+-----------------+---+--------+--------------------------------------+
| OMB Number:     |   |        |                                      |
| 4040-0004       |   |        |                                      |
|                 |   |        |                                      |
| Expiration      |   |        |                                      |
| Date:           |   |        |                                      |
| 07/31/2006      |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| **Application   |   |        |                                      |
| for Federal     |   |        |                                      |
| Assistance      |   |        |                                      |
| SF-424**        |   |        |                                      |
|                 |   |        |                                      |
| Version 02      |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| \* 1. Type of   | \ |        |                                      |
| Submission:     | * |        |                                      |
|                 | 2 |        |                                      |
|                 | . |        |                                      |
|                 | T |        |                                      |
|                 | y |        |                                      |
|                 | p |        |                                      |
|                 | e |        |                                      |
|                 | o |        |                                      |
|                 | f |        |                                      |
|                 | A |        |                                      |
|                 | p |        |                                      |
|                 | p |        |                                      |
|                 | l |        |                                      |
|                 | i |        |                                      |
|                 | c |        |                                      |
|                 | a |        |                                      |
|                 | t |        |                                      |
|                 | i |        |                                      |
|                 | o |        |                                      |
|                 | n |        |                                      |
|                 | : |        |                                      |
|                 | \ |        |                                      |
|                 | * |        |                                      |
|                 | I |        |                                      |
|                 | f |        |                                      |
|                 | R |        |                                      |
|                 | e |        |                                      |
|                 | v |        |                                      |
|                 | i |        |                                      |
|                 | s |        |                                      |
|                 | i |        |                                      |
|                 | o |        |                                      |
|                 | n |        |                                      |
|                 | , |        |                                      |
|                 | s |        |                                      |
|                 | e |        |                                      |
|                 | l |        |                                      |
|                 | e |        |                                      |
|                 | c |        |                                      |
|                 | t |        |                                      |
|                 | a |        |                                      |
|                 | p |        |                                      |
|                 | p |        |                                      |
|                 | r |        |                                      |
|                 | o |        |                                      |
|                 | p |        |                                      |
|                 | r |        |                                      |
|                 | i |        |                                      |
|                 | a |        |                                      |
|                 | t |        |                                      |
|                 | e |        |                                      |
|                 | l |        |                                      |
|                 | e |        |                                      |
|                 | t |        |                                      |
|                 | t |        |                                      |
|                 | e |        |                                      |
|                 | r |        |                                      |
|                 | ( |        |                                      |
|                 | s |        |                                      |
|                 | ) |        |                                      |
|                 | : |        |                                      |
+-----------------+---+--------+--------------------------------------+
| □               | □ |        |                                      |
| Preapplication  | N |        |                                      |
|                 | e |        |                                      |
|                 | w |        |                                      |
+-----------------+---+--------+--------------------------------------+
| □ Application   | □ |        |                                      |
|                 | C |        |                                      |
|                 | o |        |                                      |
|                 | n |        |                                      |
|                 | t |        |                                      |
|                 | i |        |                                      |
|                 | n |        |                                      |
|                 | u |        |                                      |
|                 | a |        |                                      |
|                 | t |        |                                      |
|                 | i |        |                                      |
|                 | o |        |                                      |
|                 | n |        |                                      |
|                 | \ |        |                                      |
|                 | * |        |                                      |
|                 | O |        |                                      |
|                 | t |        |                                      |
|                 | h |        |                                      |
|                 | e |        |                                      |
|                 | r |        |                                      |
|                 | ( |        |                                      |
|                 | S |        |                                      |
|                 | p |        |                                      |
|                 | e |        |                                      |
|                 | c |        |                                      |
|                 | i |        |                                      |
|                 | f |        |                                      |
|                 | y |        |                                      |
|                 | ) |        |                                      |
+-----------------+---+--------+--------------------------------------+
