   |   |       |   |      |   |
| of any   |                                 |   |   |       |   |      |   |
| agency,  |                                 |   |   |       |   |      |   |
| a Member |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| C        |                                 |   |   |       |   |      |   |
| ongress, |                                 |   |   |       |   |      |   |
| an       |                                 |   |   |       |   |      |   |
| officer  |                                 |   |   |       |   |      |   |
| or       |                                 |   |   |       |   |      |   |
| employee |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| C        |                                 |   |   |       |   |      |   |
| ongress, |                                 |   |   |       |   |      |   |
| or an    |                                 |   |   |       |   |      |   |
| employee |                                 |   |   |       |   |      |   |
| of a     |                                 |   |   |       |   |      |   |
| Member   |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| Congress |                                 |   |   |       |   |      |   |
| in       |                                 |   |   |       |   |      |   |
| co       |                                 |   |   |       |   |      |   |
| nnection |                                 |   |   |       |   |      |   |
| with a   |                                 |   |   |       |   |      |   |
| covered  |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| action.  |                                 |   |   |       |   |      |   |
| Use the  |                                 |   |   |       |   |      |   |
| SF-LLL-A |                                 |   |   |       |   |      |   |
| Cont     |                                 |   |   |       |   |      |   |
| inuation |                                 |   |   |       |   |      |   |
| Sheet    |                                 |   |   |       |   |      |   |
| for      |                                 |   |   |       |   |      |   |
| ad       |                                 |   |   |       |   |      |   |
| ditional |                                 |   |   |       |   |      |   |
| inf      |                                 |   |   |       |   |      |   |
| ormation |                                 |   |   |       |   |      |   |
| if the   |                                 |   |   |       |   |      |   |
| space on |                                 |   |   |       |   |      |   |
| the form |                                 |   |   |       |   |      |   |
| is       |                                 |   |   |       |   |      |   |
| ina      |                                 |   |   |       |   |      |   |
| dequate. |                                 |   |   |       |   |      |   |
| Complete |                                 |   |   |       |   |      |   |
| all      |                                 |   |   |       |   |      |   |
| items    |                                 |   |   |       |   |      |   |
| that     |                                 |   |   |       |   |      |   |
| apply    |                                 |   |   |       |   |      |   |
| for both |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| initial  |                                 |   |   |       |   |      |   |
| filing   |                                 |   |   |       |   |      |   |
| and      |                                 |   |   |       |   |      |   |
| material |                                 |   |   |       |   |      |   |
| change   |                                 |   |   |       |   |      |   |
| report.  |                                 |   |   |       |   |      |   |
| Refer to |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| impl     |                                 |   |   |       |   |      |   |
| ementing |                                 |   |   |       |   |      |   |
| guidance |                                 |   |   |       |   |      |   |
| p        |                                 |   |   |       |   |      |   |
| ublished |                                 |   |   |       |   |      |   |
| by the   |                                 |   |   |       |   |      |   |
| Office   |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| Ma       |                                 |   |   |       |   |      |   |
| nagement |                                 |   |   |       |   |      |   |
| and      |                                 |   |   |       |   |      |   |
| Budget   |                                 |   |   |       |   |      |   |
| for      |                                 |   |   |       |   |      |   |
| ad       |                                 |   |   |       |   |      |   |
| ditional |                                 |   |   |       |   |      |   |
| info     |                                 |   |   |       |   |      |   |
| rmation. |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| 1\.      |                                 |   |   |       |   |      |   |
| Identify |                                 |   |   |       |   |      |   |
| the type |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| covered  |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| action   |                                 |   |   |       |   |      |   |
| for      |                                 |   |   |       |   |      |   |
| which    |                                 |   |   |       |   |      |   |
| lobbying |                                 |   |   |       |   |      |   |
| activity |                                 |   |   |       |   |      |   |
| is       |                                 |   |   |       |   |      |   |
| and/or   |                                 |   |   |       |   |      |   |
| has been |                                 |   |   |       |   |      |   |
| secured  |                                 |   |   |       |   |      |   |
