52

B Number: 4040-0004

Expiration Date: 01/31/2009

Version 02

Application for Federal Assistance SF-424 

*1. Type of Submission:

 Preapplication

 Application

 Changed/Corrected Application

*2. Type of Application

 New

 Continuation

Revision 

* If Revision, select appropriate letter(s)

 

*Other (Specify)

3. Date Received: 4. Applicant Identifier:

5a. Federal Entity Identifier: *5b. Federal Award Identifier:

State Use Only:

6. Date Received by State: 7. State Application Identifier: 

8. APPLICANT INFORMATION: 

*a. Legal Name: 

*b. Employer/Taxpayer Identification Number (EIN/TIN): *c. Organizational DUNS:

d. Address:

*Street 1:

 Street 2:

*City:

 County:

*State:

 Province:

*Country:

*Zip / Postal Code

e. Organizational Unit:

Department Name: Division 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: 
52

*Email: 

OMB Number: 4040-0004

Expiration Date: 01/31/2009

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:
52

OMB Number: 4040-0004

Expiration Date: 01/31/2009

Application for Federal Assistance SF-424 Version 02

16. Congressional Districts Of:

*a. Applicant: *b. Program/Project: 

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)
52

 Prescribed by OMB 

Circular A-102

OMB Number: 4040-0004

Expiration Date: 01/31/2009

Application for Federal Assistance SF-424 

Version 02

*Applicant Federal Debt Delinquency Explanation

The following should contain an explanation if the Applicant organization is delinquent of any Federal Debt. 
52

SUPPLEMENTAL INFORMATION REQUIRED FOR DEPARTMENT OF 

EDUCATION

1. Project Director:

Prefix: *First Name: Middle Name: *LastName: Suffix:

Address:

* Street1:

Street2:

* City:

County:

* State * Zip Code: * Country:

* Phone Number (give area code) Fax Number (give area code)

Email Address:

2. Applicant Experience:

Novice Applicant

Yes No Not applicable to this program

3. Human Subjects Research:

Are any research activities involving human subjects planned at any time during the proposed 

project Period?

 Yes No

Are ALL the research activities proposed designated to be exempt from the regulations?

 Yes Provide Exemption(s) #: 

 No Provide Assurance #, if available: 

Please attach an explanation Narrative:

OMB Control No. 1894-0007

Add 

Attachment

Delete Attachment View 

Attachment
52

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 apply for Federal assistance, 

and the institutional, managerial and financial capability 

(including funds sufficient to pay the non-Federal share 

of project cost) to ensure proper planning, management, 

and completion of the project described in this 

application.

2. Will give the awarding agency, the Comptroller General 

of the United States, and if appropriate, the State, 

through any authorized representative, access to and 

the right to examine all records, books, papers, or 

documents related to the award; and will establish a 

proper accounting system in accordance with generally 

accepted accounting standards or agency directives.

3. Will establish safeguards to prohibit employees from 

using their positions for a purpose that constitutes or 

presents the appearance of personal or organizational 

conflict of interest, or personal gain.

4. Will initiate and complete the work within the applicable 

time frame after receipt of approval of the awarding 

agency.

5. Will comply with the Intergovernmental Personnel Act of 

1970 (42 U.S.C. 4728-4763) relating to prescribed 

standards for merit systems for programs funded under 

one of the 19 statutes or regulations specified in 

Appendix A of OPM's Standards for a Merit System of 

Personnel Administration (5 C.F.R. 900, Subpart F).