| □               | □ |        |                                      |
| Ch              | R |        |                                      |
| anged/Corrected | e |        |                                      |
| Application     | v |        |                                      |
|                 | i |        |                                      |
|                 | s |        |                                      |
|                 | i |        |                                      |
|                 | o |        |                                      |
|                 | n |        |                                      |
+-----------------+---+--------+--------------------------------------+
| 3\. Date        |   |        |                                      |
| Received: 4.    |   |        |                                      |
| Applicant       |   |        |                                      |
| Identifier:     |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| 5a. Federal     |   |        | \* 5b. Federal Award Identifier:     |
| Entity          |   |        |                                      |
| Identifier:     |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| **State Use     |   |        |                                      |
| Only:**         |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| 6\. Date        |   | 7\.    |                                      |
| Received by     |   | State  |                                      |
| State:          |   | Appli  |                                      |
|                 |   | cation |                                      |
|                 |   | Ident  |                                      |
|                 |   | ifier: |                                      |
+-----------------+---+--------+--------------------------------------+
| **8. APPLICANT  |   |        |                                      |
| INFORMATION:**  |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| \* a. Legal     |   |        |                                      |
| Name:           |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| \* b.           |   |        | \* c. Organizational DUNS:           |
| Em              |   |        |                                      |
| ployer/Taxpayer |   |        |                                      |
| Identification  |   |        |                                      |
| Number          |   |        |                                      |
| (EIN/TIN):      |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| **d. Address:** |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| \* Street1:     |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| Street2:        |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| \* City:        |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| County:         |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| \* State:       |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| Province:       |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| \* Country:     |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| \* Zip / Postal |   |        |                                      |
| Code:           |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| **e.            |   |        |                                      |
| Organizational  |   |        |                                      |
| Unit:**         |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| Department      |   |        | Division Name:                       |
| Name:           |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| **f. Name and   |   |        |                                      |
| contact         |   |        |                                      |
| information of  |   |        |                                      |
| person to be    |   |        |                                      |
| contacted on    |   |        |                                      |
| matters         |   |        |                                      |
| involving this  |   |        |                                      |
| application:**  |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| Prefix: \*First |   |        |                                      |
| Name:           |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| Middle Name:    |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| \* Last Name:   |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| Suffix:         |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| Title:          |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| Organizational  |   |        |                                      |
| Affiliation:    |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| \* Telephone    |   |        |                                      |
| Number: Fax     |   |        |                                      |
| Number:         |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| \* Email:       |   |        |                                      |
+-----------------+---+--------+--------------------------------------+
| Authorized for  |   |        |                                      |
| Local           |   |        |                                      |
| Reproduction    |   |        |                                      |
| Standard Form   |   |        |                                      |
| 424 (Revised    |   |        |                                      |
| 10/2005)        |   |        |                                      |
|                 |   |        |                                      |
| Prescribed by   |   |        |                                      |
| OMB Circular    |   |        |                                      |
| A-102           |   |        |                                      |
+-----------------+---+--------+--------------------------------------+

+-----------------------------------------------------------------------+
| OMB Number: 4040-0004                                                 |
|                                                                       |
| Expiration Date: 07/31/2006                                           |
+-----------------------------------------------------------------------+
| **Application for Federal Assistance SF-424**                         |
|                                                                       |
| Version 02                                                            |
+-----------------------------------------------------------------------+
| **9. Type of Applicant 1: Select Applicant Type:**                    |
+-----------------------------------------------------------------------+
| Type of Applicant 2: Select Applicant Type:                           |
+-----------------------------------------------------------------------+
| Type of Applicant 3: Select Applicant Type:                           |
+-----------------------------------------------------------------------+
| \* Other (specify):                                                   |
+-----------------------------------------------------------------------+
| **\* 10. Name of Federal Agency:**                                    |
+-----------------------------------------------------------------------+
| **11. Catalog of Federal Domestic Assistance Number:**                |
+-----------------------------------------------------------------------+
| CFDA Title:                                                           |
+-----------------------------------------------------------------------+
| **\* 12. Funding Opportunity Number:**                                |
+-----------------------------------------------------------------------+
| \* Title:                                                             |
+-----------------------------------------------------------------------+
