State and Local Government Applicants 

Nongovernmental Applicants for Health Services Projects

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

PUBLIC HEALTH SERVICE

GRANT APPLICATION

For use by:

FORM PHS-5161-1

(Revised 7/00)

a progress or performance report for activities previously undertaken.

The seventh and last section is the Checklist, which

must be included with all applications.

Before completing the application, it is advisable to

refer to any relevant program guidelines provided with

the application kit. The kit may also contain additional

supplementary instructions pertaining to unique program requirements set forth in legislation or regulations.

For additional information about, or copies of, material

referred to in this application, contact the grants

management office which supplied the application kit. 

Comments concerning the accuracy of the burden estimates for the Program Narrative and the Checklist and

any suggestions for reducing this burden should be

addressed to:

CDC Reports Clearance Officer

1600 Clifton Road

MS-D-24

Atlanta, GA 30333

Attention: PRA (0920-0428)

NOTE: The grant application which you are

submitting may be subject to the reporting

requirements of the Public Health System Impact

Statement. Consult the Program Announcement or

the Grants Management Officer for the program to

which you are applying for additional information.

TYPES OF APPLICATIONS

The Form PHS-5161-1 may be used for any of the

following types of applications: 

1. New - A new application is a request for financial

assistance for a project or program not currently

receiving PHS support. If recommended for

approval it must compete with other new applications, competing continuation applications, and

competing supplemental applications for any

available funds in accordance with Federal

awarding office funding priorities. A complete

submission of all information requested, including

budget justification, is required for all new

applications.

INTRODUCTION 

This application form, the PHS 5161-1, is used for a

variety of grant programs administered by the Public

Health Service (PHS). The basic format (Standard Form

424) is prescribed by OMB Circular A-102 for use by

State and local government applicants. The PHS-5161-1

is also intended for use by nongovernmental applicants

seeking support for health services projects.

The application consists of this section, General Information and Instructions, followed by six additional sections which comprise the standard application.

This section contains information about PHS policies

and procedures.

The second section, the SF-424, is the face page of the

application which requests basic information about the

applicant and the project.

The third section, Budget Information (nonconstruction

or construction) requests information on the applicant’s

financial plan for carrying out the project or program.

Both the Federal and non-Federal shares are to be

included in the financial plan. The application kit contains budget forms for both nonconstruction (SF-424A)

and construction (SF-424C) projects or programs.

Please be sure that you use the correct form.

The fourth section, Assurances (nonconstruction or

construction) sets forth certain requirements with which

applicants must certify that they will comply if a grant

is awarded. The application kit includes assurances for

both nonconstruction (SF-424B) and construction

(SF-424D) projects or programs. Please be sure that you

submit the correct assurance form and that the back of

the form is signed by a duly authorized official of the

applicant organization.

The fifth section, Certifications, sets forth certain

requirements for grantees which have been legislatively

implemented since the SF-424 assurances pages were

last revised. This form must also be signed by a duly

authorized official of the applicant organization and

submitted.

The sixth section, Program Narrative, requests the

applicant to describe the objectives of the program and

to relate how those objectives will be attained. For

projects funded beyond the first year, this section is

used to describe the objectives and activities to be undertaken during the next period of support and also as

GENERAL INFORMATION AND INSTRUCTIONS FOR GRANT APPLICATION

(FORM PHS-5161-1, Revised 7/00)
PHS-5161-1 (7/00)

noncompeting, but are subject to the approval of the

awarding office and the availability of funds.

A supplemental application must justify the need

for the additional funds. It should describe how the

supplemental award, or lack of it, would influence

program results.

On the budget page(s), show only the supplemental

funds requested, and any matching/cost participation amounts (as appropriate). As part of the budget

justification, include a statement as to whether any

changes have been made or are anticipated in the

allocation of funds among categories for the

previously approved budget.

PROJECT DEVELOPMENT

All new applicants are urged to discuss their interests

and ideas for developing projects early in the planning

stage with State, regional, and local planning agencies

and/or health departments. Community support should

be assured by providing opportunities for public and

private participation in the planning and development

phases. When applicable, comments must be sought

from State Single Points of Contact in accord with

requirements under Executive Order 12372 as

implemented by the Department of Health and Human

Services (DHHS) through regulations at 45 CFR Part

100 (see checklist instructions).

Staff of the administering office from which funds are

being requested are also available to assist applicants.

COMPLETING THE APPLICATION

In preparing the application, use English language and

avoid jargon. Type, using black typewriter ribbon,

single spaced where possible. Instructions for

completing the pages of the form are found either on the

reverse of the forms or on supplemental pages. If more

space is needed than is provided, use a blank sheet of

paper to complete the item, using the identical format.

Clearly identify the continuation page as such, and the

information item(s) contained thereon, and attach the

page after the appropriate page of the application. 

Computer generated facsimiles may be substituted for

any of the forms provided in this packet. Such substitute

forms should be printed in black ink and must maintain

the exact wording and format of the government-printed

forms, including all captions and spacing. Any deviation

may be grounds for PHS to reject the entire application.

2. Noncompeting Continuation - A noncompeting

continuation application is a request for support

beyond the initial budget period within a previously

approved project period . These applications do not

compete with other applications, and the level of

support is determined by the awarding office after

considering the previously recommended level of

support and the progress achieved on the project.

A complete resubmission of the material contained

in the initially approved application is not

necessary, but the continuation application should

include: a detailed justification, as necessary;

information on the qualifying experience of key

personnel added since the previous application; a

report of progress relative to approved objectives;

and a narrative discussing any significant changes

to the originally approved project plan. Refer to

Item 6(b) in the Program Narrative instructions, and

to program guidelines for additional guidance on

preparing the progress report.

3. Competing Continuation - A competing continuation application is a request for the extension of

support for one or more budget periods of a project

which would otherwise expire. These applications

are subject to the same review and analysis as new

applications and they compete for available funds

with other competing continuation applications,

new applications, and competing supplemental

applications. The information requirements applicable to competing continuation applications are

the same as those that apply to new applications

except that competing continuation applications

must also include a progress report as described

under Item 6(b) of the Program Narrative section.

4. Supplemental - A supplemental application is a

request for additional funding within an approved

budget period for program expansion or

administrative increases. Applications for funds to

expand the scope of the project are subject to the

same review procedures as new or competing

continuation applications. Applications for funds to

meet increases in costs incurred during a current

budget period (such as increases in fringe

benefits, salaries, or other project costs not included in the previous application) are generally

Page 2

Budget Period - The interval of the time (usually 12 months) into which the project

period is divided for funding and reporting purposes.

Project Period - The total time for which support of a project has been programmatically approved. A project period may consist of one or more budget periods

2

1

2

1
PHS-5161-1 (7/00)

NONCONFORMING APPLICATIONS

Applications which are determined to be nonconforming shall not be accepted for processing and

shall be returned to the applicant. A grant application

may be classified as nonconforming if it does not meet

the requirements of the program announcement to

which it is responding.

APPLICATION REVIEW

Applications will be evaluated and rated according to

criteria and priorities which are established for the

particular grant program involved and which are

described in program announcements and program

guidelines.

UNSUCCESSFUL APPLICANTS 

After a decision has been reached either to disapprove

or not fund a grant application during a given review

cycle, a written notice shall be sent to the unsuccessful

applicant within 30 days after that decision. 

