OMB Number: 4040-0004 

Expiration Date: 03/31/2012

 

* 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-424
Application 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 accordance 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 closing date.

2. Type of Application: (Required) Select one type of application 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. This can include renewals.

• Revision ‐Any change in the Federal Government’s financial obligation or

contingent liability from an existing obligation. If a revision, enter the appropriate

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

text box provided.

A. Increase Award

B. Decrease Award

C. Increase Duration

D. Decrease Duration

E. Other (specify)

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

4. Applicant Identifier: Enter the entity identifier assigned buy the Federal agency, if any, or the

applicant’s control number if applicable.

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

Agency, if any.

5b. Federal 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

changed/corrected application, enter the Federal Identifier in accordance with agency

instructions.

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

applicable.

7. State Application Identifier: Leave this field blank. This identifier will be assigned by the State,

if applicable.

8. Applicant Information: Enter the following in accordance with agency instructions:

a. Legal Name: (Required): Enter the legal name of applicant that will undertake the

assistance activity. This is that the organization has registered with the Central

Contractor Registry. Information on registering with CCR may be obtained by visiting

the Grants.gov website.

b. Employer/Taxpayer Number (EIN/TIN): (Required): Enter the Employer or Taxpayer

Identification Number (EIN or TIN) as assigned by the Internal Revenue Service. If your
organization is not in the US, enter 44‐4444444.

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

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

obtained by visiting the Grants.gov website.

d. Address: Enter the complete address as follows: Street address (Line 1 required), City

(Required), County, State (Required, if country is US), Province, Country (Required),

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

e. Organizational Unit: Enter the name of the primary organizational unit (and

department or division, (if applicable) that will undertake the assistance activity, if

applicable.

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

applicant required), organizational affiliation (if affiliated with an organization other

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

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

on matters related to this application.

9. Type of Applicant: (Required) Select up to three applicant type(s) in accordance with agency

instructions.

A. State Government

B. County Government

C. City or Township Government

D. Special District Government

E. Regional Organization

F. U.S. Territory or Possession

G. Independent School District

H. Public/State Controlled Institution of Higher Education

I. Indian/Native American Tribal Government (Federally Recognized)

J. Indian/Native American Tribal Government (Other than Federally Recognized)

K. Indian/Native American Tribally Designated Organization

L. Public/Indian Housing Authority

M. Nonprofit

N. Nonprofit

O. Private Institution of Higher Education

P. Individual

Q. For‐Profit Organization (Other than Small Business)

R. Small Business

S. Hispanic‐serving Institution

T. Historically Black Colleges and Universities (HBCUs)

U. Tribally Controlled Colleges and Universities (TCCUs)

V. Alaska Native and Native Hawaiian Serving Institutions

W. Non‐domestic (non‐US) Entity

X. Other (specify)

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

assistance is being requested with this application.

11. Catalog Of Federal Domestic Assistance Number/Title: Enter the Catalog of Federal Domestic

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

the program announcement, if applicable.

12. Funding Opportunity Number/Title: (Required) Enter the Funding Opportunity Number and
title of the opportunity under which assistance is requested, as found in the program

announcement.

13. Competition Identification Number/Title: Enter the Competition Identification Number and

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

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

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

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

areas, if needed.

15. Descriptive Title of Applicant’s Project: (Required) Enter a brief descriptive title of the project.

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

projects). For pre‐applications, attach a summary description of the project.

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

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

State Abbreviation – 3 characters District Number, e.g., CA‐005 for California 5th district, CA012

for California 12th district, NC‐103 for North Carolina’s 103rd district. • If all congressional

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

congressional districts in Maryland. • If nationwide, i.e. all districts within all states are

affected, enter US‐all. • If the program/project is outside the US, enter 00‐000.

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

of the project.

18. Estimated Funding: (Required) Enter the 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.

19. Is Application Subject to Review by State Under Executive Order 12372 Process? 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.

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

the State.

20. Is the Applicant Delinquent on any Federal Debt? (Required) Select the appropriate box. This 

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

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: (Required) 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.)