| **13. Competition Identification Number:**                            |
+-----------------------------------------------------------------------+
| Title:                                                                |
+-----------------------------------------------------------------------+
| **14. Areas Affected by Project (Cities, Counties, States, etc.):**   |
+-----------------------------------------------------------------------+
| **\* 15. Descriptive Title of Applicant\'s Project:**                 |
+-----------------------------------------------------------------------+
| Attach supporting documents as specified in agency instructions.      |
+-----------------------------------------------------------------------+
| Authorized for Local Reproduction Standard Form 424 (Revised 10/2005) |
|                                                                       |
| Prescribed by OMB Circular A-102                                      |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| OMB Number: 4040-0004                                                 |
|                                                                       |
| Expiration Date: 07/31/2006                                           |
+-----------------------------------------------------------------------+
| **Application for Federal Assistance SF-424**                         |
|                                                                       |
| Version 02                                                            |
+-----------------------------------------------------------------------+
| **16. Congressional Districts Of:**                                   |
+-----------------------------------------------------------------------+
| \* a. Applicant \* b. Program/Project                                 |
+-----------------------------------------------------------------------+
| Attach an additional list of Program/Project Congressional Districts  |
| if needed.                                                            |
+-----------------------------------------------------------------------+
| **17. Proposed Project:**                                             |
+-----------------------------------------------------------------------+
| \* a. Start Date: \* b. End Date:                                     |
+-----------------------------------------------------------------------+
| **18. Estimated Funding (\$):**                                       |
+-----------------------------------------------------------------------+
| \* a. Federal                                                         |
+-----------------------------------------------------------------------+
| \* b. Applicant                                                       |
+-----------------------------------------------------------------------+
| \* c. State                                                           |
+-----------------------------------------------------------------------+
| \* d. Local                                                           |
+-----------------------------------------------------------------------+
| \* e. Other                                                           |
+-----------------------------------------------------------------------+
| \* f. Program Income                                                  |
+-----------------------------------------------------------------------+
| \* g. TOTAL                                                           |
+-----------------------------------------------------------------------+
| **\* 19. Is Application Subject to Review By State Under Executive    |
| Order 12372 Process?**                                                |
+-----------------------------------------------------------------------+
| □ a. This application was made available to the State under the       |
| Executive Order 12372 Process for review on .                         |
+-----------------------------------------------------------------------+
| □ b. Program is subject to E.O. 12372 but has not been selected by    |
| the State for review.                                                 |
+-----------------------------------------------------------------------+
| □ c. Program is not covered by E.O. 12372.                            |
+-----------------------------------------------------------------------+
| **\* 20. Is the Applicant Delinquent On Any Federal Debt? (If         |
| \"Yes\", provide explanation.)**                                      |
+-----------------------------------------------------------------------+
| □ Yes □ No                                                            |
+-----------------------------------------------------------------------+
| **21. \*By signing this application, I certify (1) to the statements  |
| contained in the list of certifications\*\* and (2) that the          |
| statements herein are true, complete and accurate to the best of my   |
| knowledge. I also provide the required assurances\*\* and agree to    |
| comply with any resulting terms if I accept an award. I am aware that |
| any false, fictitious, or fraudulent statements or claims may subject |
| me to criminal, civil, or administrative penalties. (U.S. Code, Title |
| 218, Section 1001)**                                                  |
+-----------------------------------------------------------------------+
| □ **\*\* I AGREE**                                                    |
+-----------------------------------------------------------------------+
| \*\* The list of certifications and assurances, or an internet site   |
| where you may obtain this list, is contained in the announcement or   |
| agency specific instructions.                                         |
+-----------------------------------------------------------------------+
| **Authorized Representative:**                                        |
+-----------------------------------------------------------------------+
| Prefix: \* First Name:                                                |
+-----------------------------------------------------------------------+
| Middle Name:                                                          |
+-----------------------------------------------------------------------+
| \* Last Name:                                                         |
+-----------------------------------------------------------------------+
| Suffix:                                                               |
+-----------------------------------------------------------------------+
| \* Title:                                                             |
+-----------------------------------------------------------------------+
| \* Telephone Number: Fax Number:                                      |
+-----------------------------------------------------------------------+
| \* Email:                                                             |
+-----------------------------------------------------------------------+
| \* Signature of Authorized Representative: \* Date Signed:            |
+-----------------------------------------------------------------------+
| Authorized for Local Reproduction Standard Form 424 (Revised 10/2005) |
|                                                                       |
| Prescribed by OMB Circular A-102                                      |
+-----------------------------------------------------------------------+

**Application for Federal Assistance SF-424** Version 02

![](media/image1.jpeg){width="7.611805555555556in"
height="2.013888888888889e-2in"}

**\* Applicant Federal Debt Delinquency Explanation**

The following field should contain an explanation if the Applicant
organization is delinquent on any Federal Debt. Maximum number of
characters that can be entered is 4,000. Try and avoid extra spaces and
carriage returns to maximize the availability of space.