PRIVACY ACT 

The Privacy Act of 1974 (5 U.S.C. § 552a) gives

individuals the right of access to information concerning themselves and provides a mechanism for

correction or amendment of such records. The Privacy

Act also provides for protection of information

pertaining to an individual, but it does not prevent

disclosure of such information if its release is required

under the Freedom of Information Act. The Privacy Act

requires that a Federal agency must advise each

individual whom it asks to supply the information (1) of

the authority which authorizes the solicitation, (2)

whether disclosure is voluntary or mandatory, (3) the

principal purpose or purposes for which the information is to be used, (4) the use outside the agency

which may be made of the information, and (5) the

effects on the individual, if any, of not providing all or

any part of the requested information. 

PHS is requesting the information called for in this

application pursuant to its statutory authority to award

grants. Provision of the information requested is entirely

voluntary. The collection of this information is for the

purpose of aiding in the review of applications prior to

grant award decisions and for management of PHS

programs. Insufficient information may hinder PHS

ability to review applications, monitor grantee

performance, or perform overall management of grant

programs.

ASSEMBLING AND MAILING 

To facilitate review and processing of the application by

the awarding office, all pages should be numbered and

preceded by a table of contents. Assemble the

application with a cover letter on top indicating the

specific program for which you are applying, followed

by a table of contents, the printed forms, the program

narrative, biographical sketches, and any remaining

documents. Completed applications should be signed in

ink by an authorized official of the applicant organization and duplicated in accord with applicable

requirements. Mail completed applications to the

appropriate grants management office (unless other

instructions have been provided) in time to meet the

deadline date for receipt established by the awarding

office.

ACKNOWLEDGMENT 

Applicants will be sent a written acknowledgment of

receipt by PHS administering offices. 

LATE APPLICATIONS 

New/Competing Continuation 

Applications will be considered to be "on time" if they

are (1) received on or before the established deadline

date or (2) sent on or before the established deadline

date and received in time for orderly processing.

Applicants should request a legibly dated U.S. Postal

Service postmark or obtain a legibly dated receipt from

a commercial carrier or the U.S. Postal Service. Private

metered postmarks shall not be acceptable as proof of

timely mailing. Late competing applications not

accepted for processing may either be returned to the

applicant or held for the next regularly scheduled

review cycle. 

Noncompeting Continuation 

Applications which are not received in time to permit

orderly review, processing, and award issuance on or

before the beginning date of the continuation budget

period, may result in: (1) an extension of the current

budget period without additional Federal funds, and (2)

a delay in the beginning date of the new budget period.

Page 3
6. To individuals and organizations deemed

qualified by PHS to carry out specific research

related to the review and award processes of PHS.

7. To organizations in the private sector with whom

PHS has contracted for the purpose of collating,

analyzing, aggregating, or otherwise refining

records in a system. Relevant records will be

disclosed to such a contractor. The contractor

shall be required to maintain Privacy Act

safeguards with respect to such records.

8. To the grantee institution relative to performance

or administration under the terms and conditions

of the award.

FREEDOM OF INFORMATION ACT 

The Freedom of Information Act and the associated

Public Information Regulations (45 CFR Part 5) of the

Department of Health and Human Services require the

release of certain information regarding grants

requested by any member of the public. The intended

use of the information will not be a criterion for release.

Grant applications and grant related reports are

generally available for inspection and copying except

that information considered to be an unwarranted

invasion of personal privacy will not be disclosed. For

specific guidance on the availability of information,

refer to 45 CFR Part 5.

This information will be used within the Department of

Health and Human Services, and may also be disclosed

outside the Department as permitted by the Privacy Act,

including disclosures to the public as required by the

Freedom of Information Act, to the Congress, the

National Archives, the Bureau of the Census, law

enforcement agencies upon their request, the General

Accounting Office, and pursuant to court order. It may

also be disclosed outside the Department, if necessary,

for the following purposes: 

1. To the cognizant audit agency for auditing.

2. To the Department of Justice as required for

litigation.

3. To a congressional office from the record of an

individual in response to an inquiry from the

congressional office made at the request of that

individual.

4. To qualified experts not within the definition of

Department employees as prescribed in the

Department’s regulations [45 CFR Part 5(b)(2)]

for their opinions, as part of the application

review process.

5. To a Federal agency in response to its request, in

connection with the letting of a contract, or the

issuance of a license, grant, or other benefit by the

requesting agency, to the extent that the record is

relevant and necessary to the requesting agency’s

decision on the matter.

Page 4 PHS-5161-1 (7/00)
Preapplication

Construction

Non-Construction

17. IS APPLICATION DELINQUENT ON ANY FEDERAL DEBT?

YES If "Yes," attach an explanation. No

OMB Approval No. 0348-0043

Federal Identifier

14. CONGRESSIONAL DISTRICTS OF:

APPLICATION FOR

FEDERAL ASSISTANCE

1. TYPE OF SUBMISSION: 3. DATE RECEIVED BY STATE

Application

Construction

Non-Construction

State Application Identifier

4. DATE RECEIVED BY FEDERAL AGENCY

12. AREAS AFFECTED BY PROJECT (cities, counties, states, etc.):

Legal Name: Organizational Unit:

Address (give city, county, state, and zip code):

7. TYPE OF APPLICANT: (enter appropriate letter in box)

A. State H. Independent School Dist.

B. County I. State Controlled Institution of Higher Learning

C. Municipal J. Private University

D. Township K. Indian Tribe

E. Interstate L. Individual

F. Intermunicipal M. Profit Organization

G. Special District N. Other (Specify):

6. EMPLOYER IDENTIFICATION NUMBER (EIN):

Name and telephone number of the person to be contacted on matters involving this

application (give area code)

9. NAME OF FEDERAL AGENCY:

8. TYPE OF APPLICATION:

New Continuation Revision

If Revision, enter appropriate letter(s) in box(es):

A. Increase Award B. Decrease Award C. Increase Duration

D. Decrease Duration Other (specify):

2. DATE SUBMITTED

18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT, THE DOCUMENT HAS BEEN DULY

AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.

10. CATALOG OF FEDERAL DOMESTIC

ASSISTANCE NUMBER:

TITLE:

5. APPLICANT INFORMATION

Previous Editions Not Usable

Authorized for Local Reproduction

.00 

b. Project

15. ESTIMATED FUNDING:

b. Applicant

d. Local

c. State

e. Other

f. Program Income

g. TOTAL

a. Federal

$

$

$

$

$

$

11. DESCRIPTIVE TITLE OF APPLICANT’S PROJECT:

.00 

.00 

.00 

.00 

.00 

.00 

13. PROPOSED PROJECT:

Start Date Ending Date a. Applicant

$

16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS?

a. YES. THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE STATE EXECUTIVE

ORDER 12372 PROCESS FOR REVIEW ON:

DATE

b. NO. PROGRAM IS NOT COVERED BY E.O. 12372

OR PROGRAM HAS NOT BEEN SELECTED STATE FOR REVIEW

d. Signature of Authorized Representative

a. Typed Name of Authorized Representative b. Title c. Telephone number

e. Date Signed

Standard Form 424 (Rev. 7-97)

Prescribed by OMB Circular A-102

Applicant Identifier
12. List only the largest political entities affected (e.g.,

State, counties, cities).

13. Self-explanatory

14. List the applicant’s Congressional District and

District(s) affected by the program or project.

15. Amount requested or to be contributed during the

first funding/budget period by each contributor.

Value of 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.

If both basic and supplemental amounts are

included, show breakdown on an attached sheet.

For multiple program funding, use totals and

show breakdown using same categories as item

15.

16. Applicants should contact the State Single Point

of Contact (SPOC) for Federal Executive Order

12372 to determine whether the application is

subject to the State intergovernmental review

process.

17. This question applies to the applicant organization, not the person who signs as the

authorized representative. Categories of debt

include delinquent audit disallowances, loans and

taxes.