| to       |                                 |   |   |       |   |      |   |
| i        |                                 |   |   |       |   |      |   |
| nfluence |                                 |   |   |       |   |      |   |
| the\     |                                 |   |   |       |   |      |   |
| outcome  |                                 |   |   |       |   |      |   |
| of a     |                                 |   |   |       |   |      |   |
| covered  |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| action.  |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| 2\.      |                                 |   |   |       |   |      |   |
| Identify |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| status   |                                 |   |   |       |   |      |   |
| of the   |                                 |   |   |       |   |      |   |
| covered  |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| action.  |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| 3\.      |                                 |   |   |       |   |      |   |
| Identify |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| app      |                                 |   |   |       |   |      |   |
| ropriate |                                 |   |   |       |   |      |   |
| classi   |                                 |   |   |       |   |      |   |
| fication |                                 |   |   |       |   |      |   |
| of this  |                                 |   |   |       |   |      |   |
| report.  |                                 |   |   |       |   |      |   |
| If this  |                                 |   |   |       |   |      |   |
| is a     |                                 |   |   |       |   |      |   |
| f        |                                 |   |   |       |   |      |   |
| ollow-up |                                 |   |   |       |   |      |   |
| report   |                                 |   |   |       |   |      |   |
| caused   |                                 |   |   |       |   |      |   |
| by a     |                                 |   |   |       |   |      |   |
| material |                                 |   |   |       |   |      |   |
| change   |                                 |   |   |       |   |      |   |
| to the\  |                                 |   |   |       |   |      |   |
| inf      |                                 |   |   |       |   |      |   |
| ormation |                                 |   |   |       |   |      |   |
| pr       |                                 |   |   |       |   |      |   |
| eviously |                                 |   |   |       |   |      |   |
| r        |                                 |   |   |       |   |      |   |
| eported, |                                 |   |   |       |   |      |   |
| enter    |                                 |   |   |       |   |      |   |
| the year |                                 |   |   |       |   |      |   |
| and      |                                 |   |   |       |   |      |   |
| quarter  |                                 |   |   |       |   |      |   |
| in which |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| change   |                                 |   |   |       |   |      |   |
| o        |                                 |   |   |       |   |      |   |
| ccurred. |                                 |   |   |       |   |      |   |
| Enter    |                                 |   |   |       |   |      |   |
| the date |                                 |   |   |       |   |      |   |
| of the   |                                 |   |   |       |   |      |   |
| last     |                                 |   |   |       |   |      |   |
| pr       |                                 |   |   |       |   |      |   |
| eviously |                                 |   |   |       |   |      |   |
| s        |                                 |   |   |       |   |      |   |
| ubmitted |                                 |   |   |       |   |      |   |
| report   |                                 |   |   |       |   |      |   |
| by this  |                                 |   |   |       |   |      |   |
| r        |                                 |   |   |       |   |      |   |
| eporting |                                 |   |   |       |   |      |   |
| entity   |                                 |   |   |       |   |      |   |
| for this |                                 |   |   |       |   |      |   |
| covered  |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| action.  |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| 4\.      |                                 |   |   |       |   |      |   |
| Enter    |                                 |   |   |       |   |      |   |
| the full |                                 |   |   |       |   |      |   |
| name,    |                                 |   |   |       |   |      |   |
| address, |                                 |   |   |       |   |      |   |
| city,    |                                 |   |   |       |   |      |   |
| state    |                                 |   |   |       |   |      |   |
| and zip  |                                 |   |   |       |   |      |   |
| code of  |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| r        |                                 |   |   |       |   |      |   |
| eporting |                                 |   |   |       |   |      |   |
| entity.  |                                 |   |   |       |   |      |   |
| Include  |                                 |   |   |       |   |      |   |
| Congr    |                                 |   |   |       |   |      |   |
| essional |                                 |   |   |       |   |      |   |
| D        |                                 |   |   |       |   |      |   |
| istrict, |                                 |   |   |       |   |      |   |
| if       |                                 |   |   |       |   |      |   |