**INSTRUCTIONS FOR THE SF-424**

Public reporting burden for this collection of information is estimated
to average 60 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Management and Budget, Paperwork
Reduction Project (0348-0043), Washington, DC 20503.

**PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT
AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.**

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

+---+----------------------------------+---+---+---------------------------+
| I | Entry:                           | I | E |                           |
| t |                                  | t | n |                           |
| e |                                  | e | t |                           |
| m |                                  | m | r |                           |
|   |                                  |   | y |                           |
|   |                                  |   | : |                           |
+---+----------------------------------+---+---+---------------------------+
| 1 | **Type of Submission:**          | 1 |   | **Name Of Federal         |
| \ | (Required): Select one type of   | 0 |   | Agency**: (Required)      |
| . | submission in accordance with    | \ |   | Enter the name of the     |
|   | agency instructions.             | . |   | Federal agency from which |
|   |                                  |   |   | assistance is being       |
|   | • Preapplication                 |   |   | requested with this       |
|   |                                  |   |   | application.              |
|   | • Application                    |   |   |                           |
|   |                                  |   |   |                           |
|   | • Changed/Corrected Application  |   |   |                           |
|   | -- If requested by the agency,   |   |   |                           |
|   | check if this submission is to   |   |   |                           |
|   | change or correct a previously   |   |   |                           |
|   | submitted application. Unless    |   |   |                           |
|   | requested by the agency,         |   |   |                           |
|   | applicants may not use this to   |   |   |                           |
|   | submit changes after the closing |   |   |                           |
|   | date.                            |   |   |                           |
+---+----------------------------------+---+---+---------------------------+
|   |                                  | 1 |   | **Catalog Of Federal      |
|   |                                  | 1 |   | Domestic Assistance       |
|   |                                  | \ |   | Number/Title:** Enter the |
|   |                                  | . |   | Catalog of Federal        |
|   |                                  |   |   | Domestic Assistance       |
|   |                                  |   |   | number and title of the   |
|   |                                  |   |   | program under which       |
|   |                                  |   |   | assistance is requested,  |
|   |                                  |   |   | as found in the program   |
|   |                                  |   |   | announcement, if          |
|   |                                  |   |   | applicable.               |
+---+----------------------------------+---+---+---------------------------+
| 2 | **Type of Application**:         | 1 |   | **Funding Opportunity     |
| \ | (Required) Select one type of    | 2 |   | Number/Title:**           |
| . | application in accordance with   | \ |   | (Required) Enter the      |
|   | agency instructions.             | . |   | Funding Opportunity       |
|   |                                  |   |   | Number and title of the   |
|   | • New -- An application that is  |   |   | opportunity under which   |
|   | being submitted to an agency for |   |   | assistance is requested,  |
|   | the first time.                  |   |   | as found in the program   |
|   |                                  |   |   | announcement.             |
|   | • Continuation - An extension    |   |   |                           |
|   | for an additional funding/budget |   |   |                           |
|   | period for a project with a      |   |   |                           |
|   | projected completion date. This  |   |   |                           |
|   | can include renewals.            |   |   |                           |
|   |                                  |   |   |                           |
|   | • Revision - Any change in the   |   |   |                           |
|   | Federal Government's financial   |   |   |                           |
|   | obligation or contingent         |   |   |                           |
|   | liability from an existing       |   |   |                           |
|   | obligation. If a                 |   |   |                           |
|   |                                  |   |   |                           |
|   | revision, enter the appropriate  |   |   |                           |
|   | letter(s). More than one may be  |   |   |                           |
|   |                                  |   |   |                           |
|   | selected. If \"Other\" is        |   |   |                           |
|   | selected, please specify in text |   |   |                           |
|   | box provided.                    |   |   |                           |