18. To be signed by the authorized representative of

the applicant. A copy of the governing body’s

authorization for you to sign this application as

official representative must be on file in the

applicant’s office. (Certain Federal agencies may

require that this authorization be submitted as

part of the application.)

1. Self-explanatory.

2. Date application submitted to Federal agency (or

State if applicable) & applicant’s control number (if

applicable).

3. State use only (if applicable).

4. If this application is to continue or revise an

existing award, enter present Federal identifier

number. If for a new project, leave blank.

5. Legal name of applicant, name of primary

organizational unit which will undertake the

assistance activity, complete address of the

applicant, and name and telephone number of the

person to contact on matters related to this

application.

6. Enter Employer Identification Number (EIN) as

assigned by Internal Revenue Service.

7. Enter the appropriate letter in the space provided.

8. Check appropriate box and enter appropriate

letter(s) in the space(s) provided:

- "New" means a new assistance award.

- "Continuation" means an extension for an

additional funding/budget period for a project

with a projected completion date.

- "Revision" means any change in the Federal

Governments financial obligation or contingent

liability from an existing obligation.

9. Name of Federal agency from which assistance is

being requested with this application.

10. Use the Catalog of Federal Domestic Assistance

number and title of the program under which

assistance is requested.

11. Enter a brief descriptive title of the project. If

more than one program is involved, you should

append an explanation on a separate sheet. If

appropriate (e.g., construction or real property

projects), attach a map showing project location.

For preapplications, use a separate sheet to

provide a summary description of this project.

This is a standard form used by applicants as a required facesheet for preapplications and applications submitted

for Federal assistance. It will be used by Federal agencies to obtain applicant certification that States which have

established a review and comment procedure in response to Executive Order 12372 and have selected the program

to be included in their process, have been given an opportunity to review the applicant’s submission.

Item: Entry:

INSTRUCTIONS FOR THE SF-424

Item: Entry:

SF-424 (Rev. 7-97) Back

Public reporting burden for this collection of information is estimated to average 45 minutes per response, including time for

reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and

reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of

information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction

Project (0348-0043), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. 

SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
New or Revised 

BUDGET INFORMATION - Non-Construction Programs

GRANT PROGRAM, FUNCTION OR ACTIVITY

Grant Program

Function

or Activity

(a)

Catalog of Federal

Domestic Assistance

Number

(b)

Estimated Unobligated Funds

Non-Federal

(d)

Federal

(e)

Non-Fede

(f)

Federal

(c)

1.2.3.4.

a. Personnel

(1) (2) (3) (4)

$ $$ $ $ $$ $ $ $$ $ $ $$ $ 

SECTION A - BUDGET SUMMARY

SECTION B - BUDGET CATEGORIES

5. TOTALS6. Object Class Categories

b. Fringe Benefitsd. Equipmentc. Travele. Suppliesf. Contractualg. Constructionh. Otheri. Total Direct Charges (sum of 6a - 6h)j. Indirect Charges

7. Program Income

k. TOTALS (sum of 6i and 6j)

$ $$ $ 
SECTION C - NON-FEDERAL RESOURCES

SECTION D - FORECASTED CASH NEEDS

(b) First

13. Federal

$$$ 

$

18.

(a) Grant Program

17.

22. Indirect Charges:

23. Remarks14. Non-Federal

Total for 1st Year

19.

$$$ 

21. Direct Charges:

$$$ 

$

(b) Applicant (c) State 

FUTURE FUNDING PERIODS (Yea

SECTION F - OTHER BUDGET INFORMATION

20. TOTALS (sum of lines 16 - 19)

(d) Othe

15. TOTAL (sum of lines 13 and 14)

$$$ $$$ 

(a) Grant Program

(c) Second 

(d) T

1st Quarter 2nd Quarter 

3rd Q

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

8.9.10.11.12. TOTALS (sum of lines 8 and 11)16. $$$ 
Lines 1 - 4, Columns (c) through (g.) (continued)

For continuing grant program applications, submit

these forms before the end of each funding period as

required by the grantor agency. Enter in Columns (c)

and (d) the estimated amounts of funds which will

remain unobligated at the end of the grant funding

period only if the Federal grantor agency instructions

provide for this. Otherwise, leave these columns blank.

Enter in columns (e) and (f) the amounts of funds

needed for the upcoming period. The amount(s) in

Column (g) should be the sum of amounts in Columns

(e) and (f). 

For supplemental grants and changes to existing

grants, do not use Columns (c) and (d). Enter in column

(e) the amount of the increase or decrease of Federal

Funds and enter in Column (f) the amount of the

increase or decrease of non-Federal funds. In Column

(g) enter the new total budgeted amount (Federal and

non-Federal) which includes the total previous

authorized budgeted amounts plus or minus, as

appropriate, the amounts shown in Columns (e) and (f).

The amount(s) in Column (g) should not equal the sum

of amounts in Columns (e) and (f). 

Line 5 - Show the totals for all columns used.

Section B. Budget Categories 

In the column heading (1) through (4), enter the titles of

the same programs, functions, and activities shown on

Lines 1 - 4, Column (a), Section A. When addi- tional

sheets are prepared for Section A, provide similar

column headings on each sheet. For each program,

function or activity, fill in the total re- quirements for

funds (both Federal and non-Federal) by object class

categories. 

Lines 6a-i - Show the totals of Lines 6a to 6h in each

column. 

Line 6j - Show the amount of indirect cost.

Line 6k - Enter the total of amounts on Lines 6i and 6j.

For all applications for new grants and continuation

grants the total amount in column (5), Line 6k, should

be the same as the total amount shown in Section A,

Column (g), Line 5. For supplemental grants and

changes to grants, the total amount of the increase or

decrease as shown in Columns (1) - (4), Line 6k should

be the same as the sum of the amounts in Section A,

Columns (e) and (f) on Line 5.

Line 7 - Enter the estimated amount of income, if any,

expected to be generated from this project. Do not add

or subtract this amount from the total project amount. 

General Instructions

This form is designed so that application can be made

for funds from one or more grant programs. In preparing the budget, adhere to any existing Federal

grantor agency guidelines which prescribe how and

whether budgeted amounts should be separately shown

for different functions or activities within the program.

For some programs, grantor agencies may require

budgets to be separately shown by function or activity.

For other programs, grantor agencies may require a

breakdown by function or activity. Sections A, B, C, and

D should include budget estimates for the whole project

except when applying for assistance which requires

Federal authorization in annual or other funding period

increments. In the latter case, Sections A, B, C, and D

should provide the budget for the first budget period

(usually a year) and Section E should present the need

for Federal assistance in the subsequent budget

periods. All applications should contain a breakdown by

the object class categories shown in Lines a - k of

Section B. 

Section A. Budget Summary Lines 1 - 4, Columns

(a) and (b) 

For applications pertaining to a single Federal grant

program (Federal Domestic Assistance Catalog

number) and not requiring a functional or activity

breakdown, enter on Line 1 under Column (a) the

catalog program title and the catalog number in Column

(b).

For applications pertaining to a single program

requiring budget amounts by multiple functions or

activities, enter the name of each activity or function on

each line in Column (a), and enter the catalog number

in Column (b). For applications pertaining to multiple

programs where none of the programs require a

breakdown by function or activity, enter the catalog

program title on each line in Column (a) and the

respective catalog number on each line in Column (b). 

For applications pertaining to multiple programs

where one or more programs require a breakdown by

function or activity, prepare a separate sheet for each

program requiring the breakdown. Additional sheets

should be used when one form does not provide

adequate space for all breakdown of data required.