| known.   |                                 |   |   |       |   |      |   |
| Check    |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| app      |                                 |   |   |       |   |      |   |
| ropriate |                                 |   |   |       |   |      |   |
| classi   |                                 |   |   |       |   |      |   |
| fication |                                 |   |   |       |   |      |   |
| of the   |                                 |   |   |       |   |      |   |
| r        |                                 |   |   |       |   |      |   |
| eporting |                                 |   |   |       |   |      |   |
| entity   |                                 |   |   |       |   |      |   |
| that     |                                 |   |   |       |   |      |   |
| de       |                                 |   |   |       |   |      |   |
| signates |                                 |   |   |       |   |      |   |
| if it    |                                 |   |   |       |   |      |   |
| is, or   |                                 |   |   |       |   |      |   |
| expects  |                                 |   |   |       |   |      |   |
| to be, a |                                 |   |   |       |   |      |   |
| prime or |                                 |   |   |       |   |      |   |
| subaward |                                 |   |   |       |   |      |   |
| re       |                                 |   |   |       |   |      |   |
| cipient. |                                 |   |   |       |   |      |   |
| Identify |                                 |   |   |       |   |      |   |
| the tier |                                 |   |   |       |   |      |   |
| of the   |                                 |   |   |       |   |      |   |
| sub      |                                 |   |   |       |   |      |   |
| awardee, |                                 |   |   |       |   |      |   |
| e.g.,    |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| first    |                                 |   |   |       |   |      |   |
| su       |                                 |   |   |       |   |      |   |
| bawardee |                                 |   |   |       |   |      |   |
| of the   |                                 |   |   |       |   |      |   |
| prime is |                                 |   |   |       |   |      |   |
| the 1st  |                                 |   |   |       |   |      |   |
| tier.\   |                                 |   |   |       |   |      |   |
| S        |                                 |   |   |       |   |      |   |
| ubawards |                                 |   |   |       |   |      |   |
| include  |                                 |   |   |       |   |      |   |
| but are  |                                 |   |   |       |   |      |   |
| not      |                                 |   |   |       |   |      |   |
| limited  |                                 |   |   |       |   |      |   |
| to       |                                 |   |   |       |   |      |   |
| subco    |                                 |   |   |       |   |      |   |
| ntracts, |                                 |   |   |       |   |      |   |
| s        |                                 |   |   |       |   |      |   |
| ubgrants |                                 |   |   |       |   |      |   |
| and      |                                 |   |   |       |   |      |   |
| contract |                                 |   |   |       |   |      |   |
| awards   |                                 |   |   |       |   |      |   |
| under    |                                 |   |   |       |   |      |   |
| grants.  |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| 5\. If   |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| orga     |                                 |   |   |       |   |      |   |
| nization |                                 |   |   |       |   |      |   |
| filing   |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| report   |                                 |   |   |       |   |      |   |
| in item  |                                 |   |   |       |   |      |   |
| 4 checks |                                 |   |   |       |   |      |   |
| \"subaw  |                                 |   |   |       |   |      |   |
| ardee\", |                                 |   |   |       |   |      |   |
| then     |                                 |   |   |       |   |      |   |
| enter    |                                 |   |   |       |   |      |   |
| the full |                                 |   |   |       |   |      |   |
| name,    |                                 |   |   |       |   |      |   |
| address, |                                 |   |   |       |   |      |   |
| city,    |                                 |   |   |       |   |      |   |
| state    |                                 |   |   |       |   |      |   |
| and zip  |                                 |   |   |       |   |      |   |
| code of  |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| prime    |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| re       |                                 |   |   |       |   |      |   |
| cipient. |                                 |   |   |       |   |      |   |
| Include  |                                 |   |   |       |   |      |   |
| Congr    |                                 |   |   |       |   |      |   |
| essional |                                 |   |   |       |   |      |   |
| D        |                                 |   |   |       |   |      |   |
| istrict, |                                 |   |   |       |   |      |   |
| if       |                                 |   |   |       |   |      |   |
| known.   |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| 6\.      |                                 |   |   |       |   |      |   |
| Enter    |                                 |   |   |       |   |      |   |