|   |                                  |   |   |                           |
|   | A. Increase Award B. Decrease    |   |   |                           |
|   | Award                            |   |   |                           |
|   |                                  |   |   |                           |
|   | C. Increase Duration D. Decrease |   |   |                           |
|   | Duration                         |   |   |                           |
|   |                                  |   |   |                           |
|   | E. Other (specify)               |   |   |                           |
+---+----------------------------------+---+---+---------------------------+
|   |                                  | 1 |   | **Competition             |
|   |                                  | 3 |   | Identification            |
|   |                                  | \ |   | Number/Title:** Enter the |
|   |                                  | . |   | Competition               |
|   |                                  |   |   | Identification Number and |
|   |                                  |   |   | title of the competition  |
|   |                                  |   |   | under which assistance is |
|   |                                  |   |   | requested, if applicable. |
+---+----------------------------------+---+---+---------------------------+
|   |                                  | 1 |   | **Areas Affected By       |
|   |                                  | 4 |   | Project:** List the areas |
|   |                                  | \ |   | or entities using the     |
|   |                                  | . |   | categories (e.g., cities, |
|   |                                  |   |   | counties, states, etc.)   |
|   |                                  |   |   | specified in agency       |
|   |                                  |   |   | instructions. Use the     |
|   |                                  |   |   | continuation sheet to     |
|   |                                  |   |   | enter additional areas,   |
|   |                                  |   |   | if needed.                |
+---+----------------------------------+---+---+---------------------------+
| 3 | **Date Received:** Leave this    | 1 |   | **Descriptive Title of    |
| \ | field blank. This date will be   | 5 |   | Applicant's Project:**    |
| . | assigned by the Federal agency.  | \ |   | (Required) Enter a brief  |
|   |                                  | . |   | descriptive title of the  |
|   |                                  |   |   | project. If appropriate,  |
|   |                                  |   |   | attach a map showing      |
|   |                                  |   |   | project location (e.g.,   |
|   |                                  |   |   | construction or real      |
|   |                                  |   |   | property projects). For   |
|   |                                  |   |   | preapplications, attach a |
|   |                                  |   |   | summary description of    |
|   |                                  |   |   | the project.              |
+---+----------------------------------+---+---+---------------------------+
| 4 | **Applicant Identifier:** Enter  |   |   |                           |
| \ | the entity identifier assigned   |   |   |                           |
| . | buy the Federal agency, if any,  |   |   |                           |
|   | or the applicant's control       |   |   |                           |
|   | number if applicable.            |   |   |                           |
+---+----------------------------------+---+---+---------------------------+
| 5 | **Federal Entity Identifier**:   | 1 |   | **Congressional Districts |
| a | Enter the number assigned to     | 6 |   | Of**: (Required) 16a.     |
| . | your                             | \ |   | Enter the applicant's     |
|   |                                  | . |   | Congressional District,   |
|   | organization by the Federal      |   |   | and 16b. Enter all        |
|   | Agency, if any.                  |   |   | District(s) affected by   |
|   |                                  |   |   | the program or project.   |
|   |                                  |   |   | Enter in the format: 2    |
|   |                                  |   |   | characters State          |
|   |                                  |   |   | Abbreviation -- 3         |
|   |                                  |   |   | characters District       |
|   |                                  |   |   | Number, e.g., CA-005 for  |
|   |                                  |   |   | California 5th district,  |
|   |                                  |   |   | CA-012 for California     |
|   |                                  |   |   | 12th district, NC-103 for |
|   |                                  |   |   | North Carolina's 103rd    |
|   |                                  |   |   | district. • If all        |
|   |                                  |   |   | congressional districts   |
|   |                                  |   |   | in a state are affected,  |
|   |                                  |   |   | enter "all" for the       |
|   |                                  |   |   | district number, e.g.,    |
|   |                                  |   |   | MD-all for all            |
|   |                                  |   |   | congressional districts   |