However, when more than one sheet is used, the first

page should provide the summary totals by programs. 

Lines 1 - 4, Columns (c) through (g.) 

For new applications, leave Columns (c) and (d) blank.

For each line entry in Columns (a) and (b), enter in

Columns (e), (f), and (g) the appropriate amounts of

funds needed to support the project for the first funding

period (usually a year).

INSTRUCTIONS FOR THE SF-424A

SF-424A (Rev. 7-97) Page 3

Public reporting burden for this collection of information is estimated to average 180 minutes per response, including time for

reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and

reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of

information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction

Project (0348-0044), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. 

SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Line 15 - Enter the totals of amounts on Lines 13 and

14. 

Section E. Budget Estimates of Federal Funds

Needed for Balance of the Project 

Lines 16 - 19 - Enter in Column (a) the same grant

program titles shown in column (a), Section A. A

breakdown by function or activity is not necessary. For

new applications and continuation grant applications,

enter in the proper columns amounts of Federal funds

which will be needed to complete the program or project

over the succeeding funding periods (usually in years).

This section need not be completed for revisions

(amendments, changes, or supplements) to funds for

the current year of existing grants. 

If more than four lines are needed to list the program

titles, submit additional schedules as necessary. 

Line 20 - Enter the total for each of the Columns (b) -

(e). When additional schedules are prepared for this

Section, annotate accordingly and show the overall

totals on this line. 

Section F. Other Budget Information 

Line 21 - Use this space to explain amounts for

individual direct object-class cost categories that may

appear to be out of the ordinary or to explain the details

as required by the Federal grantor agency. 

Line 22 - Enter the type of indirect rate (provisional,

predetermined, final or fixed) that will be in effect during

the funding period, the estimated amount of the base to

which the rate is applied, and the total indirect expense. 

Line 23 - Provide any other explanations or comments

deemed necessary.

Line 7 - (continued)

Show under the program narrative statement the nature

and source of income. The estimated amount of

program income may be considered by the Federal

grantor agency in determining the total amount of the

grant. 

Section C. Non-Federal Resources 

Lines 8 - 11 - Enter amounts of non-Federal resources

that will be used on the grant. If in-kind contributions are

included, provide a brief explanation on a separate

sheet. 

Column (a) - Enter the program titles identical to

Column (a), Section A. A breakdown by function or

activity is not necessary.

Column (b) - Enter the contribution to be made by

the applicant.

Column (c) - Enter the amount of the State’s cash

and in-kind contribution if the applicant is not a

State or State agency. Applicants which are a

State or State agencies should leave this column

blank.

Column (d) - Enter the amount of cash and in-kind

contributions to be made from all other sources.

Column (e) - Enter totals of Columns (b), (c), and

(d).

Line 12 - Enter the total for each of Columns (b) - (e).

The amount in Column (e) should be equal to the

amount on Line 5, Column (f), Section A. 

Section D. Forecasted Cash Needs

Line 13 - Enter the amount of cash needed by quarter

from the grantor agency during the first year. 

Line 14 - Enter the amount of cash from all other

sources needed by quarter during the first year. 

INSTRUCTIONS FOR THE SF-424A (Continued)

SF-424A (Rev. 7-97) Page 4
(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 non- discrimination

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 Title 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 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.

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.

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:

OMB Approval No. 0348-0040

Standard Form 424B (Rev.7-97)

Prescribed by OMB Circular A-102

ASSURANCES - NON-CONSTRUCTION PROGRAMS

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 costs) 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

standard 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 nineteen statutes

or regulations specified in Appendix A of OPM’s

Standard 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;

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.
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 of 1984.

18. Will comply with all applicable requirements of all

other Federal laws, executive orders, re- gulations

and policies governing this program.

SF-424B (Rev. 7-97) Back

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 wetland

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 Costal 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. §§1271 et seq.) related to

protecting components or potential components of

the national wild and scenic rivers system.

DATE SUBMITTED

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

APPLICANT ORGANIZATION

TITLE
2. Land, structures, rights-of-way, appraisals, etc.

NOTE: Certain Federal assistance programs require additional computations to arrive at the Federal share of project costs eligible for participation. If such is the c

BUDGET INFORMATION - Construction Programs

4. Architectural and engineering fees3. Relocation expenses and payments5. Other architectural and engineering fees6. Project inspection fees7. Site work8. Demolition and removal9. Construction10. Equipment11. Miscellaneous12. SUBTOTAL (sum of lines 1-11)13. Contingencies14. SUBTOTAL15. Project (program) income

FEDERAL FUNDING

16. TOTAL PROJECT COSTS (subtract # 15 from # 14)

COST CLASSIFICATION 

1. Administrative and legal expenses

$ .00 

a. Total Cost b. Costs Not Allowable for Participation

.00 

$ .00 

.00 

$

.00 

$

.00 

$

.00 

$

.00 

$

.00 

$

.00 

$

.00 

$

.00 

$

.00 

$

.00 

$

.00 

$

.00 

$$

$ $ $$$$$$$$$$$$$$

17. Federal assistance requested, calculate as follows:

(Consult Federal agency for Federal percentage share).Enter the resulting Federal share.

Enter eligible costs from line 16c Multiply X %
Line 4 - Enter estimated basic engineering fees related

to construction (this includes start-up services and

preparation of project performance work plan).

Line 5 - Enter estimated engineering costs, such as

surveys, tests, soil borings, etc.

Line 6 - Enter estimated engineering inspection costs.

Line 7 - Enter estimated costs of site preparation and

restoration which are not included in the basic

construction contract.

Line 9 - Enter estimated cost of the construction

contract.

Line 10 - Enter estimated cost of office, shop,

laboratory, safety equipment, etc. to be used at the

facility, if such costs are not included in the

construction contract.

Line 11 - Enter estimated miscellaneous costs.

Line 12 - Total of items 1 through 11.

Line 13 - Enter estimated contingency costs.(Consult

the Federal agency for the percentage of the

estimated construction cost to use.)

Line 14 - Enter the total of lines 12 and 13.

Line 15 - Enter estimated program income to be

earned during the grant period, e.g., salvaged

materials, etc.

Line 16 - Subtract line 15 from line 14.

Line 17 - This block is for the computation of the

Federal share. Multiply the total allowable project

costs from line 16, column "c." by the Federal

percentage share (this may be up to 100 percent;

consult Federal agency for Federal percentage share)

and enter the product in line 17.

This sheet is to be used for the following types of applications: (1) "New" (means a new [previously unfunded]

assistance award); (2) "Continuation" (means funding in a succeeding budget period which stemmed from a prior

agreement to fund); and (3) "Revised" (means any changes in the Federal government’s financial obligations or

contingent liability from an existing obligation). If there is no change in the award amount there is no need to

complete this form. Certain Federal agencies may require only an explanatory letter to effect minor (no cost)

changes. If you have questions please contact the Federal agency.

SF-424C (Rev. 7-97) Back

Column a. - If this is an application for a "New" project,

enter the total estimated cost of each of the items

listed on the lines 1 through 16 (as applicable) under

"COST CLASSIFICATIONS."

If this application entails a change to an existing

award, enter the eligible amounts approved under the

previous award for the items under "COST

CLASSIFICATION."

Column b. - If this is an application for "New" project,

enter that portion of the cost of each item in Column a.

which is not allowable for Federal assistance. Contact

the Federal agency for assistance in determining the

allowability of specific costs.

If this application entails a change to an existing

award, enter the adjustment [+ or (-)] to the previously

approved costs (from column a.) reflected in this

application.

