OMB Number:
4040-0010
Expiration
Date: 12/31/2022
Tracking Number:
Funding Opportunity Number:
. Received Date:
APPLICATION FOR FEDERAL ASSISTANCE
SF 424
(R&R)
3. DATE RECEIVED
BY STATE
State
Application Identifier
1. TYPE OF
SUBMISSION*
4.a. Federal
Identifier
Y: Yes
N: No
Pre-application
Y: Yes
N: No
Application
Y: Yes
N: No
Changed/Corrected Application
b. Agency
Routing Number
2. DATE
SUBMITTED
Application
Identifier
c. Previous
Grants.gov Tracking Number
5.
APPLICANT INFORMATION
Organizational DUNS*:
Legal Name*:
Person to be contacted on matters
involving this application
6. EMPLOYER IDENTIFICATION NUMBER
(EIN) or (TIN)
*
7. TYPE OF
APPLICANT*
Other (Specify):
Small Business Organization Type
Women Owned
Socially and Economically Disadvantaged
8. TYPE OF
APPLICATION*
If Revision, mark appropriate box(es).
Y: Yes
N: No
New
Y: Yes
N: No
Resubmission
Y: Yes
N: No
A. Increase Award
Y: Yes
N: No
B. Decrease Award
Y: Yes
N: No
C. Increase Duration
Y: Yes
N: No
Renewal
Y: Yes
N: No
Continuation
Y: Yes
N: No
Revision
Y: Yes
N: No
D. Decrease Duration
Y: Yes
N: No
E. Other
(specify)
:
Is this
application being submitted to other agencies?*
Y: Yes
N: No
Yes
Y: Yes
N: No
No
What other Agencies?
9. NAME OF
FEDERAL AGENCY*
10. CATALOG OF
FEDERAL DOMESTIC ASSISTANCE NUMBER
TITLE:
11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT*
12. PROPOSED
PROJECT
Start Date*
Ending Date*
13.
CONGRESSIONAL DISTRICTS OF APPLICANT
SF 424
(R&R)
APPLICATION FOR FEDERAL
ASSISTANCE
Page 2
14. PROJECT
DIRECTOR/PRINCIPAL INVESTIGATOR CONTACT INFORMATION
Position/Title:
Organization Name*:
15. ESTIMATED
PROJECT FUNDING
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
Y: Yes
N: No
PROGRAM IS NOT COVERED BY E.O.
12372; OR
Y: Yes
N: No
PROGRAM HAS NOT BEEN SELECTED
BY STATE FOR REVIEW
a. Total Federal Funds Requested*
b. Total Non-Federal Funds*
c. Total Federal &
Non-Federal Funds*
d. Estimated Program Income*
17.
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 18, Section 1001)
I agree*
* The list
of certifications and assurances, or an Internet site
where you may obtain this list, is contained in the
announcement or agency specific instructions.
18. SFLLL or
OTHER EXPLANATORY DOCUMENTATION
File Name:
19. AUTHORIZED REPRESENTATIVE
Position/Title*:
Organization Name*:
Signature
of Authorized Representative*
Date
Signed*
20. PRE-APPLICATION
File Name:
Mime Type:
21. COVER LETTER ATTACHMENT File
Name:
Mime Type:
/
/
,
Position/Title:
Street1*:
Street2:
City*:
County:
State*:
Province:
Country*:
ZIP / Postal Code*:
Department:
Division:
Street1*:
Street2:
City*:
County:
State*:
Province:
Country*:
ZIP / Postal Code*:
Prefix:
First Name*:
Middle Name:
Last Name*:
Suffix:
Phone Number*:
Fax Number:
Email*:
Phone Number*:
Fax Number:
Email:
Y: Yes
●
❍
❍
Yes
●
No
●
Yes
❍
No