| the name |                                 |   |   |       |   |      |   |
| of the   |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| agency   |                                 |   |   |       |   |      |   |
| making   |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| award or |                                 |   |   |       |   |      |   |
| loan     |                                 |   |   |       |   |      |   |
| com      |                                 |   |   |       |   |      |   |
| mitment. |                                 |   |   |       |   |      |   |
| Include  |                                 |   |   |       |   |      |   |
| at least |                                 |   |   |       |   |      |   |
| one      |                                 |   |   |       |   |      |   |
| organi   |                                 |   |   |       |   |      |   |
| zational |                                 |   |   |       |   |      |   |
| level    |                                 |   |   |       |   |      |   |
| below    |                                 |   |   |       |   |      |   |
| agency   |                                 |   |   |       |   |      |   |
| name, if |                                 |   |   |       |   |      |   |
| known.   |                                 |   |   |       |   |      |   |
| For      |                                 |   |   |       |   |      |   |
| example, |                                 |   |   |       |   |      |   |
| De       |                                 |   |   |       |   |      |   |
| partment |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| Transpo  |                                 |   |   |       |   |      |   |
| rtation, |                                 |   |   |       |   |      |   |
| United   |                                 |   |   |       |   |      |   |
| States   |                                 |   |   |       |   |      |   |
| Coast    |                                 |   |   |       |   |      |   |
| Guard.   |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| 7\.      |                                 |   |   |       |   |      |   |
| Enter    |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| program  |                                 |   |   |       |   |      |   |
| name or  |                                 |   |   |       |   |      |   |
| des      |                                 |   |   |       |   |      |   |
| cription |                                 |   |   |       |   |      |   |
| for the  |                                 |   |   |       |   |      |   |
| covered  |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| action   |                                 |   |   |       |   |      |   |
| (item    |                                 |   |   |       |   |      |   |
| 1). If   |                                 |   |   |       |   |      |   |
| known,   |                                 |   |   |       |   |      |   |
| enter    |                                 |   |   |       |   |      |   |
| the full |                                 |   |   |       |   |      |   |
| Catalog  |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| Domestic |                                 |   |   |       |   |      |   |
| As       |                                 |   |   |       |   |      |   |
| sistance |                                 |   |   |       |   |      |   |
| (CFDA)   |                                 |   |   |       |   |      |   |
| number   |                                 |   |   |       |   |      |   |
| for      |                                 |   |   |       |   |      |   |
| grants,  |                                 |   |   |       |   |      |   |
| coo      |                                 |   |   |       |   |      |   |
| perative |                                 |   |   |       |   |      |   |
| agr      |                                 |   |   |       |   |      |   |
| eements, |                                 |   |   |       |   |      |   |
| loans,   |                                 |   |   |       |   |      |   |
| and loan |                                 |   |   |       |   |      |   |
| comm     |                                 |   |   |       |   |      |   |
| itments. |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| 8\.      |                                 |   |   |       |   |      |   |
| Enter    |                                 |   |   |       |   |      |   |
| the most |                                 |   |   |       |   |      |   |
| app      |                                 |   |   |       |   |      |   |
| ropriate |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| ide      |                                 |   |   |       |   |      |   |
| ntifying |                                 |   |   |       |   |      |   |
| number   |                                 |   |   |       |   |      |   |
| a        |                                 |   |   |       |   |      |   |
| vailable |                                 |   |   |       |   |      |   |
| for the  |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| action   |                                 |   |   |       |   |      |   |
| id       |                                 |   |   |       |   |      |   |
| entified |                                 |   |   |       |   |      |   |
| in item  |                                 |   |   |       |   |      |   |
| 1        |                                 |   |   |       |   |      |   |
| \[e.g.,\ |                                 |   |   |       |   |      |   |
| Request  |                                 |   |   |       |   |      |   |
| for      |                                 |   |   |       |   |      |   |
| Proposal |                                 |   |   |       |   |      |   |
| (RFP)    |                                 |   |   |       |   |      |   |
| number;  |                                 |   |   |       |   |      |   |