Column c. - This is the net of lines 1 through 16 in

columns "a." and "b."

Line 1 - Enter estimated amounts needed to cover

administrative expenses. Do not include costs which

are related to the normal functions of the government.

Allowable legal costs are generally only those

associated with the purchase of the land which is

allowable for Federal participation and certain services

in support of construction of the project.

Line 2 - Enter estimated site and right(s)-of-way

acquisition costs (this includes purchase, lease, and/or

easements).

Line 3 - Enter estimated costs related to relocation

advisory assistance, replacement housing, relocation

payments to displaced persons and businesses, etc.

INSTRUCTIONS FOR THE SF-424C

Public reporting burden for this collection of information is estimated to average 180 minutes per response, including time for

reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and

reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of

information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction

Project (0348-0041), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. 

SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
8. 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 nineteen

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).

9. 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.

10. Will comply with all Federal statutes relating to

non-discrimination. These include but are not

limited to: (a) Title VI of the Civil Rights Act of

1964 (P.L. 88-352) which prohibits discrim- ination

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

prohibit discrimination of the basis of handicaps;

(d) the Age Discrimination Act 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.

93-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the

Comprehensive Alcohol Abuse and Alco- holism

Prevention, Treatment and Rehabilitation Act of

1970 (P.L. 91-616), as amended, relating to

non-discrimination 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

non-discrimination in the sale, rental or financing

of housing; (i) any other non- discrimination

provisions in the specific statute(s) under which

application for Federal assistance is being made,

and (j) the requirements on any other nondiscrimination Statute(s) which may apply to the

application.

Note: Certain of these assurances may not be applicable to your project or program. If you have questions,

please contact the Awarding Agency. Further, certain federal assistance awarding agencies may require

applicants to certify to additional assurances. If such is the case, you will be notified.

As the duly authorized representative of the applicant I certify that the applicant:

OMB Approval No. 0348-0042

Standard Form 424D (Rev. 7-97)

Prescribed by OMB Circular A-102

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 costs) 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

assistance; and will establish a proper accounting

system in accordance with generally accepted

accounting standards or agency directives.

3. Will not dispose of, modify the use of, or change the

terms of the real property title, or other interest in

the site and facilities without permission and

instructions from the awarding agency. Will record

the Federal interest in the title of real property in

accordance with awarding agency directives and

will include a covenant in the title of real property

acquired in whole or in part with Federal assistance

funds to assure non- discrimination during the

useful life of the project.

4. Will comply with the requirements of the assistance

awarding agency with regard to the drafting, review

and approval of construction plans and

specifications.

5. Will provide and maintain competent and adequate

engineering supervision at the construction site to

ensure that the complete work conforms with the

approved plans and specifications and will furnish

progress reports and such other information as

may be required by the assistance awarding agency

or State.

6. Will initiate and complete the work within the

applicable time frame after receipt of approval of the

awarding agency.

7. Will establish safeguards to prohibit employees from

using their positions for a purpose that con- stitutes

or represents the appearance of personal or

organizational conflict of interest, or personal gain.

ASSURANCES - CONSTRUCTION PROGRAMS

Public reporting burden for this collection of information is estimated to average 180 minutes per response, including time for

reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and

reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of

information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction

Project (0348-0041), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. 

SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
SF-424D (Rev. 7-97) Back

11. 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 provides for fair and equitable treatment of

persons displaced or whose property is acquired

as a result of Federal and federally assisted

programs. These requirements apply to all

interests in real property acquired for project

purposes regardless of Federal participation in

purchases.

12. Will comply with the provisions of the Hatch Act (5

U.S.C. §§1501-1508 and 7324-7328) which limit

the political activities of employee whose principal

employment activities are funded in whole or in

part with Federal funds.

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

the Davis-Bacon Act (40 U.S.C. §§276a to 276a7), the Copeland Act (40 U.S.C. §276c and 18

U.S.C. §874), the Contract Work Hours and Safety

Standards Act (40 U.S.C. §§327-333) regarding

labor standards for federal assisted construction

subagreements.

14. Will comply with the 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.

15. 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)

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 (Clean Air) Implementation Plans

under Section 176(c) of the Clean Air Act of 1955,

as amended (42 U.S.C. §§7401 et seq.); (g)

protection of underground sources of drinking

water under the Safe Drinking Water Act of 1974,

as amended, (P.L. 93-523); and (h) protection of

endangered species under the Endangered

Species Act of 1973, as amended, (P.L. 93-205).

16. Will comply with the Wild and Scenic Rivers Act of

1968 (16 U.S.C. §§1271 et seq.) related to

protecting components or potential components of

the national wild and scenic rivers system.

17. Will assist the awarding agency in assuring

compliance with Section 106 of the National

Historic Preservation Act of 1966, as amended (16

U.S.C. §470), EO 11593 (identification and

preservation of historic properties), and the

Archaeological and Historic Preservation Act of

1974 (16 U.S.C. §§469a-1 et seq.).

18. Will cause to be performed the required financial

and compliance audits in accordance with the

Single Audit Act of 1984.

19. Will comply with all applicable requirements of all

other Federal laws, Executive Orders, re- gulations

and policies governing this program.

DATE SUBMITTED

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

APPLICANT ORGANIZATION

TITLE
1. CERTIFICATION REGARDING DEBARMENT

AND SUSPENSION

The undersigned (authorized official signing for the

applicant organization) certifies to the best of his or

her knowledge and belief, that the applicant, defined

as the primary participant in accordance with 45 CFR

Part 76, and its principals:

(a) are not presently debarred, suspended, proposed

for debarment, declared ineligible, or voluntarily

excluded from covered transactions by any

Federal Department or agency;

(b) have not within a 3-year period preceding this

proposal been convicted of or had a civil

judgment rendered against them for commission

of fraud or a criminal offense in connection with

obtaining, attempting to obtain, or performing a

public (Federal, State, or local) transaction or

contract under a public transaction; violation of

Federal or State antitrust statutes or commission

of embezzlement, theft, forgery, bribery,

falsification or destruction of records, making

false statements, or receiving stolen property;

(c) are not presently indicted or otherwise

criminally or civilly charged by a governmental

entity (Federal, State, or local) with commission of any of the offenses enumerated in

paragraph (b) of this certification; and

(d) have not within a 3-year period preceding this

application/proposal had one or more public

transactions (Federal, State, or local) terminated

for cause or default.

Should the applicant not be able to provide this

certification, an explanation as to why should be

placed after the assurances page in the application

package.

The applicant agrees by submitting this proposal that

it will include, without modification, the clause titled

"Certification Regarding Debarment, Suspension, In

eligibility, and Voluntary Exclusion--Lower Tier

Covered Transactions" in all lower tier covered

transactions (i.e., transactions with sub- grantees

and/or contractors) and in all solicitations for lower

tier covered transactions in accordance with 45 CFR

Part 76.