6. Will comply with all Federal statutes relating to 

nondiscrimination. These include but are not limited to: 

(a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) 

which prohibits discrimination on the basis of race, color 

or national origin; (b) Title IX of the Education 

Amendments of 1972, as amended (20 U.S.C. 1681-

1683, and 1685-1686), which prohibits discrimination on 

the basis of sex; (c) Section 504 of the Rehabilitation Act 

of 1973, as amended (29 U.S.C. 794), which prohibits 

discrimination on the basis of handicaps; (d)

 

 the Age Discrimination Act of 1975, as amended (42 

U.S.C.  6101-6107), which prohibits discrimination on 

the basis of 

age; (e) the Drug Abuse Office and Treatment Act of 1972 

(P.L. 92-255), as amended, relating to nondiscrimination 

on the basis of drug abuse; (f) the Comprehensive Alcohol 

Abuse and Alcoholism Prevention, Treatment and 

Rehabilitation Act of 1970 (P.L. 91-616), as amended, 

relating to nondiscrimination on the basis of alcohol abuse 

or alcoholism; (g)  523 and 527 of the Public Health 

Service Act of 1912 (42 U.S.C.  290 dd-3 and 290 ee 

3), as amended, relating to confidentiality of alcohol and 

drug abuse patient records; (h) Title VIII of the Civil Rights 

Act of 1968 (42 U.S.C.  3601 et seq.), as amended, 

relating to nondiscrimination in the sale, rental or financing 

of housing; (i) any other nondiscrimination provisions in 

the specific statute(s) under which application for Federal 

assistance is being made; and (j) the requirements of any 

other nondiscrimination statute(s) which may apply to the 

application.

7. Will comply, or has already complied, with the 

requirements of Titles II and III of the uniform Relocation 

Assistance and Real Property Acquisition Policies Act of 

1970 (P.L. 91-646) which provide for fair and equitable 

treatment of persons displaced or whose property is 

acquired as a result of Federal or federally assisted 

programs. These requirements apply to all interests in real 

property acquired for project purposes regardless of 

Federal participation in purchases.

8. Will comply, as applicable, with the provisions of the Hatch 

Act (5 U.S.C. 1501-1508 and 7324-7328) which limit 

the political activities of employees whose principal 

employment activities are funded in whole or in part with 

Federal funds.
52

9. Will comply, as applicable, with the provisions of the 

Davis-Bacon Act (40 U.S.C. 276a to 276a-7), the 

Copeland Act (40 U.S.C. 276c and 18 U.S.C. 874) 

and the Contract Work Hours and Safety Standards Act 

(40 U.S.C.  327-333), regarding labor standards for 

federally assisted construction subagreements.

10. Will comply, if applicable, with flood insurance purchase 

requirements of Section 102(a) of the Flood Disaster 

Protection Act of 1973 (P.L. 93-234) which requires 

recipients in a special flood hazard area to participate in 

the program and to purchase flood insurance if the total

cost of insurable construction and acquisition is 

$10,000 or more.

 

11. Will comply with environmental standards which may be 

prescribed pursuant to the following: (a) institution of 

environmental quality control measures under the 

National Environmental Policy Act of 1969 (P.L. 91-190) 

and Executive Order (EO) 11514; (b) notification of 

violating facilities pursuant to EO 11738; (c) protection 

of wetlands pursuant to EO 11990; (d) evaluation of 

flood hazards in floodplains in accordance with EO 

11988; (e) assurance of project consistency with the 

approved State management program developed under 

the Coastal Zone Management Act of 1972 (16 U.S.C. 

1451 et seq.); (f) conformity of Federal actions to 

State (Clear Air) Implementation Plans under Section 

176(c) of the Clear 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).

12 Will comply with the Wild and Scenic Rivers Act of 1968 

(16 U.S.C. 1721 et seq.) related to protecting 

components or potential components of the national 

wild and scenic rivers system.

13. Will assist the awarding agency in assuring compliance 

with Section 106 of the National Historic Preservation 

Act of 1966, as amended (16 U.S.C. 470), EO 11593 

(identification and protection of historic properties), and 

the Archaeological and Historic Preservation Act of 

1974 (16 U.S.C. 469a-1 et seq.).

14. Will comply with P.L. 93-348 regarding the protection of 

human subjects involved in research, development, and 

related activities supported by 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 construction or 

rehabilitation of residence structures.