| In       |                                 |   |   |       |   |      |   |
| vitation |                                 |   |   |       |   |      |   |
| for Bid  |                                 |   |   |       |   |      |   |
| (IFB)    |                                 |   |   |       |   |      |   |
| number;  |                                 |   |   |       |   |      |   |
| grant    |                                 |   |   |       |   |      |   |
| anno     |                                 |   |   |       |   |      |   |
| uncement |                                 |   |   |       |   |      |   |
| number;  |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| co       |                                 |   |   |       |   |      |   |
| ntract,\ |                                 |   |   |       |   |      |   |
| grant,   |                                 |   |   |       |   |      |   |
| or loan  |                                 |   |   |       |   |      |   |
| award    |                                 |   |   |       |   |      |   |
| number;  |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| appl     |                                 |   |   |       |   |      |   |
| ication/ |                                 |   |   |       |   |      |   |
| proposal |                                 |   |   |       |   |      |   |
| control  |                                 |   |   |       |   |      |   |
| number   |                                 |   |   |       |   |      |   |
| assigned |                                 |   |   |       |   |      |   |
| by the   |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| a        |                                 |   |   |       |   |      |   |
| gency\]. |                                 |   |   |       |   |      |   |
| Include\ |                                 |   |   |       |   |      |   |
| p        |                                 |   |   |       |   |      |   |
| refixes, |                                 |   |   |       |   |      |   |
| e.g.,    |                                 |   |   |       |   |      |   |
| ''       |                                 |   |   |       |   |      |   |
| RFP-DE-9 |                                 |   |   |       |   |      |   |
| 0-001.'' |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| 9\. For  |                                 |   |   |       |   |      |   |
| a        |                                 |   |   |       |   |      |   |
| covered  |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| action   |                                 |   |   |       |   |      |   |
| where    |                                 |   |   |       |   |      |   |
| there    |                                 |   |   |       |   |      |   |
| has been |                                 |   |   |       |   |      |   |
| an award |                                 |   |   |       |   |      |   |
| or loan  |                                 |   |   |       |   |      |   |
| co       |                                 |   |   |       |   |      |   |
| mmitment |                                 |   |   |       |   |      |   |
| by the   |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| agency,  |                                 |   |   |       |   |      |   |
| enter    |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| amount   |                                 |   |   |       |   |      |   |
| of the   |                                 |   |   |       |   |      |   |
| aw       |                                 |   |   |       |   |      |   |
| ard/loan |                                 |   |   |       |   |      |   |
| co       |                                 |   |   |       |   |      |   |
| mmitment |                                 |   |   |       |   |      |   |
| for the  |                                 |   |   |       |   |      |   |
| prime    |                                 |   |   |       |   |      |   |
| entity   |                                 |   |   |       |   |      |   |
| id       |                                 |   |   |       |   |      |   |
| entified |                                 |   |   |       |   |      |   |
| in item  |                                 |   |   |       |   |      |   |
| 4 or 5.  |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| 10\. (a) |                                 |   |   |       |   |      |   |
| Enter    |                                 |   |   |       |   |      |   |
| the full |                                 |   |   |       |   |      |   |
| name,    |                                 |   |   |       |   |      |   |
| address, |                                 |   |   |       |   |      |   |
| city,    |                                 |   |   |       |   |      |   |
| state    |                                 |   |   |       |   |      |   |
| and zip  |                                 |   |   |       |   |      |   |
| code of  |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| lobbying |                                 |   |   |       |   |      |   |
| entity   |                                 |   |   |       |   |      |   |
| engaged  |                                 |   |   |       |   |      |   |
| by the   |                                 |   |   |       |   |      |   |
| r        |                                 |   |   |       |   |      |   |
| eporting |                                 |   |   |       |   |      |   |
| entity\  |                                 |   |   |       |   |      |   |
| id       |                                 |   |   |       |   |      |   |
| entified |                                 |   |   |       |   |      |   |
| in item  |                                 |   |   |       |   |      |   |
| 4 to     |                                 |   |   |       |   |      |   |
| i        |                                 |   |   |       |   |      |   |
| nfluence |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| covered  |                                 |   |   |       |   |      |   |
