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<tbody>
<tr class="odd">
<td colspan="43"><strong>OMB Approval No. 0348-0043</strong></td>
</tr>
<tr class="even">
<td colspan="18"><p><strong>APPLICATION FOR</strong></p>
<p><strong>FEDERAL ASSISTANCE</strong></p></td>
<td colspan="16"><p><strong>2. Date Submitted</strong> (mm/dd/yyyy)</p>
<p>     </p></td>
<td colspan="9"><strong>Applicant Identifier</strong></td>
</tr>
<tr class="odd">
<td colspan="6"><p><strong>1. Type of Submissiom</strong></p>
<p><em><strong>Application</strong></em></p></td>
<td colspan="12"><em><strong>Preapplication</strong></em></td>
<td colspan="16"><strong>3. Date Received by State</strong>
(mm/dd/yyyy)</td>
<td colspan="9"><strong>State Applicant Identifier</strong></td>
</tr>
<tr class="even">
<td colspan="6"><p> Construction</p>
<p> Non-Construction</p></td>
<td colspan="12"><p> Construction</p>
<p> Non-Construction</p></td>
<td colspan="16"><strong>4. Date Received by Federal Agency</strong>
(mm/dd/yyyy)</td>
<td colspan="9"><strong>Federal Identifier</strong></td>
</tr>
<tr class="odd">
<td colspan="43"><strong>5. APPLICANT INFORMATION</strong></td>
</tr>
<tr class="even">
<td colspan="31"><p>Legal Name:</p>
<p>     </p></td>
<td colspan="12"><p>Organizational Unit:</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="31"><p>Address <em>(give city, county, state, and zip
code)</em>:</p>
<p>     </p>
<p>     </p></td>
<td colspan="12"><p>Name and telephone number of the person to be
contacted on matters involving this</p>
<p>application (give area code)</p>
<p>     </p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="31"></td>
<td colspan="6"></td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="31"><strong>6. EMPLOYER IDENTIFICATION NUMBER
(EIN):</strong></td>
<td colspan="9"><p><strong>7. TYPE OF APPLICANT:</strong></p>
<p><em><strong>(enter appropriate letter in box)</strong></em></p></td>
<td colspan="2"> </td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"> </td>
<td> </td>
<td colspan="2">—</td>
<td> </td>
<td colspan="3"> </td>
<td colspan="2"> </td>
<td colspan="3"> </td>
<td colspan="5"> </td>
<td colspan="3"> </td>
<td colspan="2"> </td>
<td colspan="5"></td>
<td colspan="5">A. State</td>
<td colspan="7">I. State Controlled Institution of Higher Learning</td>
</tr>
<tr class="odd">
<td colspan="31"></td>
<td colspan="5">B. County</td>
<td colspan="7">J. Private University</td>
</tr>
<tr class="even">
<td colspan="31"><strong>8. TYPE OF APPLICATION:</strong></td>
<td colspan="5">C. Municipal</td>
<td colspan="7">K. Indian Tribe</td>
</tr>
<tr class="odd">
<td colspan="31"></td>
<td colspan="5">D. Township</td>
<td colspan="7">L. Individual</td>
</tr>
<tr class="even">
<td colspan="31"> New Continuation Revision</td>
<td colspan="5">E. Interstate</td>
<td colspan="7">M. Profit Organization</td>
</tr>
<tr class="odd">
<td colspan="30"></td>
<td colspan="5">F. Intermunicipal</td>
<td colspan="8">N. Nonprofit</td>
</tr>
<tr class="even">
<td colspan="12">If Revision, enter appropriate letter(s) in
box(es):</td>
<td colspan="3"> </td>
<td colspan="4"></td>
<td colspan="4"> </td>
<td colspan="7"></td>
<td colspan="5">G. Special District</td>
<td colspan="8">O. Public Housing Agency</td>
</tr>
<tr class="odd">
<td colspan="31">A. Increase Award B. Decrease Award C. Increase
Duration</td>
<td colspan="5">H. Independent School Dist.</td>
<td colspan="2">P. Other (Specify)</td>
<td colspan="5">     </td>
</tr>
<tr class="even">