17. Will cause to be performed the required financial and 

compliance audits in accordance with the Single Audit 

Act Amendments of 1996 and OMB Circular No. A-133, 

Audits of States, Local Governments, and Non-Profit 

Organizations.

18. Will comply with all applicable requirements of all other 

Federal laws, executive orders, regulations and policies 

governing this program

Standard Form 424B (Rev. 7-97) Back

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE

APPLICANT ORGANIZATION DATE SUBMITTED
52

U.S. DEPARTMENT OF EDUCATION

BUDGET INFORMATION

NON-CONSTRUCTION PROGRAMS

OMB Control Number: 1894-0008

Expiration Date: 02/28/2011

Name of Institution/Organization Applicants requesting funding for only one year should complete the column under "Project Year 

1." Applicants requesting funding for multi-year grants should complete all applicable columns. 

Please read all instructions before completing form.

SECTION A - BUDGET SUMMARY

U.S. DEPARTMENT OF EDUCATION FUNDS

Budget Categories Project Year 1

(a)

Project Year 2

(b)

Project Year 3

(c)

Project Year 4

(d)

Project Year 5

(e)

Total

(f)

1. Personnel

2. Fringe Benefits

3. Travel

4. Equipment

5. Supplies

6. Contractual

7. Construction

8. Other

9. Total Direct Costs (lines 1-8)

10. Indirect Costs*

11. Training Stipends

12. Total Costs (lines 9-11)

*Indirect Cost Information (To Be Completed by Your Business Office):

If you are requesting reimbursement for indirect costs on line 10, please answer the following questions:

(1) Do you have an Indirect Cost Rate Agreement approved by the Federal government? ____Yes ____ No 

(2) If yes, please provide the following information:

 Period Covered by the Indirect Cost Rate Agreement: From: ___/___/______ To: ___/___/______ (mm/dd/yyyy)

 Approving Federal agency: ____ ED ____ Other (please specify): __________________________

(3) For Restricted Rate Programs (check one) -- Are you using a restricted indirect cost rate that:

___ Is included in your approved Indirect Cost Rate Agreement? or ___ Complies with 34 CFR 6.564(c)(2)?
52

Name of Institution/Organization Applicants requesting funding for only one year should complete the column under 

"Project Year 1." Applicants requesting funding for multi-year grants should complete all 

applicable columns. Please read all instructions before completing form.

SECTION B - BUDGET SUMMARY

NON-FEDERAL FUNDS

Budget Categories

Project Year 1

(a)

Project Year 2

(b)

Project Year 3

(c)

Project Year 4

(d)

Project Year 5

(e)

Total

(f)

1. Personnel

2. Fringe Benefits

3. Travel

4. Equipment

5. Supplies

6. Contractual

7. Construction

8. Other

9. Total Direct 

Costs

(Lines 1-8)

10. Indirect Costs

11. Training 

Stipends

12. Total Costs

(Lines 9-11)

SECTION C – BUDGET NARRATIVE (see instructions)

ED 524
52

CERTIFICATION REGARDING LOBBYING

Certification for Contracts, Grants, Loans and Cooperative Agreements.

The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for 

influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of 

Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of 

any Federal grant, the making of any Federal Loan, the entering into of any cooperative agreement, and the extension, 

continuation, renewal, amendment, or modification of any Federal contract, grant, loan or cooperative agreement.

(2) If any funds other Federal appropriated funds have been paid or will be paid to any person for influencing or 

attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of 

Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loam or 

cooperative agreement, the undersigned shall complete and submit Standard Form – LLL, “Disclosure of Lobbying 

Activities,” in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award documents for all 

subawards at all tiers (including subcontracts, subgrants and contracts under grants, loans, and cooperative 

agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material 

representation of fact upon which reliance was placed when this transaction was made or entered into. Submission 

of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, 

U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than 

$10,000 and not more than $100,000 for each such failure.