| Federal  |                                 |   |   |       |   |      |   |
| action.  |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| \(b\)    |                                 |   |   |       |   |      |   |
| Enter    |                                 |   |   |       |   |      |   |
| the full |                                 |   |   |       |   |      |   |
| names of |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| indiv    |                                 |   |   |       |   |      |   |
| idual(s) |                                 |   |   |       |   |      |   |
| pe       |                                 |   |   |       |   |      |   |
| rforming |                                 |   |   |       |   |      |   |
| s        |                                 |   |   |       |   |      |   |
| ervices, |                                 |   |   |       |   |      |   |
| and      |                                 |   |   |       |   |      |   |
| include  |                                 |   |   |       |   |      |   |
| full     |                                 |   |   |       |   |      |   |
| address  |                                 |   |   |       |   |      |   |
| if       |                                 |   |   |       |   |      |   |
| d        |                                 |   |   |       |   |      |   |
| ifferent |                                 |   |   |       |   |      |   |
| from     |                                 |   |   |       |   |      |   |
| 10(a).   |                                 |   |   |       |   |      |   |
| Enter    |                                 |   |   |       |   |      |   |
| Last     |                                 |   |   |       |   |      |   |
| Name,    |                                 |   |   |       |   |      |   |
| First    |                                 |   |   |       |   |      |   |
| Name,    |                                 |   |   |       |   |      |   |
| and      |                                 |   |   |       |   |      |   |
| Middle   |                                 |   |   |       |   |      |   |
| Initial  |                                 |   |   |       |   |      |   |
| (MI).    |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| 11\.     |                                 |   |   |       |   |      |   |
| Enter    |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| amount   |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| comp     |                                 |   |   |       |   |      |   |
| ensation |                                 |   |   |       |   |      |   |
| paid or  |                                 |   |   |       |   |      |   |
| re       |                                 |   |   |       |   |      |   |
| asonably |                                 |   |   |       |   |      |   |
| expected |                                 |   |   |       |   |      |   |
| to be    |                                 |   |   |       |   |      |   |
| paid by  |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| r        |                                 |   |   |       |   |      |   |
| eporting |                                 |   |   |       |   |      |   |
| entity   |                                 |   |   |       |   |      |   |
| (item 4) |                                 |   |   |       |   |      |   |
| to the\  |                                 |   |   |       |   |      |   |
| lobbying |                                 |   |   |       |   |      |   |
| entity   |                                 |   |   |       |   |      |   |
| (item    |                                 |   |   |       |   |      |   |
| 10).     |                                 |   |   |       |   |      |   |
| Indicate |                                 |   |   |       |   |      |   |
| whether  |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| payment  |                                 |   |   |       |   |      |   |
| has been |                                 |   |   |       |   |      |   |
| made     |                                 |   |   |       |   |      |   |
| (actual) |                                 |   |   |       |   |      |   |
| or will  |                                 |   |   |       |   |      |   |
| be made  |                                 |   |   |       |   |      |   |
| (p       |                                 |   |   |       |   |      |   |
| lanned). |                                 |   |   |       |   |      |   |
| Check    |                                 |   |   |       |   |      |   |
| all      |                                 |   |   |       |   |      |   |
| boxes    |                                 |   |   |       |   |      |   |
| that     |                                 |   |   |       |   |      |   |
| apply.   |                                 |   |   |       |   |      |   |
| If this  |                                 |   |   |       |   |      |   |
| is a     |                                 |   |   |       |   |      |   |
| material |                                 |   |   |       |   |      |   |
| change   |                                 |   |   |       |   |      |   |
| report,  |                                 |   |   |       |   |      |   |
| enter    |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| cu       |                                 |   |   |       |   |      |   |
| mulative |                                 |   |   |       |   |      |   |
| amount   |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| payment  |                                 |   |   |       |   |      |   |
| made or  |                                 |   |   |       |   |      |   |
| planned  |                                 |   |   |       |   |      |   |
| to be    |                                 |   |   |       |   |      |   |
| made.    |                                 |   |   |       |   |      |   |
