OMB Number: 4040-0004

Expiration Date: 0 3 /31/201 2

* 1. Type of Submission:

Preapplication

Application

Changed/Corrected Application * 2. Type of Application: * If Revision, select appropriate letter(s):

* Other (Specify) New

Continuation

Revision

* 3. Date Received: 4. Applicant Identifier:

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

State Use Only:

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

8. APPLICANT INFORMATION:

* a. Legal Name:

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

d. Address:

* Street1:

Street2:

* City:

County:

* State:

Province:

* Country:

* Zip / Postal Code: USA: UNITED STATES

e. Organizational Unit:

Department Name: Division Name:

f. Name and contact information of person to be contacted on matters involving this application:

Prefix: * First Name:

Middle Name:

* Last Name:

Suffix:

Title:

Organizational Affiliation:

* Telephone Number: Fax Number:

* Email: Application for Federal Assistance SF-424Application for Federal Assistance SF-424

9. Type of Applicant 1: Select Applicant Type:

Type of Applicant 2: Select Applicant Type:

Type of Applicant 3: Select Applicant Type:

* Other (specify):

* 10. Name of Federal Agency:

11. Catalog of Federal Domestic Assistance Number:

CFDA Title:

* 12. Funding Opportunity Number:

* Title:

13. Competition Identification Number:

Title:

14. Areas Affected by Project (Cities, Counties, States, etc.):

* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.Application for Federal Assistance SF-424

* a. Applicant * b. Program/Project 16. Congressional Districts Of:

Attach an additional list of Program/Project Congressional Districts if needed.

* a. Start Date: * b. End Date: 17. Proposed Project:

18. Estimated Funding ($):

* a. Federal

* b. Applicant

* c. State

* d. Local

* e. Other

* f. Program Income

* g. TOTAL

. a. This application was made available to the State under the Executive Order 12372 Process for review on

b. Program is subject to E.O. 12372 but has not been selected by the State for review.

c. Program is not covered by E.O. 12372. * 19. Is Application Subject to Review By State Under Executive Order 12372 Process?

Yes No * 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes", provide explanation.) Applicant Federal Debt Delinquency Explanation

21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements

herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to

comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may

subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)

** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency

specific instructions. ** I AGREE

Authorized Representative:

Prefix: * First Name:

Middle Name:

* Last Name:

Suffix:

* Title:

* Telephone Number: Fax Number:

* Email:

* Signature of Authorized Representative: * Date Signed:Application for Federal Assistance SF-424

* Applicant Federal Debt Delinquency Explanation

The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debt. Maximum number of

characters that can be entered is 4,000. Try and avoid extra spaces and carriage returns to maximize the availability of space.

### Item: Entry:

1. Type of Submission: (Required): Select one type of submission in accordanc e with agency

instructions.

• Pre

‐ application

• Application

• Changed/Corrected Application

– If requested by the agency, check if this submission

is to change or correct a previously submitted application. Unless requested by the

agency, applicants may not use this to submit changes after the clos ing date.

2. Type of Application: ( Required) Select one type of a p plication in accordance with agency

instructions.

• New

– An application that is being submitted to an agency for the first time.

• Continuation

‐ An extension for an additional funding/budget period for a project

with a projected completion date. Th is can include renewals.

• Revision

‐ Any change in the Federal Government’s financial ob lig ation or

contingent liability from an existi ng obligation. If a rev ision, enter the appropria te

letter(s). More than one may be sele cted. If "Other" is selected, please specify in

text box provided.

A. Increase Award

B. Decrease Award

C. Increase Du rati on

D. Decrease Duration

E. Other (spe cify)

3. Date Received: Leave this field blank. Th is date will be assigned by the Federal agency.

4. Applicant Identif ier: Enter the entity identi fi er assigned buy the Federal agency, if any, or the

applicant’s control nu mber if applicable.

5a. Federal Entity Identifier: Enter the number assigned to your organi zation by the Federal

Agency, if any.

5b. Feder al Award Identifier: For new applications leave blank. For a continuation or revision to an

existing award, enter the previously assigned Federal award identifier number. If a

change d/corrected application, enter the Federal Id en tifier in accordance with agency

instructions.

6. Date Received by State: Leave this field blank. This date will be assigned by the State

, if

applicable.

7. State Application Identifier: Leave this fiel d blank. This identifier will be assigned by the St ate,

if applicable.