Statement for Loan Guarantees and Loan Insurance.

The undersigned states, to the best of his or her knowledge and belief, that:

If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or 

employee or any agency, a member of Congress, an officer or employee of Congress or an employee of a Member 

of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the 

undersigned shall complete and submit Standard Form-LLL, “Disclosure of Lobbying Activities,” in accordance with 

its instructions. Submission of this statement is a prerequisite for making or entering into this transaction imposed 

by section 1352, title 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil 

penalty of not less than $10,000 and not more than $100,000 for each such failure.

Applicant’s Organization

Printed Name of Authorized Representative Printed Title of Authorized Representative

Signature Date

ED 80-0013 08/05
52

 OMB No. 1890-0014, Exp. 02/28/09

Survey on Ensuring Equal Opportunity for Applicants

 

Applicant’s (Organization) Name: 

____________________________________________________________

Applicant’s DUNS Number: 

_________________________________________________________________

Federal Program: ________________________________________________CFDA Number: 

___________ 

1. Has the applicant ever received a grant or 

contract from the Federal government?

Yes No

2. Is the applicant a faith-based organization? 

Yes No

3. Is the applicant a secular organization? 

Yes No

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

Yes No

5. Is the applicant a local affiliate of a national

organization? 

Yes No

6. 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

7. 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

Purpose: The Federal government is committed to ensuring that all qualified applicants, small or large, non-religious 

or faith-based, have an equal opportunity to compete for Federal funding. In order for us to better understand the 

population of applicants for Federal funds, we are asking nonprofit private organizations (not including private 

universities) to fill out this survey. 

Upon receipt, the survey will be separated from the application. Information provided on the survey will not be 

considered in any way in making funding decisions and will not be included in the Federal grants database. While 

your help in this data collection process is greatly appreciated, completion of this survey is voluntary. 

Instructions for Submitting the Survey: If you are applying using a hard copy 

application, please place the completed survey in an envelope labeled 

“Applicant Survey.” Seal the envelope and include it along with your 
52

Approved by OMB

0348-0046

Disclosure of Lobbying Activities

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352

(See reverse for public burden disclosure)

1. Type of Federal Action:

 a. contract

____ b. grant

 c. cooperative agreement

 d. loan

 e. loan guarantee

 f. loan insurance 

2. Status of Federal Action:

 a. 

bid/offer/application

 _____ b. initial award

 c. post-award 

3. Report Type:

 a. initial filing

_____ b. material change

For material change only:

Year _______ quarter _______

Date of last report___________

 

4. Name and Address of Reporting Entity:

 ____ Prime _____ Subawardee

 Tier______, if Known: 

 Congressional District, if known: 

5. If Reporting Entity in No. 4 is Subawardee, Enter 

Name and Address of Prime: 

 Congressional District, if known: 

6. Federal Department/Agency: 7. Federal Program Name/Description: 

CFDA Number, if applicable: __________________

7. Federal Action Number, if known: 9. Award Amount, if known: 

$ 

10. a. Name and Address of Lobbying Registrant

 (if individual, last name, first name, MI): 

b. Individuals Performing Services (including address 

if different from No. 10a)

 (last name, first name, MI): 

11. Information requested through this form is authorized 

by title 31 U.S.C. section 1352. This disclosure of 

lobbying activities is a material representation of fact upon 

which reliance was placed by the tier above when this 

transaction was made or entered into. This disclosure is 

required pursuant to 31 U.S.C. 1352. This information will 

be reported to the Congress semi-annually and will be 

available for public inspection. Any person who fails to 

file the required disclosure shall be subject to a civil 

penalty of not less than $10,000 and not more than 

$100,000 for each such failure.

Signature: __________________________________

Print Name: _____

Title: _____

Telephone No.: ____________ Date: _______

Federal Use Only Authorized for Local Reproduction

Standard Form - LLL (Rev. 7-97)