<td colspan="31">D. Decrease Duration Other <em>(specify):</em></td>
<td colspan="12"><strong>9. NAME OF FEDERAL AGENCY:</strong></td>
</tr>
<tr class="odd">
<td colspan="31"></td>
<td colspan="12">     </td>
</tr>
<tr class="even">
<td></td>
<td colspan="27">     </td>
<td colspan="3"></td>
<td colspan="12"></td>
</tr>
<tr class="odd">
<td colspan="31"></td>
<td colspan="12"></td>
</tr>
<tr class="even">
<td colspan="10"><p><strong>10. CATALOG OF FEDERAL DOMESTIC</strong></p>
<p><strong>ASSISTANCE NUMBER: (xx-yyy)</strong></p></td>
<td colspan="4"> </td>
<td colspan="3"> </td>
<td colspan="3">•</td>
<td colspan="5"> </td>
<td colspan="2"> </td>
<td colspan="4"> </td>
<td colspan="12"><p><strong>11. DESCRIPTIVE TITLE OF APPLICANT’S
PROJECT:</strong></p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="31"></td>
<td colspan="12">     </td>
</tr>
<tr class="even">
<td colspan="31">TITLE:      </td>
<td colspan="12">     </td>
</tr>
<tr class="odd">
<td colspan="31">     </td>
<td colspan="12">     </td>
</tr>
<tr class="even">
<td colspan="31"><strong>12. AREAS AFFECTED BY PROJECT <em>(cities,
counties, states, etc.):</em></strong></td>
<td colspan="12">     </td>
</tr>
<tr class="odd">
<td colspan="31"></td>
<td colspan="12">     </td>
</tr>
<tr class="even">
<td colspan="31">     </td>
<td colspan="12">     </td>
</tr>
<tr class="odd">
<td colspan="31"></td>
<td colspan="12">     </td>
</tr>
<tr class="even">
<td colspan="31"></td>
<td colspan="12">     </td>
</tr>
<tr class="odd">
<td colspan="9"><strong>13. PROPOSED PROJECT:</strong></td>
<td colspan="34"><strong>14. CONGRESSIONAL DISTRICTS OF:</strong></td>
</tr>
<tr class="even">
<td colspan="3"><p>Start Date</p>
<p>(mm/dd/yyyy)</p>
<p>     </p></td>
<td colspan="6"><p>Ending Date</p>
<p>(mm/dd/yyyy)</p>
<p>     </p></td>
<td colspan="24"><p>a. Applicant</p>
<p>     </p></td>
<td colspan="10"><p>b. Project</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="22"><strong>15. ESTIMATED FUNDING:</strong></td>
<td colspan="21"><strong>16. IS APPLICATION SUBJECT TO REVIEW BY STATE
EXECUTIVE ORDER 12372 PROCESS?</strong></td>
</tr>
<tr class="even">
<td colspan="22"></td>
<td colspan="21"><p>a. YES. THIS PREAPPLICATION/APPLICATION WAS MADE
AVAILABLE TO THE</p>
<p>STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON:</p></td>
</tr>
<tr class="odd">
<td colspan="22"></td>
<td colspan="10">DATE (mm/dd/yyyy)</td>
<td colspan="7">     </td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="22"><strong>Complete form HUD-424-M, Funding
Matrix</strong></td>
<td colspan="21">b. NO. PROGRAM IS NOT COVERED BY E.O. 12372</td>
</tr>
<tr class="odd">
<td colspan="22"></td>
<td colspan="21">OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR
REVIEW</td>
</tr>
<tr class="even">
<td colspan="22"></td>
<td colspan="21"></td>
</tr>
<tr class="odd">
<td colspan="22"></td>
<td colspan="21"><strong>17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL
DEBT?</strong></td>
</tr>
<tr class="even">
<td colspan="22"></td>
<td colspan="21"> Yes If “Yes,” attach an explanation. No</td>
</tr>
<tr class="odd">
<td colspan="43"><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="even">
<td colspan="29"><p>a. Typed Name of Authorized Representative</p>
<p>     </p></td>
<td colspan="8"><p>b. Title</p>
<p>     </p></td>
<td colspan="6"><p>c. Telephone number</p>
<p>(Include Area Code)      </p></td>
</tr>
<tr class="odd">
<td colspan="37">d. Signature of Authorized Representative</td>
<td colspan="6">e. Date Signed (mm/dd/yyyy)</td>
</tr>
</tbody>
</table>