|   |                                  |   |   | in Maryland. • If         |
|   |                                  |   |   | nationwide, i.e. all      |
|   |                                  |   |   | districts within all      |
|   |                                  |   |   | states are affected,      |
|   |                                  |   |   | enter US-all. • If the    |
|   |                                  |   |   | program/project is        |
|   |                                  |   |   | outside the US, enter     |
|   |                                  |   |   | 00-000.                   |
+---+----------------------------------+---+---+---------------------------+
| 5 | **Federal Award Identifier**:    |   |   |                           |
| b | For new applications leave       |   |   |                           |
| . | blank. For a continuation or     |   |   |                           |
|   | revision to an existing award,   |   |   |                           |
|   | enter the previously assigned    |   |   |                           |
|   | Federal award identifier number. |   |   |                           |
|   | If a changed/corrected           |   |   |                           |
|   | application, enter the Federal   |   |   |                           |
|   | Identifier in accordance with    |   |   |                           |
|   | agency instructions.             |   |   |                           |
+---+----------------------------------+---+---+---------------------------+
| 6 | **Date Received by State:**      |   |   |                           |
| \ | Leave this field blank. This     |   |   |                           |
| . | date will be assigned by the     |   |   |                           |
|   | State, if applicable.            |   |   |                           |
+---+----------------------------------+---+---+---------------------------+
| 7 | **State Application              |   |   |                           |
| \ | Identifier:** Leave this field   |   |   |                           |
| . | blank. This identifier will be   |   |   |                           |
|   | assigned by the State, if        |   |   |                           |
|   | applicable.                      |   |   |                           |
+---+----------------------------------+---+---+---------------------------+
| 8 | **Applicant Information**: Enter |   |   |                           |
| \ | the following in accordance with |   |   |                           |
| . | agency instructions:             |   |   |                           |
+---+----------------------------------+---+---+---------------------------+
|   | **a. Legal Name**: (Required):   | 1 |   | **Proposed Project Start  |
|   | Enter the legal name of          | 7 |   | and End Dates**:          |
|   | applicant that will undertake    | \ |   | (Required) Enter the      |
|   | the assistance activity. This is | . |   | proposed start date and   |
|   | ththat the organization has      |   |   | end date of the project.  |
|   | registered with the Central      |   |   |                           |
|   | Contractor Registry. Information |   |   |                           |
|   | on registering with CCR may be   |   |   |                           |
|   | obtained by visiting the         |   |   |                           |
|   | Grants.gov website.              |   |   |                           |
+---+----------------------------------+---+---+---------------------------+
|   | **b. Employer/Taxpayer Number    | 1 |   | **Estimated Funding:**    |
|   | (EIN/TIN):** (Required): Enter   | 8 |   | (Required) Enter the      |
|   | the Employer or Taxpayer         | \ |   | amount requested or to be |
|   | Identification Number (EIN or    | . |   | contributed during the    |
|   | TIN) as assigned by the Internal |   |   | first funding/budget      |
|   | Revenue Service. If your         |   |   | period by each            |
|   | organization is not in the US,   |   |   | contributor. Value of     |
|   | enter 44-4444444.                |   |   | in-kind contributions     |
|   |                                  |   |   | should be included on     |
|   |                                  |   |   | appropriate lines, as     |
|   |                                  |   |   | applicable. If the action |
|   |                                  |   |   | will result in a dollar   |
|   |                                  |   |   | change to an existing     |
|   |                                  |   |   | award, indicate only the  |
|   |                                  |   |   | amount of the change. For |
|   |                                  |   |   | decreases, enclose the    |
|   |                                  |   |   | amounts in parentheses.   |
+---+----------------------------------+---+---+---------------------------+

+---+---+-----------------+---------------+---+---+---+---------------------------+
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+---+---+-----------------+---------------+---+---+---+---------------------------+
|   | * |                 |               |   | 2 | * |                           |
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+---+---+-----------------+---------------+---+---+---+---------------------------+
|   |   | **e.            |               | 2 |   |   | **Authorized              |
|   |   | Organizational  |               | 1 |   |   | Representative**:         |