CERTIFICATIONS

Page 17

OMB Approval No. 0920-0428

2. CERTIFICATION REGARDING DRUG-FREE

WORKPLACE REQUIREMENTS

The undersigned (authorized official signing for the

applicant organization) certifies that the applicant

will, or will continue to, provide a drug-free workplace in accordance with 45 CFR Part 76 by:

(a) Publishing a statement notifying employees that

the unlawful manufacture, distribution, dispensing, possession or use of a controlled

substance is prohibited in the grantee’s workplace and specifying the actions that will be

taken against employees for violation of such

prohibition;

(b) Establishing an ongoing drug-free awareness

program to inform employees about--

(1) The dangers of drug abuse in the

workplace;

(2) The grantee’s policy of maintaining a

drug-free workplace;

(3) Any available drug counseling, rehabilitation, and employee assistance programs;

and

(4) The penalties that may be imposed upon

employees for drug abuse violations

occurring in the workplace;

(c) Making it a requirement that each employee to

be engaged in the performance of the grant be

given a copy of the statement required by

paragraph (a) above;

(d) Notifying the employee in the statement required by paragraph (a), above, that, as a

condition of employment under the grant, the

employee will--

(1) Abide by the terms of the statement; and

(2) Notify the employer in writing of his or her

conviction for a violation of a criminal drug

statute occurring in the workplace no later

than five calendar days after such

conviction;

(e) Notifying the agency in writing within ten

calendar days after receiving notice under

paragraph (d)(2) from an employee or otherwise

receiving actual notice of such conviction.

Employers of convicted employees must provide

notice, including position title, to every grant

officer or other designee on whose grant activity

the convicted employee was working, unless

the Federal agency has designated a central

PHS-5161-1 (7/00)
signed, 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 than Federally 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, loan, or cooperative

agreement, the undersigned shall complete and

submit Standard Form-LLL, "Disclosure of

Lobbying Activities," in accordance with its

instructions. (If needed, Standard Form-LLL,

"Disclosure of Lobbying Activities," its

instructions, and continuation sheet are included at

the end of this application form.)

(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, 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.

4. CERTIFICATION REGARDING PROGRAM

FRAUD CIVIL REMEDIES ACT (PFCRA)

The undersigned (authorized official signing for the

applicant organization) certifies that the statements

herein are true, complete, and accurate to the best of

his or her knowledge, and that he or she is aware

that any false, fictitious, or fraudulent statements or

claims may subject him or her to criminal, civil, or

administrative penalties. The undersigned agrees

that the applicant organization will comply with the

Public Health Service terms and conditions of

award if a grant is awarded as a result of this

application.

Page 18 PHS-5161-1 (7/00)

point for the receipt of such notices. Notice shall

include the identification number(s) of each

affected grant;

(f) Taking one of the following actions, within 30

calendar days of receiving notice under

paragraph (d) (2), with respect to any employee

who is so convicted--

(1) Taking appropriate personnel action against

such an employee, up to and including

termination, consistent with the

requirements of the Rehabilitation Act of

1973, as amended; or

(2) Requiring such employee to participate

satisfactorily in a drug abuse assistance or

rehabilitation program approved for such

purposes by a Federal, State, or local health,

law enforcement, or other appropriate

agency;

(g) Making a good faith effort to continue to

maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e),

and (f).

For purposes of paragraph (e) regarding agency

notification of criminal drug convictions, the DHHS has

designated the following central point for receipt of

such notices:

3. CERTIFICATION REGARDING LOBBYING

Title 31, United States Code, Section 1352, entitled

"Limitation on use of appropriated funds to influence certain Federal contracting and financial

transactions," generally prohibits recipients of

Federal grants and cooperative agreements from

using Federal (appropriated) funds for lobbying the

Executive or Legislative Branches of the Federal

Government in connection with a SPECIFIC grant or

cooperative agreement. Section 1352 also requires

that each person who requests or receives a Federal

grant or cooperative agreement must disclose

lobbying undertaken with non-Federal (nonappropriated) funds. These requirements apply to

grants and cooperative agreements EXCEEDING

$100,000 in total costs (45 CFR Part 93).

The undersigned (authorized official signing for the

applicant organization) 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 underOffice of Grants and Acquisition Management

Office of Grants Management

Office of the Assistant Secretary for Management and

 Budget

Department of Health and Human Services

200 Independence Avenue, S.W., Room 517-D

Washington, D.C. 20201
Failure to comply with the provisions of the law

may result in the imposition of a civil monetary

penalty of up to $1,000 for each violation and/or the

imposition of an administrative compliance order on

the responsible entity.

By signing the certification, the undersigned

certifies that the applicant organization will comply

with the requirements of the Act and will not allow

smoking within any portion of any indoor facility

used for the provision of services for children as

defined by the Act.

The applicant organization agrees that it will require

that the language of this certification be included in

any subawards which contain provisions for

children’s services and that all subrecipients shall

certify accordingly.

The Public Health Services strongly encourages all

grant recipients to provide a smoke-free workplace

and promote the non-use of tobacco products. This

is consistent with the PHS mission to protect and

advance the physical an mental health of the

American people.

5. CERTIFICATION REGARDING

ENVIRONMENTAL TOBACCO SMOKE

Public Law 103-227, also known as the Pro-Children

Act of 1994 (Act), requires that smoking not be

permitted in any portion of any indoor facility owned

or leased or contracted for by an entity and used

routinely or regularly for the provision of health, day

care, early childhood development services,

education or library services to children under the

age of 18, if the services are funded by Federal

programs either directly or through State or local

governments, by Federal grant, contract, loan, or loan

guarantee. The law also applies to children’s

services that are provided in indoor facilities that are

constructed, operated, or maintained with such

Federal funds. The law does not apply to children’s

services provided in private residence, portions of

facilities used for inpatient drug or alcohol treatment,

service providers whose sole source of applicable

Federal funds is Medicare or Medicaid, or facilities

where WIC coupons are redeemed.

DATE SUBMITTED

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

APPLICANT ORGANIZATION

TITLE

PHS-5161-1 (7/00) Page 19

which the applicant estimates are required to carry

out activities under the proposed project. (A

narrative budget justification must also be provided;

see Budget Narrative, below.)

Applicants must clearly identify the physical,

economic, social, financial, institutional, or other

problem(s) requiring a solution. The need for

assistance must be demonstrated and the principal

and subordinate objectives of the project must be

clearly stated; supporting documentation or other

testimonies from concerned interests other than the

applicant may be included. Any relevant data based

on planning studies should be included or

referenced in footnotes.

In developing the narrative, the applicant may

volunteer or be requested to provide information on

the total range of health programs currently

conducted and supported (or to be initiated), some

of which may be outside the scope of the program

announcement.

Applicants are encouraged to provide information

on their organizational structure, staff, related

experience, and other information considered to be

relevant. Awarding offices use this and other

information to determine whether the applicant has

the capability and resources necessary to carry out

the proposed project. It is important, therefore, that

this information be included in the application. It is

equally important that the narrative distinguish

between applicant resources which are directly

related to the proposed budget and those which will

not be used in support of the specific project for

which funds are requested.

2. RESULTS OR BENEFITS EXPECTED

Identify results and benefits to be derived. For

example, when applying for a grant to establish a

neighborhood health center, provide a description of

who will occupy the facility, how the facility will be

used, and how the facility will benefit the general

public.

3. APPROACH

(a) Outline a plan of action which describes the

scope and detail of how the proposed work will

be accomplished for each grant program,

function or activity provided in the budget. Cite

factors which might accelerate or decelerate the

work and state your reason for takings this

PHS-5161-1 (7/00) Page 21

PROGRAM NARRATIVE

OMB Approval No. 0920-0428

Public Burden Statement: Public reporting burden of

this collection of information is estimated to average 4

hours 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. An agency may

not conduct or sponsor, and a person is not required to

respond to a collection of information unless it displays

a currently valid OMB control number. Send comments

regarding this burden estimate or any other aspect of

this collection of information, including suggestions for

reducing this burden to CDC, Project Clearance Officer,

1600 Clifton Road, MS D-24, Atlanta, GA 30333,

ATTN: PRA (0920-0428). Do not send the completed

form to this address.

Prepare the program narrative statement in accordance

with the following instructions for all new and

competing continuation applications. Noncompeting

continuation applications and requests for changes to an

approved project should respond to Item 6(b) only.