8. Applicant Info rmati on: Enter the following in accordance with agency instructions:

a. Legal Name: ( Required): Ent er the legal name of appl icant that will undertake the

assistance activity. This is that the organi zation has registered with the Central

Contractor Regist ry. Information on registering with CCR may be obtained by vis iting

the Grants.gov website.

b. Empl oyer/Taxpayer Number (EIN/TIN): (Required): Enter the Em ployer or Taxpayer

Identification Number (EIN or TIN) as assigned by the Internal Revenue Service. If yourorganization is not in the US, enter 44

‐ 4444444.

c. Organizational DUNS: (Required) Enter the organiza tion’s DUNS or DUNS+4 number

received from Dun and Bradstreet. Information on obtaining a DUNS numb er may be

obtained by visit ing the Grants.gov website.

d. Address: Enter th e complete address as follows: Street address (Line 1 r equired), City

(Required), Co unty, State (Required, if country is US), Province, Country (Requir ed),

Zip/Postal Code (Required, if country is US).

e. Organizational Unit: Enter the name of the primary or ganizational unit (an d

department or division, (if applic able) that will undertake the assistance ac tivity, if

applicable.

f. Name and con tac t information of person to be contac te d on matters involving this

applicant re quired), organizational affili ation (if affiliated with an organization other

on: Enter the name (First and last name than the applicant organization), telephone

number (Required), fax number, and email address (Required) of the person to contact

on matters related to this applica tion.

9. Type of Applicant : (Req uir ed) Sele ct up to three applicant type(s) in accordance with agency

instructions.

A. Stat e Government

B. County Government

C. City or Township Government

D. Special Dist rict Go vernment

E. Regional Organization

F. U.S. Territory or Possession

G. Inde pendent School District

H. Public/State Controlled Institution of Higher Education

I. Indian/Native American Tribal Government (Federa lly Recognized)

J. I ndian/Nat ive American Tribal Government (Other than Federall y Recognized)

K. Indian/Native American Tribally Designated Organization

L. Public/Indian Housing Authority

M. Nonprofit

N. Non profit

O. Private Ins titution of Higher Edu cation

P. Individual

Q. For

‐ Profit Organization (Other than Small Business)

R. Sm all Business

S. Hispani c

‐ se rving Institution

T. Historically Black College s and Universities (HB C Us)

U. Tribally Controlled Colleges and Universities (TCCUs)

V. Alaska Native and Native Hawaiian Serving Institut ions

W. Non

‐ domestic (non

‐ US) Entity

X. Othe r (specify)

10. Name Of Federal Agency: (Required ) Enter the name of the Federal agency from which

assistance is being requested wi th this application.

11. Catalog Of Federal Domest ic Assistance Number/Title: Enter th e Catalog of Fe deral Domestic

Assistance numb er and title of the program under which assistance is requested, as found in

the program announce ment, if applicable.

12. Funding Opportunit y Number/Title: (Requir ed) Enter the Fundi ng Opportunity Number andtitle of the opportunity under which assistance is requested, as found in the program

announceme nt.

13. Competition Identification Number/Title: Enter the Competition Identification Nu mbe r and

title of the competition under which assistance is requested, if applicable.

C. Increase Dura tion D. Decrease Duration E. Other (specify)

14. Areas Affected By Project: List the areas or entities using the categories (e.g., cities, coun ties

,

states, etc.) specified in agency instructi ons. Use the continuation sheet to enter additional

areas, if needed.

15. Descriptive Titl e of Applic ant’s Project: (Required) Enter a brief descriptive title of the project.

If appropriate, attach a map showing projec t location (e.g., construction or real property

projects). For pre

‐ applications, attach a summary description of the project.

16. Congressional Districts Of: (Required) 16a. Enter the applicant’s Congressional District, and

16b. Ente r all District(s) affected by the program or project. Enter in the format: 2 characters

State Abbreviation

– 3 characters District Nu mber, e.g., CA

‐ 005 for California 5th district, CA012

for California 12th district, NC

‐ 103 for North Carolina’s 103rd district. • If all congressional

districts in a state are affected, ent er “all” for the district number, e.g., MD

‐ all for all

congressional districts in Maryland. • If nat ionwide

, i.e. all districts within all states are

affected, enter US

‐ all. • If the program/ project is outside the US, ente r 00

‐ 000.

17. Proposed Project Sta r t and End Dates: (Required) Enter the proposed start date and end date

of the project.

18. Estim ated Funding: (Required) Enter the amount requested or to be contribute d during the

first funding/budget period by each cont ributor. Value of in

‐ kind contributions should be

included on appropriate li nes, 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 a mounts in

parentheses.

19. Is Application Subject to Review by Stat e Under Executive Order 12372 Process? Applicants

should cont act the Stat e S ingle Point of Contact (SPOC) for Federal Executive Order 12372 to

deter mine whethe r the application is subject to the State interg overnmental review process.

Select the appropriate box. If “a.” is selected, enter the date the application was submitted to

the State.

20. Is th e Applicant Delinquent on any Federal Debt? (Required) Select the appro p riate box. This

question applies to the applicant organization, not the person who signs as the au thorized

representative. Categories of debt include: But may not be limited to; delinquent

audit disallowances, loans and taxes. If yes, include an explanation in an attachement.

21. Authorized Representative: (Require d) To be signed and dated by the authorized

representative of the applicant organization. Enter the name (First and last name required) title

(Required), telephone number (Required), fax number, and email address (Required) of the

person authorized to sign for the applicant. A copy of the governing body’s authorization for

you to sign this application as the official representative must be on file in the applicant’s

office. (Certain Federal agencies may require that this authorization be submitted as part of the

application.)