|   |   | Unit:** Enter   |               | \ |   |   | (Required) To be signed   |
|   |   | the name of the |               | . |   |   | and dated by the          |
|   |   | primary         |               |   |   |   | authorized representative |
|   |   | organizational  |               |   |   |   | of the applicant          |
|   |   | unit (and       |               |   |   |   | organization. Enter the   |
|   |   | department or   |               |   |   |   | name (First and last name |
|   |   | division, (if   |               |   |   |   | required) title           |
|   |   | applicable)     |               |   |   |   | (Required), telephone     |
|   |   | that will       |               |   |   |   | number (Required), fax    |
|   |   | undertake the   |               |   |   |   | number, and email address |
|   |   | assistance      |               |   |   |   | (Required) of the person  |
|   |   | activity, if    |               |   |   |   | authorized to sign for    |
|   |   | applicable.     |               |   |   |   | the applicant. A copy of  |
|   |   |                 |               |   |   |   | the governing body's      |
|   |   |                 |               |   |   |   | authorization for you to  |
|   |   |                 |               |   |   |   | sign this application as  |
|   |   |                 |               |   |   |   | the official              |
|   |   |                 |               |   |   |   | representative must be on |
|   |   |                 |               |   |   |   | file in the applicant's   |
|   |   |                 |               |   |   |   | office. (Certain Federal  |
|   |   |                 |               |   |   |   | agencies may require that |
|   |   |                 |               |   |   |   | this authorization be     |
|   |   |                 |               |   |   |   | submitted as part of the  |
|   |   |                 |               |   |   |   | application.)             |
+---+---+-----------------+---------------+---+---+---+---------------------------+
|   |   | **f. Name and   |               |   |   |   |                           |
|   |   | contact         |               |   |   |   |                           |
|   |   | information of  |               |   |   |   |                           |
|   |   | person to be    |               |   |   |   |                           |
|   |   | contacted on    |               |   |   |   |                           |
|   |   | matters         |               |   |   |   |                           |
|   |   | involving this  |               |   |   |   |                           |
|   |   | applicat**      |               |   |   |   |                           |
|   |   | required),      |               |   |   |   |                           |
|   |   | organizational  |               |   |   |   |                           |
|   |   | affiliation (if |               |   |   |   |                           |
|   |   | affiliated with |               |   |   |   |                           |
|   |   | an organization |               |   |   |   |                           |
|   |   | other **on**:   |               |   |   |   |                           |
|   |   | Enter the name  |               |   |   |   |                           |
|   |   | (First and last |               |   |   |   |                           |
|   |   | name than the   |               |   |   |   |                           |
|   |   | applicant       |               |   |   |   |                           |
|   |   | organization),  |               |   |   |   |                           |
|   |   | telephone       |               |   |   |   |                           |
|   |   | number          |               |   |   |   |                           |
|   |   | (Required), fax |               |   |   |   |                           |
|   |   | number, and     |               |   |   |   |                           |
|   |   | email address   |               |   |   |   |                           |
|   |   | (Required) of   |               |   |   |   |                           |
|   |   | the person to   |               |   |   |   |                           |
|   |   | contact on      |               |   |   |   |                           |
|   |   | matters related |               |   |   |   |                           |
|   |   | to this         |               |   |   |   |                           |
|   |   | application.    |               |   |   |   |                           |
+---+---+-----------------+---------------+---+---+---+---------------------------+
| 9 |   | Type of         |               |   |   |   |                           |
| \ |   | Applicant:      |               |   |   |   |                           |
| . |   | (Required)      |               |   |   |   |                           |
|   |   | Select up to    |               |   |   |   |                           |
|   |   | three applicant |               |   |   |   |                           |
|   |   | type(s) in      |               |   |   |   |                           |
|   |   | accordance with |               |   |   |   |                           |
|   |   | agency          |               |   |   |   |                           |
|   |   | instructions.   |               |   |   |   |                           |
