**Applicant's (Organization) Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Applicant's DUNS Number:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Grant Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_CFDA
Number: \_\_\_\_\_\_\_\_\_\_\_\_\_**

1\. Does the applicant have 501(c)(3) status?

Yes No

2\. How many full-time equivalent employees does the applicant have?
*(Check only one box).*

> 3 or Fewer 15-50
>
> 4-5 51-100
>
> 6-14 over 100

3\. What is the size of the applicant's annual budget? *(Check only one
box.)*

Less Than \$150,000

\$150,000 - \$299,999

\$300,000 - \$499,999

\$500,000 - \$999,999

\$1,000,000 - \$4,999,999

\$5,000,000 or more

4\. Is the applicant a faith-based/religious\
organization?

Yes No

5\. Is the applicant a non-religious community-based organization?

Yes No

6\. Is the applicant an intermediary that will manage the grant on
behalf of other organizations?

> Yes No

7\. Has the applicant ever received a government grant or contract
(Federal, State, or local )?

Yes No

8\. Is the applicant a local affiliate of a national\
organization?

Yes No

SF 424-SUPP (4/2004)

#  Survey Instructions on Ensuring Equal Opportunity for Applicants

# 

> **Provide the applicant's (organization) name and DUNS number and the
> grant name and CFDA number.**

1\. 501(c)(3) status is a legal designation provided on application to
the Internal Revenue Service by eligible organizations. Some grant
programs may require nonprofit applicants to have 501(c)(3) status.
Other grant programs do not.

2\. For example, two part-time employees who each work half-time equal
one full-time equivalent employee. If the applicant is a local affiliate
of a national organization, the responses to survey questions 2 and 3
should reflect the staff and budget size of the local affiliate.

3\. Annual budget means the amount of money your organization spends
each year on all of its activities.

4\. Self-identify.

5\. An organization is considered a community-based organization if its
headquarters/service location shares the same zip code as the clients
you serve.

6\. An "intermediary" is an organization that enables a group of small
organizations to receive and manage government funds by administering
the grant on their behalf.

7.  Self-explanatory.

8.  Self-explanatory.

According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless such
collection displays a valid OMB control number. The valid OMB control
number for this information collection is 1890-0014. The time required
to complete this information collection is estimated to average five (5)
minutes per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review
the information collection. **If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form,
please write to:** U.S. Department of Housing and Urban Development,
Office of Departmental Grants Management and Oversight, Room 3156,
Washington, D.C. 20410.

**If you have comments or concerns regarding the status of your
individual submission of this form, write directly to the address
above.**

> SF 424-SUPP (4/2004)