Requests for supplemental assistance should respond to

Item 6(c) only.

The Program Narrative provides a major means by

which the application is evaluated and ranked to

compete with other applications for available funds. It

should be concise and complete and should address the

activity for which Federal funds are requested.

Supporting documents should be included where they

can present information clearly and succinctly.

Cross-referencing should be used rather than repetition.

PHS is particularly interested in specific factual

information and statements of measurable goals in

quantitative terms. Narratives are evaluated on the basis

of substance, not length. Extensive exhibits are not

required. (Supporting information concerning activities

which will not be directly funded by the grant or

information which does not directly pertain to an

integral part of the grant-funded activity should be

placed in an appendix.) Pages should be numbered for

easy reference, continuing the numerical sequence of

the printed form.

1. PROJECT DESCRIPTION

Because many and varied programs employ this

application form, it is not possible to provide specific

guidance for developing a project description which

would be appropriate in all cases. One aspect of the

description that is applicable to all proposals,

however, is the requirement that all project

information described in this part relate directly to

the budget information requested. The budget

consists of the funds (both Federal and non-Federal)
6. ADDITIONAL INFORMATION

(INCLUDE IF APPLICABLE)

(a) STAFF AND POSITION DATA

Some programs require a biographical sketch for

key personnel appointed and a job description

for a vacant key position; others require both for

all positions. Refer to appropriate program

guidelines for guidance in fulfilling this

requirement. Generally, a biographical sketch is

required for original staff and new members as

appointed. Below are the suggested contents for

the biographical sketch and job description

where not otherwise set forth:

Biographical Sketch:

Existing curricula vitae of project staff members

may be used if they are updated and contain all

items of information requested below. You may

add any information items listed below to

complete existing documents. For development

of new curricula vitae include items below in the

most suitable format:

(1) Name of staff member.

(2) Educational background: school(s), location, dates attended, degrees earned (specify

year), major field of study.

(3) Professional experience.

(4) Honors received and dates.

(5) Recent relevant publications.

(6) Other sources of support. [Other support is

defined as all funds or resources, whether

Federal, non-Federal, or institutional,

available to the Project Director/Program

Director (and other key personnel named in

the application) in direct support of their

activities through grants, cooperative

agreements, contracts, fellowships, gifts,

prizes, and other means.]

Job Description:

(1) Title of position.

(2) Description of duties and responsibilities.

(3) Qualifications for position.

(4) Supervisory relationships.

(5) Skills and knowledge required.

(6) Prior experience required.

(7) Personal qualities.

(8) Amount of travel and any other special

conditions or requirements.

(9) Salary range.

(10) Hours per day or week.

approach rather than others. Describe any

unusual features of the project such as design or

technological innova- tions, reductions in cost or

time, or extraordi- nary social and community

involvement.

(b) Provide quantitative monthly or quarterly

projections of the accomplishments to be

achieved for each grant program, function or

activity in such terms as the number of people to

be served and the number of patients to be

treated. When accomplishments cannot be

quantified by activity or function, list them in

chronological order to show the schedule of

accomplishments and their target dates.

(c) Identify the kinds of data to be collected and

maintained.

(d) List organizations, cooperating entities, consultants, or other key individuals who will work

on the project along with a short description of

the nature of their effort or contribution.

4. EVALUATION

Provide a narrative addressing how you will

evaluate 1) the results of your project, and 2) the

conduct of your program.

In addressing the evaluation of results, state how

you will determine the extent to which the program

has achieved its stated objectives and the extent to

which the accomplishment of objectives can be

attributed to the program. Discuss the criteria to be

used to evaluate results and successes; explain the

methodology that will be used to determine if the

needs identified and discussed are being met and if

the results and benefits identified in Item 2 (above)

are being achieved.

With respect to the conduct of your program, define

the procedures you will employ to determine

whether the program is being conducted in a

manner consistent with the work plan you presented

and discuss the impact of the program’s various

activities upon the program’s effectiveness.

5. GEOGRAPHIC LOCATION

Give the precise location of the project or area to be

served by the proposed project. Maps or other

graphic aids may be attached.

Page 22 PHS-5161-1 (7/00)
Describe the specific functions of the personnel,

consultants, and collaborators. For all years, explain and

justify any unusual items such as major equipment,

foreign travel, alterations and renovations, patient care

costs, and tuition remission. For additional years of

support requested, itemize and justify any significant

increases or decreases in any category over the first 12

month budget period. Identify such significant changes

with asterisks against the appropriate amounts. If a

recurring annual increase or decrease in personnel or

other costs is anticipated, give the percentage. In

addition, for Competing Continuation applications,

justify any significant increases or decreases in any

category over the current level of support. 

INDIRECT COSTS 

If indirect costs are requested in the budget, submit a

copy of the applicant organization’s most current

Federal negotiated indirect cost rate agreement. If your

organization does not have a Federally negotiated rate,

contact the grants management office identified in the

program announcement for information on a contact

point to assist in the development of such a rate.

Provide a narrative budget justification which describes

how the categorical costs are derived. Discuss the

necessity, reasonableness, and allocability of the

proposed costs. 

Only the direct costs requested in this application need

to be justified. Do not include any items that are treated

by the applicant organization as indirect costs according

to a Federal rate negotiation agreement except for those

indirect costs included in consortium/ contractual costs.

If funds to be used for Matching/Cost Participation

(whether voluntary or required) are included in the

budget, only funds which will be used for this specific

project should be so identified. If an award is made, all

funds identified as dedicated to this project (including

funds used for cost participation) will be subject to the

applicable cost principles, audit and reporting

requirements. 

For a Supplemental application, you need justify only

those items for which additional funds are requested,

prorating the personnel costs and other appropriate parts

of the detailed budget if the first budget period of the

application is less than 12 months.

If the total budget has been exceeded, or if

individual budget items have changed more than the

prescribed limits contained in the applicable Office

of Management and Budget Circular (A-102 or

A-110), explain and justify the change and its effect

on the project.

(c) SUPPLEMENTAL REQUESTS

For supplemental assistance requests, explain the

reason for the request and justify the need for

additional funding.

(b) OTHER INFORMATION

Discuss accomplishments to date and list in

chronological order a schedule of accomplishments,

progress or milestones anticipated with the new

funding request. If there have been significant

changes in the project objectives, location or

approach, or time delays, explain and justify. For

other requests for changes or amendments, explain

the reason for the change(s). If the scope or

objectives have changed or an extension of time is

necessary, explain the circumstances and justify.

BUDGET NARRATIVE 

PHS-5161-1 (7/00) Page 23

Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA 30333,

ATTN: PRA (0920-0428). Do not send the completed form to this

address.

NOTE TO APPLICANT: This form must be completed and

submitted with the original of your application. Be sure to complete

both sides of this form. Check the appropriate boxes and provide

the information requested. This form should be attached as the last

page of the signed original of the application. This page is reserved

for PHS staff use only. 

Public Burden Statement: Public reporting burden of this

collection of information is estimated to average 4 hours 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. An

agency may not conduct or sponsor, and a person is not required

to respond to a collection of information unless it displays a

currently valid OMB control number. Send comments regarding

this burden estimate or any other aspect of this collection of

information, including suggestions for reducing this burden to CDC,

Noncompeting Competing

Type of Application: NEW Continuation Continuation Supplemental

CHECKLIST

OMB Approval No. 0920-0428

PART B: This part is provided to assure that pertinent information has been addressed and included in the application.