+---+---+-----------------+---------------+---+---+---+---------------------------+
|   |   | A.  State       | M.  Nonprofit |   |   |   |                           |
|   |   |     Government  |               |   |   |   |                           |
|   |   |                 | N.  Nonprofit |   |   |   |                           |
|   |   | B.  County      |               |   |   |   |                           |
|   |   |     Government  | O.  Private   |   |   |   |                           |
|   |   |                 |               |   |   |   |                           |
|   |   | C.  City or     |   Institution |   |   |   |                           |
|   |   |     Township    |     of Higher |   |   |   |                           |
|   |   |     Government  |     Education |   |   |   |                           |
|   |   |                 |               |   |   |   |                           |
|   |   | D.  Special     | P             |   |   |   |                           |
|   |   |     District    | .  Individual |   |   |   |                           |
|   |   |     Government  |               |   |   |   |                           |
|   |   |                 | Q             |   |   |   |                           |
|   |   | E.  Regional    | .  For-Profit |   |   |   |                           |
|   |   |                 |               |   |   |   |                           |
|   |   |    Organization |  Organization |   |   |   |                           |
|   |   |                 |     (Other    |   |   |   |                           |
|   |   | F.  U.S.        |     than      |   |   |   |                           |
|   |   |     Territory   |     Small     |   |   |   |                           |
|   |   |     or          |     Business) |   |   |   |                           |
|   |   |     Possession  |               |   |   |   |                           |
|   |   |                 | R.  Small     |   |   |   |                           |
|   |   | G.  Independent |     Business  |   |   |   |                           |
|   |   |     School      |               |   |   |   |                           |
|   |   |     District    | S.  His       |   |   |   |                           |
|   |   |                 | panic-serving |   |   |   |                           |
|   |   | H               |               |   |   |   |                           |
|   |   | .  Public/State |   Institution |   |   |   |                           |
|   |   |     Controlled  |               |   |   |   |                           |
|   |   |     Institution | T.            |   |   |   |                           |
|   |   |     of Higher   |  Historically |   |   |   |                           |
|   |   |     Education   |     Black     |   |   |   |                           |
|   |   |                 |     Colleges  |   |   |   |                           |
|   |   | I.              |     and       |   |   |   |                           |
|   |   |   Indian/Native |               |   |   |   |                           |
|   |   |     American    |  Universities |   |   |   |                           |
|   |   |     Tribal      |     (HBCUs)   |   |   |   |                           |
|   |   |     Government  |               |   |   |   |                           |
|   |   |     (Federally  | U.  Tribally  |   |   |   |                           |
|   |   |     Recognized) |               |   |   |   |                           |
|   |   |                 |    Controlled |   |   |   |                           |
|   |   | J.              |     Colleges  |   |   |   |                           |
|   |   |   Indian/Native |     and       |   |   |   |                           |
|   |   |     American    |               |   |   |   |                           |
|   |   |     Tribal      |  Universities |   |   |   |                           |
|   |   |     Government  |     (TCCUs)   |   |   |   |                           |
|   |   |     (Other than |               |   |   |   |                           |
|   |   |     Federally   | V.  Alaska    |   |   |   |                           |
|   |   |     Recognized) |     Native    |   |   |   |                           |
|   |   |                 |     and       |   |   |   |                           |
|   |   | K.              |     Native    |   |   |   |                           |
|   |   |   Indian/Native |     Hawaiian  |   |   |   |                           |
|   |   |     American    |     Serving   |   |   |   |                           |
|   |   |     Tribally    |               |   |   |   |                           |
|   |   |     Designated  |  Institutions |   |   |   |                           |
|   |   |                 |               |   |   |   |                           |
|   |   |    Organization | W.            |   |   |   |                           |
|   |   |                 |  Non-domestic |   |   |   |                           |
|   |   | L.              |     (non-US)  |   |   |   |                           |
|   |   |   Public/Indian |     Entity    |   |   |   |                           |
|   |   |     Housing     |               |   |   |   |                           |
|   |   |     Authority   | X.  Other     |   |   |   |                           |
|   |   |                 |     (specify) |   |   |   |                           |
+---+---+-----------------+---------------+---+---+---+---------------------------+