> Previous Edition Usable Standard Form **424** (7/97)
>
> Prescribed by OMB Circular A-102
>
> **Authorized for Local Reproduction**

**Instructions for the SF-424**

+-----------------------------------+-----------------------------------+
| Public reporting burden for this  |                                   |
| collection of information is      |                                   |
| estimated to average 45 minutes   |                                   |
| per response, including the 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 face     |                                   |
| sheet for pre-applications and    |                                   |
| applications submitted for        |                                   |
| Federal assistance. It will be    |                                   |
| used by Federal agencies to       |                                   |
| obtain applicant certification    |                                   |
| that States which have            |                                   |
| established a review and comment  |                                   |
| procedure in response to          |                                   |
| executive Order 12372 and have    |                                   |
| selected the program to be        |                                   |
| included in their process, have   |                                   |
| been given an opportunity to      |                                   |
| review the applicant\'s           |                                   |
| submission.                       |                                   |
+-----------------------------------+-----------------------------------+
| Item Entry                        | Item Entry                        |
|                                   |                                   |
| 1\. Self-explanatory.             | 12\. List only the largest        |
|                                   | political entities affected       |
| 2\. Date application submitted to | (e.g., State,                     |
| Federal agency (or State if       |                                   |
|                                   | counties, cities).                |
| applicable) and applicant\'s      |                                   |
| control number (if applicable).   | 13\. Self-explanatory.            |
|                                   |                                   |
| 3\. State use only (if            | 14\. List the applicant\'s        |
| applicable).                      | Congressional District and any    |
|                                   | District(s)                       |
| 4\. If this application is to     |                                   |
| continue or revise an existing    | affected by the program or        |
| award,                            | project.                          |
|                                   |                                   |
| enter present Federal identifier  | 15\. **Use form HUD-4243-M,       |
| number. If for a new project,     | Funding Matri**x. Amount          |
|                                   | requested                         |
| leave blank.                      |                                   |
|                                   | or to be contributed during the   |
| 5\. Legal name of applicant, name | first funding/budget period by    |
| of primary organizational unit    |                                   |
|                                   | each contributor. Value of        |
| which will undertake the          | in-kind contributions should be   |
| assistance activity, complete ad- |                                   |
|                                   | included on appropriate lines as  |
| dress of the applicant, and name  | applicable. If the action will    |
| and telephone number of           |                                   |
|                                   | result in a dollar change to an   |
| the person to contact on matters  | existing award, indicate only     |
| related to this application.      |                                   |
|                                   | the amount of the change. For     |
| 6\. Enter Employer Identification | decreases, enclose the            |
| Number (EIN) as assigned by       |                                   |
|                                   | amounts in parentheses. If both   |
| the Internal Revenue Service.     | basic and supplemental            |
|                                   |                                   |
| 7\. Enter the appropriate letter  | amounts are included, show        |
| in the space provided.            | breakdown on an attached          |
|                                   |                                   |
| 8\. Check appropriate box and     | sheet. For multiple program       |
| enter appropriate letter(s) in    | funding, use totals and show      |
| the                               |                                   |
|                                   | breakdown using same categories   |
| space(s) provided:                | as item 15.                       |
|                                   |                                   |
| -- \"New\" means a new assistance | 16\. Applicants should contact    |
| award.                            | the State Single Point of Contact |
|                                   |                                   |
| -- \"Continuation\" means an      | (SPOC) for Federal Executive      |
| extension for an additional       | Order 12372 to determine          |
|                                   |                                   |
| funding budget period for a       | whether the application is        |
| project with a projected          | subject to the State intergovern- |
|                                   |                                   |
| completion date.                  | mental review process             |
|                                   |                                   |
| -- \"Revision\" means any change  | 17\. This question applies to the |
| in the Federal Government\'s      | applicant organization, not the   |
|                                   |                                   |
| financial obligation or           | person who signs as the           |
| contingent liability from an      | authorized representative.        |
| existing                          |                                   |
|                                   | Categories of debt include        |
| obligation.                       | delinquent audit disallowances,   |
|                                   |                                   |
| 9\. Name of Federal agency from   | loans and taxes.                  |
| which assistance is being         |                                   |
|                                   | 18\. To be signed by the          |
| requested with this application.  | authorized representative of the  |
|                                   | appli-                            |
| 10\. Use the Catalog of Federal   |                                   |
| Domestic Assistance number        | cant. A copy of the governing     |
|                                   | body\'s authorization for you to  |
| and title of the program under    |                                   |
| which assistance is requested.    | sign this application as official |
|                                   | representative must be on file    |
| 11\. Enter a brief descriptive    |                                   |
| title of the project. If more     | in the applicant\'s office.       |
| than one                          | (Certain Federal agencies may re- |
|                                   |                                   |
| program is involved, you should   | quire that this authorization be  |
| append an explanation on a        | submitted as part of the          |
|                                   |                                   |
| separate sheet. If appropriate    | application.)                     |
| (e.g., construction or real       |                                   |
|                                   |                                   |
| property projects), attach a map  |                                   |
| showing project location.         |                                   |
|                                   |                                   |
| For pre-applications, use a       |                                   |
| separate sheet to provide a       |                                   |
|                                   |                                   |
| summary description of this       |                                   |
| project.                          |                                   |
+-----------------------------------+-----------------------------------+

Previous Edition Usable form **SF-424** (7/97)

Authorized for Local Reproduction Prescribed by OMB Circular A-102