NOT

YES Applicable

PART A: The following checklist is provided to assure that proper signatures, assurances, and certifications have been

submitted. NOT

Included Applicable

1. Proper Signature and Date for Item 18 on SF 424 (FACE PAGE) ............................

2. Proper Signature and Date on PHS-5161-1 "Certifications" page. ............................

3. Proper Signature and Date on appropriate "Assurances" page, i.e.,

SF-424B (Non-Construction Programs) or SF-424D (Construction Programs) .........

4. If your organization currently has on file with DHHS the following

assurances, please identify which have been filed by indicating the

date of such filing on the line provided. (All four have been

consolidated into a single form, HHS Form 690)

Civil Rights Assurance (45 CFR 80) ...........................................

Assurance Concerning the Handicapped (45 CFR 84) ...............

Assurance Concerning Sex Discrimination (45 CFR 86) ............

Assurance Concerning Age Discrimination (45 CFR 90 &

45 CFR 91) ................................................................................

5. Human Subjects Certification, when applicable (45 CFR 46) .......................................

Fax Number

1. Has a Public Health System Impact Statement for the proposed program/project

been completed and distributed as required? ...............................................................

2. Has the appropriate box been checked for item # 16 on the SF-424 (FACE PAGE)

regarding intergovernmental review under E.O. 12372 ? (45 CFR Part 100) ...............

3. Has the entire proposed project period been identified in item # 13 of the FACE

PAGE? ..........................................................................................................................

4. Have biographical sketch(es) with job description(s) been attached, when

required?........................................................................................................................

5. Has the "Budget Information" page, SF-424A (Non-Construction Programs) or

SF-424C (Construction Programs), been completed and included? ............................

6. Has the 12 month detailed budget been provided? ......................................................

7. Has the budget for the entire proposed project period with sufficient detail been

provided? ......................................................................................................................

8. For a Supplemental application, does the detailed budget address only the additional

funds requested? ..........................................................................................................

9. For Competing Continuation and Supplemental applications, has a progress report

been included? .............................................................................................................

PART C: In the spaces provided below, please provide the requested information.

(OVER)

Name

Program Director/Project Director/Principal Investigator designated to direct

the proposed project or program.

APPLICANT ORGANIZATION’S 12-DIGIT DHHS EIN (If already assigned) SOCIAL SECURITY NUMBER HIGHEST DEGREE EARNED

PHS-5161-1 (7/00) Page 25

Title

Organization

Address

E-mail Address

Telephone Number

Fax Number

Name

Business Official to be notified if an award is to be made.

Title

Organization

Address

E-mail Address

Telephone Number
PART D: A private, nonprofit organization must include evidence of its nonprofit status with the application. Any of the

following is acceptable evidence. Check the appropriate box or complete the "Previously Filed" section,

whichever is applicable.

(a) A reference to the organization’s listing in the Internal Revenue Service’s (IRS) most recent list of

tax-exempt organizations described in section 501(c)(3) of the IRS Code.

(b) A copy of a currently valid Internal Revenue Service Tax exemption certificate.

(c) A statement from a State taxing body, State Attorney General, or other appropriate State official

certifying that the applicant organization has a nonprofit status and that none of the net earnings accrue

to any private shareholders or individuals.

(d) A certified copy of the organization’s certificate of incorporation or similar document if it clearly

establishes the nonprofit status of the organization.

(e) Any of the above proof for a State or national parent organization, and a statement signed by the parent

organization that the applicant organization is a local nonprofit affiliate.

If an applicant has evidence of current nonprofit status on file with an agency of PHS, it will not be necessary to

file similar papers again, but the place and date of filing must be indicated.

Previously Filed with: (Agency) on (Date)

EXECUTIVE ORDER 12372 

If this is an application for continued support, include: (1) the report of inventions conceived or reduced to practice required by the

terms and conditions of the grant; or (2) a list of inventions already reported, or (3) a negative certification. 

INVENTIONS

Department’s programs that are subject to the provisions of Executive

Order 12372. Information regarding PHS programs subject to

Executive Order 12372 is also available from the appropriate

awarding office. 

States participating in this program establish State Single Points of

Contact (SPOCs) to coordinate and manage the review and comment

on proposed Federal financial assistance. Applicants should contact

the Governor’s office for information regarding the SPOC, programs

selected for review, and the consultation (review) process designed by

their State. 

Applicants are to certify on the face page of the SF-424 (attached)

whether the request is for a program covered under Executive Order

12372 and, where appropriate, whether the State has been given an

opportunity to comment.

Effective September 30, 1983, Executive Order 12372

(Intergovernmental Review of Federal Programs) directed OMB to

abolish OMB Circular A-95 and establish a new process for

consulting with State and local elected officials on proposed Federal

financial assistance. The Department of Health and Human Services

implemented the Executive Order through regulations at 45 CFR Part

100 (Inter-governmental Review of Department of Health and Human

Services Programs and Activities). The objectives of the Executive

Order are to (1) increase State flexibility to design a consultation

process and select the programs it wishes to review, (2) increase the

ability of State and local elected officials to influence Federal

decisions and (3) compel Federal officials to be responsive to State

concerns, or explain the reasons. 

The regulations at 45 CFR Part 100 were published in the Federal

Register on June 24, 1983, along with a notice identifying the

Page 26 PHS-5161-1 (7/00)
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.) 

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

1. Type of Federal Action:

a. contract

b. grant

c. cooperative agreement

d. loan

e. loan guarantee

f. loan insurance

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

Address of Prime:

Congressional District, if known:

4. Name and Address of Reporting Entity:

Prime Subawardee

Tier , if known:

Congressional District, if known:

7. Federal Program Name/Description:

CFDA Number, if applicable:

 6. Federal Department/Agency: 

Authorized for Local Reproduction

Standard Form - LLL (Rev. 7-97) Federal Use Only:

Signature:

Print Name:

Title:

Telephone No.: Date:

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.

9. Award Amount, if known:

$

8. Federal Action Number, if known:

b. Individuals Performing Services (including address if different

from No. 10a.)

(last name, first name, MI):

10. a. Name and Address of Lobbying Entity 

(if individual, last name, first name, MI):
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES 

This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the

initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. Section

1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Use the SF-LLL-A

Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both

the initial filing and material change report. Refer to the implementing guidance published by the Office of Management

and Budget for additional information. 

1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the

outcome of a covered Federal action.

2. Identify the status of the covered Federal action.

3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the

information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last

previously submitted report by this reporting entity for this covered Federal action.

4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known.

Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or

subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier.

Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.

5. If the organization filing the report in item 4 checks "subawardee", then enter the full name, address, city, state and

zip code of the prime Federal recipient. Include Congressional District, if known.

6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level

below agency name, if known. For example, Department of Transportation, United States Coast Guard.

7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog

of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.

8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 [e.g.,

Request for Proposal (RFP) number; Invitation for Bid (IFB) number; grant announcement number; the contract,

grant, or loan award number; the application/proposal control number assigned by the Federal agency]. Include

prefixes, e.g., ‘‘RFP-DE-90-001.’’

9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the

Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5.

10.(a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity

identified in item 4 to influence the covered Federal action.

(b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter

Last Name, First Name, and Middle Initial (MI).

11.Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to the

lobbying entity (item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all

boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be

made.

According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a

valid OMB Control Number. The valid OMB control number for this information collection is OMB No.0348-0046. Public reporting burden for

this collection of information is estimated to average 10 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 (0348-0046), Washington, DC 20503.
DISCLOSURE OF LOBBYING ACTIVITIES

CONTINUATION SHEET

Approved by OMB

 0348-0046 

Reporting Entity: Page of

Authorized for Local Reproduction

Standard Form - LLL-A