+----------+---------------------------------+---+---+-------+---+------+---+
| A        |                                 |   |   |       |   |      |   |
| ccording |                                 |   |   |       |   |      |   |
| to the   |                                 |   |   |       |   |      |   |
| P        |                                 |   |   |       |   |      |   |
| aperwork |                                 |   |   |       |   |      |   |
| R        |                                 |   |   |       |   |      |   |
| eduction |                                 |   |   |       |   |      |   |
| Act, as  |                                 |   |   |       |   |      |   |
| amended, |                                 |   |   |       |   |      |   |
| no       |                                 |   |   |       |   |      |   |
| persons  |                                 |   |   |       |   |      |   |
| are      |                                 |   |   |       |   |      |   |
| required |                                 |   |   |       |   |      |   |
| to       |                                 |   |   |       |   |      |   |
| respond  |                                 |   |   |       |   |      |   |
| to a     |                                 |   |   |       |   |      |   |
| co       |                                 |   |   |       |   |      |   |
| llection |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| inf      |                                 |   |   |       |   |      |   |
| ormation |                                 |   |   |       |   |      |   |
| unless   |                                 |   |   |       |   |      |   |
| it       |                                 |   |   |       |   |      |   |
| displays |                                 |   |   |       |   |      |   |
| a valid  |                                 |   |   |       |   |      |   |
| OMB      |                                 |   |   |       |   |      |   |
| Control  |                                 |   |   |       |   |      |   |
| Number.  |                                 |   |   |       |   |      |   |
| The      |                                 |   |   |       |   |      |   |
| valid    |                                 |   |   |       |   |      |   |
| OMB      |                                 |   |   |       |   |      |   |
| control  |                                 |   |   |       |   |      |   |
| number   |                                 |   |   |       |   |      |   |
| for this |                                 |   |   |       |   |      |   |
| inf      |                                 |   |   |       |   |      |   |
| ormation |                                 |   |   |       |   |      |   |
| co       |                                 |   |   |       |   |      |   |
| llection |                                 |   |   |       |   |      |   |
| is OMB   |                                 |   |   |       |   |      |   |
| No.03    |                                 |   |   |       |   |      |   |
| 48-0046. |                                 |   |   |       |   |      |   |
| Public   |                                 |   |   |       |   |      |   |
| r        |                                 |   |   |       |   |      |   |
| eporting |                                 |   |   |       |   |      |   |
| burden   |                                 |   |   |       |   |      |   |
| for this |                                 |   |   |       |   |      |   |
| co       |                                 |   |   |       |   |      |   |
| llection |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| inf      |                                 |   |   |       |   |      |   |
| ormation |                                 |   |   |       |   |      |   |
| is       |                                 |   |   |       |   |      |   |
| e        |                                 |   |   |       |   |      |   |
| stimated |                                 |   |   |       |   |      |   |
| to       |                                 |   |   |       |   |      |   |
| average  |                                 |   |   |       |   |      |   |
| 10       |                                 |   |   |       |   |      |   |
| minutes  |                                 |   |   |       |   |      |   |
| per      |                                 |   |   |       |   |      |   |
| r        |                                 |   |   |       |   |      |   |
| esponse, |                                 |   |   |       |   |      |   |
| i        |                                 |   |   |       |   |      |   |
| ncluding |                                 |   |   |       |   |      |   |
| time for |                                 |   |   |       |   |      |   |
| r        |                                 |   |   |       |   |      |   |
| eviewing |                                 |   |   |       |   |      |   |
| instr    |                                 |   |   |       |   |      |   |
| uctions, |                                 |   |   |       |   |      |   |
| s        |                                 |   |   |       |   |      |   |
| earching |                                 |   |   |       |   |      |   |
| existing |                                 |   |   |       |   |      |   |
| data     |                                 |   |   |       |   |      |   |
| sources, |                                 |   |   |       |   |      |   |
| g        |                                 |   |   |       |   |      |   |
| athering |                                 |   |   |       |   |      |   |
| and      |                                 |   |   |       |   |      |   |
| mai      |                                 |   |   |       |   |      |   |
| ntaining |                                 |   |   |       |   |      |   |
| the data |                                 |   |   |       |   |      |   |
| needed,  |                                 |   |   |       |   |      |   |
| and      |                                 |   |   |       |   |      |   |
| co       |                                 |   |   |       |   |      |   |
| mpleting |                                 |   |   |       |   |      |   |
| and      |                                 |   |   |       |   |      |   |
| r        |                                 |   |   |       |   |      |   |
| eviewing |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| co       |                                 |   |   |       |   |      |   |
| llection |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| info     |                                 |   |   |       |   |      |   |
| rmation. |                                 |   |   |       |   |      |   |
| Send     |                                 |   |   |       |   |      |   |
| comments |                                 |   |   |       |   |      |   |
| r        |                                 |   |   |       |   |      |   |
| egarding |                                 |   |   |       |   |      |   |
| the      |                                 |   |   |       |   |      |   |
| burden   |                                 |   |   |       |   |      |   |
| estimate |                                 |   |   |       |   |      |   |
| or any   |                                 |   |   |       |   |      |   |
| other    |                                 |   |   |       |   |      |   |
| aspect   |                                 |   |   |       |   |      |   |
| of this  |                                 |   |   |       |   |      |   |
| co       |                                 |   |   |       |   |      |   |
| llection |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| info     |                                 |   |   |       |   |      |   |
| rmation, |                                 |   |   |       |   |      |   |
| i        |                                 |   |   |       |   |      |   |
| ncluding |                                 |   |   |       |   |      |   |
| sug      |                                 |   |   |       |   |      |   |
| gestions |                                 |   |   |       |   |      |   |
| for      |                                 |   |   |       |   |      |   |
| reducing |                                 |   |   |       |   |      |   |
| this     |                                 |   |   |       |   |      |   |
| burden,  |                                 |   |   |       |   |      |   |
| to the   |                                 |   |   |       |   |      |   |
| Office   |                                 |   |   |       |   |      |   |
| of       |                                 |   |   |       |   |      |   |
| Ma       |                                 |   |   |       |   |      |   |
| nagement |                                 |   |   |       |   |      |   |
| and      |                                 |   |   |       |   |      |   |
| Budget,  |                                 |   |   |       |   |      |   |
| P        |                                 |   |   |       |   |      |   |
| aperwork |                                 |   |   |       |   |      |   |
| R        |                                 |   |   |       |   |      |   |
| eduction |                                 |   |   |       |   |      |   |
| Project  |                                 |   |   |       |   |      |   |
| (034     |                                 |   |   |       |   |      |   |
| 8-0046), |                                 |   |   |       |   |      |   |
| Was      |                                 |   |   |       |   |      |   |
| hington, |                                 |   |   |       |   |      |   |
| DC       |                                 |   |   |       |   |      |   |
| 20503.   |                                 |   |   |       |   |      |   |
+----------+---------------------------------+---+---+-------+---+------+---+
| Approved |                                 |   |   |       |   |      |   |
| by OMB   |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| **DI     |                                 |   |   |       |   |      |   |
| SCLOSURE |                                 |   |   |       |   |      |   |
| OF       |                                 |   |   |       |   |      |   |
| LOBBYING |                                 |   |   |       |   |      |   |
| ACTI     |                                 |   |   |       |   |      |   |
| VITIES** |                                 |   |   |       |   |      |   |
| 0        |                                 |   |   |       |   |      |   |
| 348-0046 |                                 |   |   |       |   |      |   |
|          |                                 |   |   |       |   |      |   |
| **CONT   |                                 |   |   |       |   |      |   |
| INUATION |                                 |   |   |       |   |      |   |
| SHEET**  |                                 |   |   |       |   |      |   |
+----------+---------------------------------+---+---+-------+---+------+---+
| **R      |                                 |   | * |       | * |      |   |
| eporting |                                 |   | * |       | * |      |   |
| E        |                                 |   | P |       | o |      |   |
| ntity:** |                                 |   | a |       | f |      |   |
|          |                                 |   | g |       | * |      |   |
|          |                                 |   | e |       | * |      |   |
|          |                                 |   | * |       |   |      |   |
|          |                                 |   | * |       |   |      |   |
+----------+---------------------------------+---+---+-------+---+------+---+
|          |                                 |   |   |       |   |      |   |
+----------+---------------------------------+---+---+-------+---+------+---+

Authorized for Local Reproduction

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